Ontario Election 2018

#Vote and have an impact.
Quick reminder for RTs in #Ontario that voting for Ontario Election is happening today (June 7th)
Check out this link for more details:

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#RTSO Leadership Summit 2018

Thank you Respiratory Therapy Society of Ontario (RTSO) for the 2018 Leadership Summit. What a great collection of motivated attendees, working together to create positive change.

#RTSO gives voice to RTs in Ontario. To support this organization I have volunteered on the board of directors for the past few months. It is an honour working along side this driven and passionate group of volunteers. Do you know an RT in Ontario who has not joined RTSO yet? See this link for more details: https://www.rtso.ca/rtso-membership-benefits/

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Thomas Piraino

I am excited to share with you my conversation with Thomas Piraino.

Tom needs no introduction but due to my diverse followers, I am going to share few words about him.  Tom is a clinical specialist working at St. Michael’s Hospital in Toronto, Canada.  His contributions expand to frequent talks at international conferences, and involvement with editorial boards such as Canadian Journal of Respiratory Therapy and American Association of Respiratory Care [1]. His published work ranges from original research to whole chapters in textbooks.  He has received many awards from various organizations such as Canadian Society of Respiratory Therapists (CSRT), Respiratory Therapy Society of Ontario (RTSO), Hamilton Health Sciences, Fanshawe College, The Michener Institute and others [1]. I strongly recommend visiting the About Me portion of his website https://thomaspiraino.com/ for the full list of his contributions.  

I first heard of Tom when we viewed one of his physiology and mechanical ventilation videos on YouTube in school.  I began to recognize his name on many articles and publications. I have been lucky to attend few of his talks at different conferences, and it is no surprise that those conference rooms get filled within seconds and beyond capacity!  When it comes to active RTs, he is one of my role models.


Let’s go back to the beginning of your career. When did you first hear about the respiratory therapy field? What made you consider respiratory therapy as a career?

Prior to becoming a Respiratory Therapist, I was a Medical Lab Technician working in a patient services lab taking blood and performing ECGs.  I worked with a lady who really became like family to me. She encouraged me to look into Respiratory Therapy. She knew two Respiratory Therapists and thought I would be interested.  She was right!


While you and your contributions are known to the RT community, I would like hear your perspective; What are some of your memorable jobs or roles so far?

I truly feel that all of my roles are memorable as they all helped me along my career path.  The role I was in the longest was my educator role at St. Joseph’s Healthcare in Hamilton. I think my time and experience there helped me the most to advance professionally.  I was able to work with an excellent group of RTs, and ICU physicians that were both supportive, inspiring, and motivated me to take a greater interest in research and how it effects best practice. My current job is like a dream job, I’ve been working in it for just over a year and it keeps getting more exciting.


As you continue to grow, expand and experience, have your career goals changed?

My career goals have evolved much like my career has evolved.  What started out as a goal of obtaining a degree, has now evolved into a goal of obtaining a Masters.  My personal life, other interests, and involvement in the profession outside of my day job has made this process slow, but I wouldn’t trade my experiences for anything else.


With various roles and responsibilities,  what does a typical day look like for you?

A typical day now involves spending time in the Intensive Care Unit at St. Michael’s both assessing patients for a number of research studies related to mechanical ventilation, and working with the bedside RTs and other members of the RT leadership team to translate research into bedside practice.  Often this involves the use of technology such as electrical impedance tomography, esophageal balloon measurements, and ultrasonography. In fact, one of our big initiatives currently is to train the majority of our RT staff to perform diaphragm ultrasound measurements. It’s a very exciting time at St. Michael’s.

I will also spend time in the “lab”, which is a room in the hospital close to the ICU, where all of the international fellows currently working under Dr. Laurent Brochard spend their day.  With the lab I help with a number of things related to research projects like developing study ideas and protocols, REB submissions, and working with industry partners to test and validate new equipment and software.  I also help with performing bedside measurements for studies (ex. esophageal pressure measurements, diaphragm ultrasound). We have regular meetings related to our research projects, and hospital working groups dedicated to acute lung injury prevention. It is truly an inspiring place to work, and every day is exciting.


To reach higher levels require more than just hard work.  What is your passion that drives you each day working as an RT?

When all the cool measurements and technology is stripped away, the underlying element that drives my passion is the patient and how vulnerable they are.  The RT plays such a vital role in protecting the patient during the sickest time in the Intensive Care Unit because we are the ones responsible for setting up and manipulating the ventilator.  For years now I have been speaking about the individualization of mechanical ventilation, and treating the individual patient using various measurements and monitoring, rather than treating every patient the same.  It has been 8 years since I published editorials for the Lung Association (2010), and the RTSO (2011) regarding optimally setting PEEP, and using the term “individualized mechanical ventilation”, and at the 2013 CSRT conference my presentation was “Individualized Mechanical Ventilation for the ARDS Patient”.   I’m happy to see now that this idea is being regularly mentioned in all the latest critical care articles (including the ATS guidelines for ARDS management published in May 2017) that care of the ventilated patient needs to be individualized.


You have been considered one of the top experts in pulmonary physiology, mechanical ventilation, and PEEP. How did you get involved with PEEP?

PEEP is the most elusive ventilator setting, and one that requires a much greater understanding of lung mechanics than we normally thinking about at the bedside.  I have a strong interest in lung mechanics and bedside monitoring, so my involvement with PEEP and individualizing it came naturally.

What is your latest approach to PEEP?

My latest/favorite approach is using an esophageal balloon to determine the safety of the impact PEEP has on Plateau pressure and lung stress.  And using EIT to balance distribution of ventilation in the lung, including overdistension and collapse.

Based on your observation, are bedside PEEP studies still done routinely?

PEEP studies are mostly done when other technologies are not available, but we should be cautious in blindly doing recruitment maneuvers and PEEP titration.   A recent trial (ART Trial, published in JAMA) found higher mortality when using an open lung approach with recruitment maneuvers and decremental PEEP titration.  There is a number of possible reasons for the results of this trial, but it clearly demonstrates that unrestricted use of recruitment maneuvers and high PEEP is still not the way to go, and is not as individualized as it seems when recruitability is not assessed beforehand.


Let’s step back and look at the RT field.  Are you happy with the RT role?

I am happy with the RT role as I have taken part in it over the past 15 years, but I’m also not sure that the RT groups I have had the opportunity to work with represent the majority of the profession.  I have been fortunate to work in hospitals that fully support innovative advancements to individualize the care we provide to patients. But there is much work to be done before this is a standard of practice in hospitals.


What is the next big growth area for the RT profession?

I think RTs should be more involved in research, and I think non-invasive monitoring tools to better understand the patient-ventilator interaction is also an area of potential growth with RTs.  Again, I’m speaking about widespread adoption. Many RTs may be working in forward-thinking organizations that are doing new and innovative things, but again, it’s not the standard of practice.


In your opinion, what are qualities that makes a good/quality RT?

Be passionate, learn to understand and critique research, and speak up for your patient.


To prepare for this interview I consulted few RTs and this question came up few times: How does it feel to be an RT celebrity?

If people view me as an RT celebrity that is fine, but I’m really just an RT nerd.  I’m VERY approachable, and love to meet people, so please don’t ever feel that you can’t come and talk to me, or message me on LinkedIn or Twitter.


To finish this interview I am going to ask a general question that is gaining more attention lately. What is your key to life-work balance?

My life-work balance is challenging, I’m not going to lie.  I get involved in many things outside of my regular job, and I also have a part-time career as a web developer.   I try my best to discipline myself to stay away from my phone and computer when my children are around, especially when doing an activity with them.  However, once they are asleep, I begin to work on these other things, which means, I don’t sleep as much as I should. Additionally, I’ll work during my commute to work on the train.

Thank you Tom for taking the time to answer these questions.  You are involved in so many projects and yet you took the time on your vacation to answer these questions.  You are a source of inspiration for many RTs. Thank you for your contributions to our field!


To read more about Tom, view his blog and to contact him, check out his website at https://thomaspiraino.com/  . He is also on LinkedIn https://www.linkedin.com/in/thomaspiraino .  If you use Twitter, you can also follow him @respresource.



[1] Thomas Piraino. About Me. Accessed: May 16, 2018.  https://thomaspiraino.com/about/

Image shared with permission of Thomas Piraino .
If you like to use the content of this blog, including the image, please ask for permission first.

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Tony Kajnar

Mr. Tony Kajnar is a senior therapist at the Sault Area Hospital.  His work experience extends from diagnostic testing to the anesthesia assistant (AA) role.  Beyond his main responsibilities at work, he has assisted with the expansion of the AA role at his hospital, co-chairs the Canadian Pulmonary Function Testing Symposium, leads the Pulmonary Diagnostic Committee with Respiratory Therapy Society of Ontario (RTSO), and assists RTs and PFT labs with adhering to the latest and best guidelines.  Tony and I crossed paths as we both actively look for clarity in the pulmonary diagnostic field.  His extensive knowledge, drive to improve the filed, and willingness to help others has positioned him to be a mentor to many including RTs.   He was kind enough to take time out of his busy schedule to answer my questions.


To begin, let me ask two of my favourite questions to ask RTs: When did you first hear about the respiratory therapy field? What made you decide to become an RT?

After my first years of college I realized I did not enjoy my choices and attempted to reevaluate my career options, I ultimately completed aptitude and interest testing to get career ideas.  I took a Myers-Briggs test and completed a book entitled “What Color is your Parachute”, these lead to several healthcare career suggestions.

At the top of the list was Respiratory Therapy, which I had never heard of.  I came up with a list of questions and contacted my local hospital RT department who were kind enough to provide a tour and answered my questions.  I was impressed with the freedom and variety that their daily role provided and then began working toward enrolment.



Since  graduating from the RT program you have had various roles, what are some of your memorable roles so far?

Like so many, I began as a staff therapist in a hospital.  The market was quite competitive so I worked part time for nine years.  I had obtained my CPR, ACLS and PALS instructor’s certificates and enjoyed providing continuing education as my schedule allowed.  During my instructor work I got involved with simulation education and simulation teaching, which I am pleased to see in concurrent education these days.

Over these years I also worked part time in my hospital’s pulmonary function lab.  When I first started it was a requirement to obtain certification as a cardiopulmonary technologist and so obtained my CACPT(P).  I certainly enjoy diagnostics

The most challenging role to date was as an anesthesia assistant.




What made you decide to study and pursue AA?

Previous exposure to OR/anesthesia rotations in the RT program and our staff anesthesia department were quite positive for me.  Our hospital was part of the MOHLTC pilot into anesthesia care teams, our site was designated for an intra-op RRT/AA component and a post-op pain management with an RNEC.  This pilot was externally funded for two years but has since become part of our hospital program.



How has your experience working as an AA been? What are some areas of satisfaction and challenges working as an AA?

This role forever changed my perspective and bolstered my interest in health care.  The role was a great opportunity with so many difficult challenges to navigate.  A mantra from the Michener’s AA programs was “you don’t know what you don’t know” and that truly was reflected in the things that we were exposed to.  The more you learn the greater the engagement.

Our hospital did not have an RT role in the OR prior to the AA pilot, this created a very challenging environment in addition to the significant time investment in completing the basic and advanced AA programs.  Travelling to the Michener for our practicums and the late hours completing weekly assignments were both difficult and awesome. 



Any comments or advice for RTs who may want to consider becoming an AA?

This is an excellent opportunity for anyone truly interested in a role related to anesthesia.  There is a lot of competition and the path is extremely challenging.  Exposure to this role could help provide a better idea if the commitment is the right fit for you.  The role will vary from site to site which may influence your decision, so it is best to learn what you can from those practicing in your area.



How has the field changed over the years and has it been due to change in technology/equipment? Pharmacology? Protocols/practices? How do you see the role of an AA and the field of AA in the future?

My AA involvement was during phase one of the MOHLTC’s anesthesia care team model.   This initiative involved the CAS, their engagement and support is extremely important.  An RRT background may provide an edge for the clinical components of the AA profession but my greatest learning challenges were with the pharmacology and physiology involved with the anesthesia role. 

Anesthesia offers a departure from the acute care RRT role.  I was surprised to learn how the AA role was present for many years in Toronto, this was highlighted by the great faculty of the Michener Institute’s AA programs.  Some of my classmates were Quebec-trained RRT’s and I was impressed to learn how much the Quebec RRT program’s entry to practice competencies focus on anesthesia, not acute care.

The AA role is young and will no doubt change in ways that we cannot foresee.  It is important that we continue to have RT involvement in this exciting role.



How did you get involved with working and managing a PFT lab?

Have always had exposure to the PFT lab through the different hospital postings I have held.  It was a role I rotated through initially then had more permanent assignment in.  This eventually led to my current senior role in our hospital based PFT lab.

It is a great blend between technology, instrumentation and patient care for me.  There are plenty of opportunities for direct patient feedback, which is a great source of satisfaction.



Any comments or advice for those who may want to work in a PFT lab?

Our entry to practice competencies provides an introduction to pulmonary diagnostics but there is a lot consider with providing a formal diagnosis of lung disease and how our findings support treatment.  The ATS, ERS, CPSO and CTS practice and quality assurance guidelines are a good place to start in understanding the technical requirements related to this area of practice.  Understand the contraindications to testing you are involved with and actively screen for them prior to testing.  The quality based procedures and certified educator roles are also important to review and understand as they apply to the continuum of care.

Knowledge and understanding of the published practice guidelines is also important.  As standards change we need to be aware how this affects both diagnosis and treatment for lung disease.



How can the field of PFT improve to better serve the population?

There are many quality assurance standards to consider with lung function testing which are essential in categorization of lung disease and treatment.  We can all appreciate that objective lung testing is required to establish lung disease but only 50% of asthmatics and even less COPD patients have had such testing.  We must appreciate that there is a care gap; we need to support more accurate diagnosis and follow up to guide appropriate treatment in any lung condition.  Many patients being treated for lung disease have not had appropriate lung function tests to confirm or rule out their diagnosis. 



For some RTs and HCPs working in the acute care settings, the only exposure they have to COPD and Asthma patients is during the exacerbations.  As someone who helps COPD and asthma patients during all stages of their disorder or disease, what advice you have to share with RTs?

We need to advocate for documenting accurate lung function, screening for post bronchodilator reversibility and ongoing follow-up testing in patients.  Many patients with COPD and Asthma are not optimized and follow-up testing or assessments may not be considered after symptoms have been controlled.  Testing can help support titration of their inhaled medications.   Careful review of treatment, effectiveness of treatment and accurate categorization is also important in an effort to prevent future exacerbations.  Many patients may not be aware of their diagnosis and some may not understand their treatment options and delivery devices.  There are many opportunities to help patients gain better control.



With a sudden burst of various puffers coming to the market over the last 3 years, what is important to keep in mind? How can RTs better assist their patients with their puffers?

The new treatment options require us to continually review and update our knowledge in order to maintain consistency for the patient.  The medications and their role in respiratory guidelines are part of our best practices.  Being familiar with these medications, their delivery devices, mechanisms of action, interactions and precautions is all part of our professional responsibility.



I am going to ask few questions about the leadership side of your career.   In Sault Area Hospital you have been involved in many projects which not only improved the quality of patient care, but also expanded the role of RTs and AAs.   How did you get involved with or initiate changes in your hospital?

Some experiences were the result of job postings; other initiatives came from interest or certifications I worked towards. 

Policy and procedure updates have always been a challenge for me.  Sometimes the need to change has been a result of ongoing best practice and clinical guideline updates.  Other times it was from staffing or operational changes that brought new duties or refined them.  Developing effective communication with administrators and clinical leaders to outline policy and training required to accomplish appropriate changes is an area where our profession could benefit from additional resources, groups and references. 



Any recommendations for those who want to initiate positive change in their work environment?

Get involved in areas you are passionate about, this makes the work you put into the role much more enjoyable.  There are many opportunities with your professional associations, get involved where you can as there is always need for our profession to support future growth with our ever-changing health care system.



You have been active in improving the quality and standards of diagnostic testing including PFT.  How did you get involved with the Canadian Pulmonary Function Symposium?   What have been your goals?   How could RTs benefit from this annual symposium?

Several clinical practice issues lead to a search for clinical resources in order to address them.  

I attended the Medgraphics Cardiorespiratory Diagnostics Seminar in 2014 and was shocked to learn that it has been offered every year since 1994.  

I got involved with the Canadian Pulmonary Function Symposium after it ran in 2015.  I attended and offered to get involved with my fellow co-chairs, Laura Seed and Murray Beaton.  The Canadian PFT symposium is intended to be a resource for any clinician interested in pulmonary diagnostics.  Speakers and topics reflect current topics in addition to reviewing best practices and quality assurance requirements for pulmonary diagnostics. 

This experience has provided opportunities to meet several individuals, researchers and manufacturers who have helped answer clinical questions and motivated my ongoing involvement in supporting pulmonary diagnostics advocacy.



On a path to clarify and improve guidelines and protocols, you have been active in asking questions, surveying practices across the country, and vocalizing important concerns that need attention.  In your opinion, what are some areas that need more attention?  What are some of the obstacles?  How can RTs get involved?

I believe communication and knowledge transfer is an obstacle for our profession given our relative numbers to other professional groups.  It is easy to get lost in our health care system. 

My hope is to have a supportive clinical practice network that includes respiratory therapists.  There are many clinical practice areas that would benefit from formal study and publication involving the RRT role across all practice settings.  Research is an area I hope to see more RRT’s getting involved in for benefit of patients, the profession and our health care system. 



Looking at the RT profession, what do you see as the next big growth area?

Don’t think I can accurately predict the next area of growth but I certainly hope that we will see the development of an advanced practice respiratory practitioner, similar to the nurse practitioner role.  Such a role could support patients with lung disease in ways that go beyond our current authorized acts.  This role could also support our profession through advocacy and research as well as providing a goal for other colleagues to work toward.



As we get close to the end of this interview, do you have any final words or comments for the readers?

Certainly hope to see more RT’s get involved in promoting health care, advocating health care reform and research.  Hope to see RT’s support others for the benefit of patient care and best practices.



Thank you, Tony, for taking the time to answer my questions.  Also, thank you for your ongoing contributions in the respiratory therapy field!


If you would like more information about the upcoming PFT Symposium check out http://www.cacpt.ca/PFT-Symposium-2018-Details.pdf  .  This year’s event is taking place in Calgary, AB, from September 21st to 22nd (2018).


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Carolyn Greer

I first met Carolyn Greer at the 2017 CSRT conference in Halifax.  After overhearing my name in a conversation, she approached me with a big smile and a determination to ask if I was the Farzad, ‘Raffi’, who will be joining Markham Stouffville Hospital’s PFT lab a few days after the conference.  I have worked with Carolyn for the past 11 months in the PFT lab, and have been amazed by her level of drive, dedication, and care.  She is proud to be an RT, and has worked in various areas including acute care, community care, home care and pulmonary function testing.  She also has volunteered for CRTO and Lung Association. To recognize her dedication and to further understand her views and gain further insights, I asked her to answer few questions.

To start, I like to ask a question that many RTs discuss when meeting other RTs: When did you first hear about the respiratory therapy field? What made you decide to become an RT?
I first learned about Respiratory Technology (at the time), when I woke up in ICU at the Wellesley Hospital in 1980, after a respiratory arrest! Post a brief intubation, I began chatting with the fellow who was giving me my aerosol treatments. He told me what his role was and right then and there, I decided to be an RT.

I had struggled with severe asthma all my life. I spent most winters in the hospital with colds that were difficult to manage. The cause of this arrest was an anaphylactic reaction to ASA. I had always taken aspirin for aches and pains, but as I was using it, my body slowly built an intolerance to it. We did not know that ASA was the culprit until 2 years later, when I was in a full resp arrest, with code blue and that was the common trigger to both arrests.

I was intubated for quite some time and while in hospital post arrest, I found out I had been accepted into the RT program at TIMT!

How did the experience of being a patient, and receiving respiratory support, shape you as a clinician?
When I was a patient, I realized the discomfort of an ETT tube in your airway, the lingering pain of an artline when it has been removed. I have struggled to breathe more times than I care to remember so being in these situations has allowed me to be a more empathetic and compassionate RT. I still love what I do.

With various roles and years of experience, what are some of your memorable roles so far?
I was lucky to train at TGH during my clinical year. In May of 1984, the first single lung transplant was performed at TGH, on an overnight shift. I was running ABG results for the OR all night. That was my most memorable experience. I loved the thrill of working at TGH- at the time it was a trauma centre, it was also at the beginning of understanding the AIDS crisis. I moved from there to West Park hospital, which gave me more memorable moments. Dealing with experimental home ventilation and ventilatory support measures- even negative pressure ventilation- (Cuirass). West Park was like becoming a family member to the long term vent patients who called it home. After that I moved to home care and dealt with a lot of the preemies and their families as they transitioned to home with ventilatory support in place. Strong bonds were formed with these families. Finally, I am here doing PFT’s and loving learning about new pharmacological advances in the respiratory field, and seeing a new patient every 30 minutes, with a different clinical presentation every time!

I want to explore the homecare side of your experience.  How did you get involve with homecare?
I was interested in home care, because I was teaching and preparing patients at West Park to transition to home. It seemed like the next step to continue in the journey of learning all facets of our field.

What were some areas of satisfaction and challenges working in homecare?
The main challenge was not having a full hospital with colleagues, and medical interventions at the ready in the event of a medical crisis. However, I really learned to hone my clinical skills and intuitions and develop my confidence in the home setting.

SRTs may not receive much time during clinical rotations to explore homecare. Any advice to share for those who want to get involved? Yes!!!! Remember, when a patient comes to a hospital- they are on your turf and you can guide them and they will usually listen….when you go into their home, you must not judge their quality of life. You are on their turf and you need to become more of a facilitator to get them to follow your suggestions. It is important to be even more respectful of a patient’s needs, wants and space when you are in a patient’s home.

Now let’s talk about our current field of Pulmonary Function Testing.  How did you get involved with working at a PFT lab?
I initially arrived at Markham Stouffville as an asthma educator working part time in the asthma clinic in the evenings. I was approached about taking over a part time position in the PFT lab and my gut reaction was “No Way.” I was remembering the archaic systems we learned in the 1980’s with water seals, and drums with a stylus. Then I thought, (after much reassurance that it was all computerized), perhaps I should move out of my comfort zone and do something to challenge myself. I had been in the field for 20yrs. At that point. So I took a leap of faith!

What are some sources of satisfaction and challenges working in this setting?
Challenges are getting good results from each and every person. There are several modifications we can make to get those results based on the scenario- ie: English as a second language etc. Satisfaction comes when you see improvement or response to tx OR improvement post lung transplant or even allaying a patient’s fears and getting excellent results.

Any comments or advice for those who may want to work in a PFT lab? Patience is a virtue, and organization and time management are key. It is a new patient every 30 minutes, so you must be able to be fluid and able to adapt quickly.

With a sudden burst of various puffers coming to the market over the last 3 years, what is important to keep in mind? How can RTs better assist their patients with their puffers?
The newest generations of MDI’s are specifically targeting certain disease processes. Before, there were generally only 2 classifications of MDI’s. It is important to keep up to date on the newest meds and their indications for use. Also, it is important to review positive reasons for compliance with taking their meds.

What is the next big growth area that you see?
I believe we will need to be aware of the new legalization of marijuana and its effects. I see an even bigger role for the RT in public education.

Any last thoughts or comments that you would like to share with my RT followers?
Always remember: No one ever wanted to have trouble breathing. No one EVER wants our services….so make it the best experience you can for the patient.

I want to thank Carolyn for sharing her story and insights with us all, and for her years of dedication to the RT field.  

[End] http://respiratory.blog/carolyngreer/

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