Chair
Susan P. Pilbeam, MS, RRT, FAARC
9 Althea St.
St. Augustine, FL 32084
pilbeamsue@aol.com

I recently struck up a conversation with a ten-year-old boy while waiting to board a flight in an airport. Since the topic ended up being respiratory in nature, I thought it worth sharing.

As I was removing all the annoying postcard advertising from my "O" Magazine (Oprah, of course), a pleasant and personable young gentleman asked me, "Do you watch Oprah?"

"Yes, I like her," I responded.

"She brainwashes people," he warned me.

"Really. Well then, I guess I don't mind being brainwashed watching her show. No sex. No violence. No foul language. Nice show," I defended, wondering at this point why I was having this discussion with a ten-year-old. I just wanted to read my magazine.

"Yeah," he admitted. "I guess that's true. But she doesn't like beef." Apparently he was referring to Oprah's lawsuit involving the beef industry, in which she was exonerated.

"I don't eat beef either," I replied.

"Why not?"

"Cholesterol," I explained. "I try to eat vegetables." Dumb answer to give a kid, but he just kept on talking.

"Yeah, but smoking breaks up cholesterol," he assured me.

I nearly fell out of my chair with his distorted sense of logic and knew immediately that someone had actually been brainwashing this poor, defenseless child. Looking him straight in the eye I demanded, "Do you know who you're talking to?"

"No."

"I'm a respiratory therapist. Smoking is bad for you." I proceeded to tell him about all the diseases caused by smoking. I told him the story of the young man in his mid-30s whom I had given a treatment to just the day before and who had been diagnosed with lung cancer. I tried to scare him enough to think again.

"Do you smoke?" he asked.

"No, I don't."

"So it doesn't break up cholesterol?"

"Whoever told you that was LYING to you," I said in a rather loud voice, hoping the offending adult might be within earshot.

As I got up to throw the advertising postcards away, I noticed an adult on the other side of this young boy who was consciously avoiding eye contact. "Guilty!" I thought to myself.

"Yes," I continued with our conversation. "Smokers keep me in business."

"So what would you do if everybody quit smoking?" he asked.

Cheer, I thought to myself. "I'd find myself another profession," I responded without hesitation.

"You're one of the good guys then," he responded.

I would certainly like to think so, and at that moment I felt very proud to be a respiratory therapist. I hope he remembers our talk.[Top]

In the April/May/June 2003 issue of the Diagnostics Section Bulletin, Tom Smalling, MS, RRT, RPFT, RPSGT, provided information on some educational resources for sleep technology. He also noted that "educational resources focusing on the training of technicians, physicians, and sales personnel have lagged far behind (the) growth" in this specialty area.

Because of the serious lack of information available, as chair of the Education Section, I would like to put together a pool of laboratory exercises, competency check-offs, and/or lectures that members of this section may have developed in the area of polysomnography and sleep technology. If you would be willing to share educational resources such as these with your fellow section members, please send them to me at pilbeamsue@aol.com and we will post them on the section homepage on the AARC web site. [Top]

A substantial amount of time and resources are invested in each student enrolled in an accredited respiratory care education program. Respiratory care educators are responsible for producing competent respiratory practitioners with the knowledge, skills, and attitudes necessary for successful practice in the profession. But since there is considerable variability in each student's clinical instruction, all respiratory care students do not receive identical clinical experiences.

Using human patient simulation technology in a laboratory setting can eliminate clinical instruction variability. A Human Patient Simulator (HPS) may be used to create combined clinical situations under the direct control of the instructor. Specific software features allow the instructor to change the pre-figured scenarios or create custom scenarios to meet specific teaching objectives. Use of the HPS is not meant to replace clinical teaching, but to eliminate the variability of the "catch-as-catch-can" teaching often occurring in that setting.

The three domains

Respiratory care educational objectives must include the three domains of learning: cognitive, affective, and psychomotor. The cognitive domain is concerned with the intellectual responses of the learner. Benjamin Bloom developed the most widely used cognitive taxonomy.(1) There are six major sub-classifications of the cognitive domain:

* Knowledge includes memorization, recall, or recognition of information.
* Comprehension includes understanding and the ability to explain or interpret.
* Application is the ability to use or apply an abstract concept in a specific situation.
* Analysis includes the ability to break down abstract concepts into their component parts and to identify the relationships that exist between them.
* Synthesis is the ability to combine elements and parts to form a new knowledge.
* Evaluation is the ability to make judgments about the value of some given purpose.

Affective learning is demonstrated by behaviors such as awareness, interest, attention, concern and responsibility, ability to listen and respond during interactions with others, and ability to demonstrate those attitudinal characteristics or values which are appropriate to the field of study.(2) Psychomotor learning is demonstrated by physical skills: coordination, dexterity, manipulation, grace, strength, speed - actions which demonstrate the fine motor skills, such as use of precision instruments or tools.(3)

These are the domains that must be mastered to enable respiratory care students to be successful critical thinkers. Respiratory care curricula address the cognitive and affective domains within the required respiratory care courses and laboratories using lectures, demonstrations, facilitated discussions, problem-based learning, clinical decision-making models, and computer-based simulations.

Problems with clinical education

To achieve the psychomotor domain of respiratory care, students are required to amass hundreds of hours in the clinical milieu. However, students' clinical experiences rely heavily on the "catch-as-catch-can" method because the clinical instructors and respiratory care students have little control over where and when events occur and what topics are addressed. In the basic sciences, for example, lectures and labs occur in a fixed place and at a scheduled time and on topics that faculty believe the students need to know about - then they are over. In the clinical sciences, patients (who remain the primary "teaching material") appear at a fixed location and at a particular time with the problem they happen to have - and then they leave. This causes considerable variability in clinical instruction. The diversity of clinical exposure during respiratory therapy training suggests further that a graduate's clinical competence also is likely to vary.(4) This method of doing educational business is so much a part of daily life in a respiratory care program that it is taken for granted.

Studies of clinical reasoning accumulated over more than 20 years suggest a "case specificity" of medical expertise - in other words, proficiency generalizes very weakly from disease to disease and more generally from one aspect of medicine to another.(5,6) The most effective method to develop proficiency over time is active practice with a wide range of cases and with as many repetitions for each subject/disease area as possible.(7) This is hardly ever the case. Despite clinical and didactic faculty's best efforts, all respiratory care students do not receive identical clinical experiences. In fact, a majority of students may complete a respiratory care program without ever participating in the management of patients who require immediate and multifaceted respiratory interventions. This includes, for instance, motor vehicle accidents and penetrating chest wounds.

Although clinical practice is fundamental to the respiratory therapy students' learning, many experience problems and difficulties during their clinical practicum.(8,9,10,11,12) Currently, the clinical setting is the only place where students can use knowledge in practice and develop competency in psychomotor skills. There are, however, extensive amounts of literature highlighting problems that affect student clinical learning. These problems include stress and anxiety in the initial clinical experience and the theory-practice gap. (8-15)

Lifelike mannequins

To help address this deficiency, the respiratory care program at the Borough of Manhattan Community College recently purchased the Human Patient Simulator and the Pediasim (pediatric simulator) from Medical Education Technologies, Inc. The HPS represents the latest in state-of-the-art computer simulation technology for training clinicians across various medical disciplines. It is an innovative training system with detailed models of respiratory, cardiovascular, and pharmacokinetic systems. The HPS and Pediasim consist of lifelike patient mannequins that breathe spontaneously, have palpable pulses, heart and lung sounds, and respond appropriately to stimuli such as electrical current from a neuromuscular blockade monitor. The mannequins can be intubated and connected to life support systems, such as mechanical ventilators or intravenous cardiac inotrope infusion pumps. A mechanical and mathematical lung model allows the patient mannequin to consume oxygen and produce carbon dioxide. The HPS and Pediasim automatically recognize and respond to intravenously injected medications and to inhaled anesthetic gases according to known pharmacokinetic and pharmacodynamic principles. Microcomputer and custom built data acquisition and control systems allow realistic clinical scenarios to be presented to the students (such as pneumothorax, cardiac tamponade, acute respiratory arrest, airway management difficulties, and cardiac dysfunction). The student is challenged to make clinical decisions and solve equipment problems. This is done "hands-on" in an interactive fashion, similar to actual clinical practice.

The HPS comes with 25 preconfigured patient profiles/scenarios representing various ages, physiologic states, medical histories, and genders. Scenarios are used to determine the initial and subsequent physiological states, as well as the responses and adverse reactions that arise during patient care. Over 80 physiological parameters can be altered to simulate a wide range of events and crises.

Simulation technology allows the instructor to modify events within a scenario in real time to increase or decrease event severity, shorten or lengthen event duration, and add or modify complications at any time during a simulation exercise. Scenarios can also be overlaid to create combined situations under direct instructor control. Utilizing specific software features, the instructor can change the prefigured scenarios or create custom scenarios to meet specific teaching objectives.

As respiratory care educators, we are challenged to develop varied teaching modalities that stimulate critical thinking. Students in health care programs are challenged to quickly master an ever-growing number of complex tasks. Integrating the HPS and Pediasim into the curriculum will give our respiratory care faculty the ability to create a simulated clinical environment. A variety of "what if" exercises can be an effective way of evaluating students one-on-one and encouraging critical thinking. The HPS and Pediasim could also be used to engage students in "what if" games, which are enormously educational. Students can ask and get answers to questions such as:

* What if I did the procedure again, just a little bit differently? This would allow the student to hone his skills and judgment. For example: a student could try giving the HPS a stronger dosage of medication and watch for and take action to stop the adverse reactions.
* What if I did this many times over, each time in a different way? This would show the student naturally occurring variability in the way the patient responds to drugs and other external stimuli.
* What if I did this in a way I know is wrong? It is difficult to experience the consequences of mistakes in the real world, because in the real clinical world, mistakes cannot be purposely made. When they do occasionally occur they are often not recognized until long after their occurrence.

Producing confident students

Current methods of clinical education and training suffer because they rely on the clinical environment, which is uncontrollable and unpredictable. Safety of the patient always takes precedence over learning. Lectures, though highly structured, are passive forms of learning, and research in education clearly shows that active, hands-on, problem-based education results in greater learning and retention of learning. The HPS and Pediasim can help our respiratory care students understand and learn to operate complex medical instruments confidently and safely and to perform complex medical procedures. The resulting curriculum will be problem-based, intensely realistic, yet completely free of any risk to patients.

References

1. Bloom BS, et al. (1956). Taxonomy of education objectives; Handbook I, the cognitive domain. New York: David McKay.
2. Krathwohl DR, et al. (1964). Taxonomy of educational objectives; Handbook II, the affective domain. New York: David McKay
3. Harrow AJ (1972). The classification of educational objectives in the psychomotor domain. In: Simpson EJ (Ed.), The psychomotor domain (pp. 43-56). Washington, D.C.: Gryphon House.
4. Douphince WD (1990). Clinical education: the legacy of Osler revisited. Academic Medicine, 65(supplement 9), S68-S73.
5. Elstein AS, Shulman LS, Sprafka SA (1978). Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, Massachusetts: Harvard University Press.
6. Schmidt HG, Norman GR, Boshuizen HP (1990). A cognitive perspective on medical expertise: theory and implication. Academic Medicine, 65, 611-621.
7. Issenberg SD, McGaghie WC, Hart IR, et al. (1999). Simulation technology for health care professional skills training and assessment. Journal of the American Medical Association, 282, 861-866.
8. Campbell C (1985). Stress survey: disturbing findings...nurses are under stress. Nursing Mirror, 160(26), 16-19.
9. Sellek T (1982). Satisfying and anxiety creating incidents for nursing students. Nursing Times, 78(48), 135-140.
10. Parks KR (1980). Occupational stress among student nurses: a comparison of medical and surgical wards. Nursing Times, 6(76), 117-119.
11. Parks KR (1985). Stressful episodes reported by first year student nurses: a descriptive account. Journal of Social Science and Medicine, 20(9), 945-953.
12. Birch J (1979). The anxious learners. Nursing Mirror, 148, 17-22.
13. Rielly DE, Oermann MH (1992). Clinical Teaching in Nursing Education. New York: National League of Nursing.
14. Beck CT (1993). Nursing students initial clinical experience: a phenomenological study. International Journal of Nursing Studies, 30(6), 489-497.
15. Lindop E (1989). Individual stress and its relationship to termination of nurse training. Nurse Education Today, 9, 172-179.[Top]

Editor's Note: The following article was adapted from Citylights, Volume 8, Issue 4, May 2003. While specific to Louisiana, the information herein can be applied to any state currently facing a shortfall of health care workers.

It has become disturbingly clear that Louisiana faces an uncertain future concerning the adequacy of its nursing and allied health workforce. Aside from the well publicized nursing shortage facing our state, a crisis is now occurring in the allied health professions as well.

In Louisiana, the shortage of health care providers has been identified by the recently developed Louisiana Health Works Commission. Allied health professionals represent a majority of the 210,000 health care workers in the state. But with more than 200 professions defined by the U.S. Department of Labor as "health care careers," the Louisiana Health Works Commission set out in 2002 to identify the health care professions and services most in demand. These professionals, who make up more than 80% of the health worker shortages, include nurses, licensed practical nurses, radiologic technicians, respiratory therapists, and physical therapists. In addition to these five groups, the commission recommended special consideration be given to pharmacists and physician assistants, due to an anticipated growth in the need for these practitioners through 2010. Current vacancies in Louisiana, documented by the March 2003 commission report, include 4,163 registered nurses, 3,318 licensed practical nurses, 283 radiologic technicians, 266 respiratory therapists, and 257 physical therapists.

The Allied Health Workforce Council, a subset of the legislatively enacted Louisiana Health Works Commission, also identified five professions experiencing personnel shortages. The five areas experiencing unprecedented growth are: pharmacists, radiology technicians, clinical laboratory science technicians, respiratory therapists, and rehabilitation therapists (including physical and occupational therapists, speech-language pathologists, and audiologists).

Given these shortages, it's clear school officials and RC faculty should encourage students interested in a health career to consider a program in allied health. Potential students should be made aware of each allied health profession's entry-level degree requirement. For example, in respiratory care the minimal entry-level degree is an associate degree, while a master's degree is necessary to practice as a physical therapist. Interested individuals should be encouraged to visit local programs to see first hand what each profession is all about, and to speak with graduates, college advisors, and department managers. This will help potential students become better informed of the job requirements, salary, and career opportunities. Once students have made a selection, applying to several programs may increase the chances of being selected for a particular health care program.

With factors such as an aging health care workforce, increasing numbers of elderly, and a reduced number of people entering the general workforce, job opportunities in health care will continue to grow and offer the graduate a wide variety of employment options.[Top]

The Educational Resources Information Center (ERIC) is a national information system providing access to the most comprehensive database of education-related literature in the world. It was established in 1966 and is supported by the U.S. Department of Education, the Institute of Education Sciences, and the National Library of Education.

ERIC provides access to over one million citations, including research documents, journal articles, technical reports, program descriptions and evaluations, and curricula in the field of education. ERIC database search options, resources, and document ordering information are available at http://www.eric.ed.gov/. The database is updated monthly and is available via the Internet, commercial vendors, and public networks.

Researchers, teachers, policymakers, librarians, journalists, students, parents, and the general public will all find ERIC a key source of education information. The free Pocket Guide to ERIC (http://www.eric.ed.gov/resources/pocket/pg99.html) provides a good overview of the database, as does the ERIC Slide Show (http://www.eric.ed.gov/resources/eric_slides.html), an excellent training tool available in several formats.[Top]

Editor's Note: The following article was adapted from "New Ways of Thinking About Career Success," by Mike Broscio, Journal of Healthcare Management, Volume 48, Number 1, January/February 2003.

Health care is being bombarded by forces of change, both internal and external. Technology, government regulations, demographic swings, and world politics all contribute to the changing environment. Consistent with this changing work world is the need for a new method of viewing our role and our success.

A new world - a new success

To be successful in today's health care environment requires a rethinking of business realities. Loyalty, security, fear, complacency, and tradition no longer provide the balance of power between employer and employee; rather, supply and demand, and a balance between the organization and individual needs, defines the work reality summarized by the term "shared success." Creating shared success begins when you fully understand your organization's needs. Career planning focused on personal needs, such as interests and values, addresses only half the equation. Although important, an individual's needs must be balanced with those of the organization issuing the paycheck. Being out of balance results in your organization asking you to leave or in your own dissatisfaction with your work.

Mike Broscio, director of Healthcare Career Management and Outplacement Practice, has developed a tool called the Q5 Framework that can help you examine both your personal needs and strengths and those of your organization, resulting in an objective measure of success.

The Q5 Framework asks important questions related to both the individual and the organization. Through the process of answering the questions, you can see your career as it is, and design a plan to achieve success.

Your Needs and Offers

* Take a hard look at yourself, take stock.
* What do you have to offer the organization?

Your Organization's Needs and Offers

* Key strategies of the organization - how does your job fit in?
* Understand expectations.
* The pros and cons of working here.

Analyze Overlaps and Gaps

* With the information obtained you have a snapshot of your work environment and how you fit into it; from this analysis comes an understanding of key gaps that you can use to develop both short- and long-term plans to achieve shared success.
* Achieving and maintaining balance requires periodic assessment of all four areas, as change in any one impacts the others.

Plan

* Map out a career plan aimed at decreasing gaps between your needs and offers and those of your employers. Fully developing the plan requires work, thought, and time.
* Begin with one thing you want to do differently - a change in attitude or behavior, or a new skill or information set you want to learn.
* Enlist the assistance of a colleague, manager, or mentor to review your plan and keep you focused.
* Write down what you plan to do and set a timeframe - focus on the one thing you identified for change and review your progress at the end of the time.

It's that simple and that hard.

No going back

The work world has changed. Letting go of old beliefs about how we achieved and maintained success in our profession is the first step in moving toward a more rewarding and successful career in this new reality.

* We are all contingent workers serving increasingly demanding customers.
* We must continually produce value and acquire the new skills needed to produce this value in the future.
* Performance expectations and related rewards will change frequently.
* We need to be willing and able to transition from one facet of an industry to another or from one industry to another.

Your future career success may depend largely on how you choose to respond to these new realities. While we may be powerless to change the work world, we do have the ability to control our success through adaptation and growth.[Top]

We recently conducted a survey in which program directors were asked to rank their top five picks for best bachelor's degree RT programs in the U.S. The survey instrument was developed and administered by Richard Rich, a student at the University of Texas Health Science Center at San Antonio. The program directors were asked to rank the top five respiratory care programs in the U.S., beginning with their number one pick. Program directors were not allowed to list their own programs in the ranking. A list of 54 schools with BS programs recognized by CoARC was provided to help them rank their top five choices. Currently, there is no formal method of ranking respiratory care educational programs. The ranking done in this survey is purely a "coaches' poll" featuring the opinions of those completing the survey, and is not a scientific rating of program quality.

The survey was sent via e-mail to the program directors of 54 institutions listed by CoARC. Two subsequent mailings were performed in an attempt to increase the response rate. Thirteen usable responses were received for a response rate of 24%. Each survey was scored using the following scale:

* A number 1 ranking was scored 5 points.
* A number 2 ranking was scored 4 points.
* A number 3 ranking was scored 3 points.
* A number 4 ranking was scored 2 point.
* A number 5 ranking was scored 1 point.

All of the scores for each ranked school from all of the surveys were combined to derive a total score for each school. The schools with the highest total points were:

In the absence of an objective method to rank RT schools, this "coaches' poll" provides us with the opinions of the people with the most experience in what it takes to run a good RT program. However, we must also realize name recognition may be the primary factor by which the schools were identified. Clearly, there are many excellent programs around the country that may not be well known to their peers because they are busy staying home and taking care of business. Indeed, one respondent noted that being well known doesn't make a program one of the best. Another respondent suggested the faculty of the top programs make themselves available for consultation and mentorship of new BS degree programs.

A professional consensus is needed on what criteria should be used to determine the best respiratory care programs in the United States so these schools can be identified and provide models for other programs. In the mean time, the use of a "coaches' poll" is a way to identify top ranked RT programs. And congratulations to the number one ranked school: Georgia State University.[Top]

Rehabilitation of the cardiopulmonary (CP) patient requires the synergistic integration of numerous medical professionals. Some of the most vital interventions are provided by clinicians from the allied health professions, specifically, physical therapists and respiratory therapists. But a separation between the roles of these professionals in cardiopulmonary rehabilitation is not well defined.

In the budding days of CP rehabilitation, programs were run by nurses, with PTs relegated to directing the physical activity component - in other words, exercise training and supervision. As the depth and scope of CP rehabilitation broadened so did the need for other specialized professionals, thus precipitating the genesis for the RT. With the birth of the RT came specialization and separation of services from that of the PT. However, this separation and specialization is not universally understood nor agreed upon, and appears to be regionally dependent.

That PTs and RTs do not compete for employment evidences the unique contributions and roles of each profession in CP rehabilitation and serves to underscore the distinct separation in the educational processes of each. In the context of CP rehabilitation, the education of the RT involves a more specific focus on cardiopulmonary treatment and management. In contrast, the PT's educational foundation encompasses a broader systems-based approach. Physical therapy involves the prevention and management of impairment, functional limitations, disability, or changes in physical function and health status resulting from injury, disease, or other causes; alleviation of pain; and maintenance and promotion of fitness and optimal quality of life as related to movement and health. In this context, the PT encompasses a much broader role in the delivery of health care, but as a result, is not as specific to CP rehabilitation as the RT.

It is not uncommon for pulmonary rehabilitation programs to consult PT for specific issues that arise with patients. Although the RT and PT may be involved with developing an exercise prescription for the CP rehabilitation patient, it is typically the RT who carries out the day-to-day exercise regimen. PTs become involved if skeletal or muscular issues arise and dysfunction other than cardiopulmonary disease limits exercise.

These distinctions in educational development are evidenced in the clinical roles of each profession. While RTs are generally more involved in procedural activities such as oxygen therapy, assisting with monitoring the patient during exercise, and chest physiotherapy, the PT may be better suited to addressing the associated co-pathologies seen in cardiopulmonary patients, such as postural dysfunction and loss of autonomous mobility.[Top]

Lambda Beta, the national honor society for the respiratory care profession, was formed in 1986 to promote, recognize, and honor scholarship, scholarly achievement, service, and character among students, graduates, and faculty members in the profession. The naming of the society is based on the goals of the respiratory care profession: sustaining "life and breath" for all mankind. Lambda is the Greek letter "L", and beta is the Greek letter "B".

During the Society's first year, 22 chapters were formed. The first Lambda Beta induction ceremony was held in November of 1987 at the Las Vegas Hilton, where each chapter presented its nominations for membership. As of January 2003 there were 113 Lambda Beta chapters, with a membership of 3,877. Lambda Beta chapters may be established by any CoARC-approved or CAAHEP-accredited respiratory care program by completing an application form available through the Lambda Beta executive office located in Lenexa, KS.

All members of the Society must be nominated for membership. The faculty members or officers of the Lambda Beta chapters may nominate students, alumni, and faculty to membership. Once nominated for membership, the candidate's membership is approved and voted upon by the Executive Board.

Within Lambda Beta there are five membership categories:

* Members include students currently enrolled in their final quarter, semester, or term who are ranked in the top 25% of their graduating class.
* Alumni members include graduates (longer than 30 days from nomination) of a CoARC-approved or CAAHEP-accredited program who ranked in the top 25% of their graduating class. Alumni nominees must have maintained an ethical and unblemished professional record since graduation.
* Faculty members include all faculty members who are teaching respiratory care in any CoARC- or CAAHEP-accredited school of respiratory care. Faculty members must have at least two years of full-time experience, or four years part-time experience as an instructor.
* National Honorary members are those individuals who have made a "one of a kind" contribution to the profession. Honorary memberships are limited to one per calendar year and are granted by the Executive Board upon nomination from any chapter or individual Lambda Beta member. A call for National Honorary member nominations will go out in August, with a deadline for submission of October 1.
* Honorary Chapter members are those individuals who have made a "one of a kind" contribution to the Chapter's institution. Honorary Chapter memberships are limited to one per calendar year per chapter and are granted by the Executive Board upon nomination from any chapter.

The purpose of the Society is to promote achievement of high scholarly standards within the schools and chapters through the encouragement of membership and graduation with honors. Membership benefits and advantages include the recognition of individual achievement and scholarship. Individuals' achievements are recognized by placement of their names into a permanent "Roll of Excellence," the right to display a graduating with honors ribbon on their graduation gown during commencement, "graduation with honors" noted on their official transcripts, the right to wear and display the Lambda Beta insignia, and the right to list honor society membership on their curriculum vitae.

In addition to recognizing the achievement of students, alumni, and faculty, Lambda Beta chapters may choose to participate in other activities promoting leadership and scholarship within the profession, including social activities such as annual luncheons, recognition dinners, or graduation breakfasts; scholarship fund raising and distribution; and special fund raising and research.

Each year the Lambda Beta Society distributes up to $2,000 in scholarships to students enrolled in respiratory care programs with a Lambda Beta chapter. These scholarships are possible through donations from Kimberly Clark, as well as the National Board for Respiratory Care/Applied Measurement Professionals (NBRC/AMP). A call for scholarship applications was sent to all chapters in August. The deadline for submitting scholarship applications is October 1.

This year the Society will host a reception on December 10 during the AARC International Respiratory Congress in Las Vegas to honor the 2003 National Honorary member, Honorary Chapter members, and scholarship winners. We look forward to meeting all new members and catching up with continuing members at the reception. If your school does not currently have a Lambda Beta chapter, please contact our executive secretary for an application at Ghocker@goamp.com.[Top]

I've been giving thought to what has gone into my choice of a health career. I'm a "thoughtful" person, my teachers say, so I know this thinking I've been doing is not in vain.

The ultimate reason why I chose this profession is that I believe I am called to lend a hand in some way to the healing process. When the smoke clears from studying and taking exams, I have to look back at the reasons why health care is my profession of choice. There are many reasons why individuals choose one of the health care professions. Through conversations with fellow students and therapists I've met while "doing clinicals," I've been able to gather some of these motives. For some, the main motive to becoming a part of the health profession is to bring home a hefty salary. Some use their first career as a stepping stone to fulfill their desire to become a prestigious individual in the community.

I believe I am fortunate to be one of a chosen few who have taken on this particular profession as a means to help people and make a positive difference in the lives of others. As my career path unfolds, I have come to believe my focus cannot be on monetary rewards or achieving the highest academic credentials possible. My inner voice tells me my focus must be on the patients for whom I provide care. My reward is the feeling of satisfaction I get from knowing that I am a vessel used in the miracle of healing. Although I am sure this choice is the right one for me, I still have questions about the map of the rest of my life. Where will this career choice take me? Will I be the same person at the end of the trip I believe I am now? Will I be a good traveler? Will I wander from the path or will I falter?

My heart tells me to try to touch someone's life in a positive way each and every day. Today, my work, school, and family schedules are heavy. I know when I actually go to work after graduation, my patients may not always be cooperative and my assigned patient load may be burdensome. I will remember most patients, like myself, are a collection of feelings and thoughts. I once, as a student, helped care for a single mother who was the caretaker of her family. She was so worried about being able to afford being in the hospital. She wondered how her children were being cared for and how she was going to face her upcoming hospital bills. In addition, she was in a state of dependency.

You may think, "What does that have to do with me?" The answer is everything. At some point in our lives, each one of us may have some of the same problems this young mother faced. Clearly, we cannot take on the burdens of each and every patient in our care, but our attitudes and the way we SHOW those attitudes to others can have quite a profound effect. As I have seen, there are always time constraints associated with every job. After all, we live in the age of "work harder, be more, get thanks (maybe) but no extra bucks." For the professional respiratory therapist who has a positive attitude and an encouraging smile, the impact on others goes beyond words. Remember Maslow's Hierarchy of needs? The most vital of the physiological needs is breathing. How much more important can our service be?

In conclusion, I urge therapists and students who have chosen to pursue a career in health care to think carefully about their reasons for choosing their profession. I believe the main goal of this soon-to-be respiratory therapist is to become a part of the healing process. I will share my optimism with co-workers and show how much I care, and hope these emotions will add something intangible to the prescribed respiratory therapy. I wish these feelings could convey the message my heart sings - that we are all traveling down the road from this life to another, greater one. We would do well to reach a hand out to those who are most needy, whether their needs are of body or of spirit.[Top]

TLS from Indiana writes: What should the RT understand about cytokines and mediators of inflammation?

The pharmacological treatment of asthma is becoming increasingly complex as we gain knowledge about the inflammatory nature of this chronic disease. As respiratory therapists, it is our responsibility to educate our patients with respect to management of asthma and other pulmonary diseases. But how many times have you questioned your patient about his or her asthma drugs, only to find that they do not know what to take when?

I recently had the experience of working with an asthma patient who is also a friend. She was using albuterol and the Advair Diskus, a fluticasone/salmeterol combination. At least those were the drugs she had in her medicine cabinet. One day, she experienced an acute exacerbation of her asthma, and I asked her how she used these drugs. She told me she used her albuterol inhaler whenever she experienced shortness of breath, and if that was not sufficient to control her symptoms, she would take a couple of puffs of Advair, up to twice a day, stopping both drugs when the episode passed. I asked her who told her to do that, and she replied that her physician, a primary care doctor, had not told her how to use her medications at all, so she had "figured it out" on her own. When I explained to her that Advair is her maintenance drug, and that she should take it daily, whether she feels she needs it or not, and that albuterol is considered a rescue drug to be used only when symptoms flair up, she was stunned. No wonder she was having so much trouble controlling her asthma!

I went on to explain how these drugs work, so she would understand exactly how her asthma was being controlled. Once she understood why she needed each drug and when, she decided to see an asthma/allergy specialist. He added Singulair, a leukotriene receptor inhibitor, not as a substitute for Advair, but as an additional drug to the mix. I explained what the various inflammatory mediators are, as well as how different drugs control different aspects of inflammation. She finally understood that her various medications are designed to address different components of the disease, and that they are not interchangeable drugs for her to take as she sees fit. I am happy to report that this young woman now has her asthma under control and is no longer living in fear of her next exacerbation.

Cytokine-directed therapy can be a critical component of asthma management for patients with moderate to severe asthma. Inhaled corticosteroids and leukotriene receptor inhibitors are two important types of drugs used to control the inflammatory component of reactive airways disease. But how much do you really know about cytokines and other inflammatory mediators? Most of us learned about the immune system and inflammation in school, but how many of us feel we really have a grasp on this information and how it relates to asthma management? Because respiratory therapists give drugs that alter the immune system, it is important to understand inflammatory mediators so we can foster a basic understanding in ourselves and in our patients about how to effectively control the inflammation associated with reactive airways disease.

The immune system is an amazing network of biochemical pathways which is designed to protect us from external and internal threats, such as bacteria and viruses. It can be divided into the following major components:

* Humoral immunity, which involves production of antibodies by B cells and plasma cells.
* Cell-mediated immunity, which involves interactions between helper and cytotoxic T cells and their various target cells.
* Neutrophils and macrophages, which ingest and destroy pathogens.

Immune cells produce a variety of mediators that have the potential to orchestrate and carry out an attack on invading organisms and foreign substances. They communicate with one another and, under normal circumstances, are self-limiting. Chronic inflammation occurs when inflammatory mediators continue to be produced in large quantities after the insult to the system has been quelled, or when repeated insults occur and the immune system is continually activated. The body recognizes damaged tissue as needing repair by the immune system. Inflammatory mediators are produced in an effort to accomplish this goal, but if produced continually, they cause additional damage to the tissue, setting up a pro-inflammatory cycle. A course of oral steroids is frequently prescribed following acute asthma exacerbation to break this cycle, allowing the tissue to heal by stopping the constant outpouring of inflammatory mediators.

Cytokines are an important class of inflammatory mediators. They are hormone-like proteins that enable immune cells to communicate with one another, and they play an integral role in the initiation, perpetuation, and subsequent down-regulation of the immune response. All cytokines have the following properties:

* Ability to signal other cells and coordinate the immune response.
* Capability of being delivered by other cells to the systemic circulation or to the local environment as needed.
* Ability to bind to high affinity cell surface receptors.
* Capability of being produced by non-immune cells, such as fibroblasts and endothelial cells.

There has been some confusion over the years about nomenclature when discussing inflammatory mediators. As with most terms, we tend to stick with the ones we originally learned, so different groups or "generations" of clinicians may use different terms for the same substance. The term "cytokine" was introduced to identify this particular class of mediators and eliminate much of the confusion. The term interleukin, or IL, has greatly simplified the nomenclature regarding inflammatory mediators. When a factor has been sufficiently characterized, it usually receives an interleukin designation, such as IL-1 or IL-6, though some cytokines have retained their descriptive names. Table 1 outlines the different cytokines and their sources.

In order to the put the role of cytokines in immune function and inflammation into perspective, we need a brief overview of normal immunity.

An antigen is recognized and then processed by an antigen-presenting cell (APC). Many cells possess the capacity to present antigen, including macrophages, dendritic cells, B cells, and Langerhans cells. Antigen processing is a complex series of events that involves antigen internalization, degradation, and re-expression on the surface of the presenting cells. T cells that express the appropriate antigen receptor then accept the antigen complex. Cytokine production will determine how T cells are stimulated by antigen and APCs. IL-1, produced primarily by macrophages, is a potent T cell activator. It induces synthesis of IL-2 and IL-4 by T cells, which then act to stimulate T cell proliferation. The type of antigen involved will have an effect on the cytokine profile produced, as will the local cytokine environment and the prevalence of specific T cell subsets. Helper T cell subsets (Thx) have been identified by the cytokines they produce.

* Th1 cells produce interferon (IFN)-gamma and IL-2, but not IL-4. These cells regulate delayed type hypersensitivity reactions.
* Th2 cells produce IL-4 and IL-10, but not IL-2 or IFN-gamma. These cells mediate allergic and antibody responses.

It is thought that diseases such as asthma may be related to dominance of one T cell subset over another. This dominance is determined by cytokines in the tissue environment. Th2 dominance is seen in patients with asthma and may be caused, in part, by lack of early exposure to endotoxin and respiratory viruses responsible for Th1 dominance. This so-called "hygiene hypothesis," the idea that the environment of infants and children in developed countries is too clean to promote the shift from Th2 dominance to Th1 dominance, is gaining acceptance. Once predominant cytokines have been determined, amplification of the cytokine response occurs through a positive feedback loop. This amplification can include recruitment of inflammatory cells, inhibition of cell migration, enhancement of antigen expression, and stimulation of T cells or B cells.

Figure 1 depicts the role of antigen and the immune system in asthma, a chronic inflammatory disease process. In this example, T cells (Th2 lymphocytes) are stimulated by antigen to release IL-4, IL-5, and IL-13. These cytokines promote differentiation of plasma cells (B cells) that produce IgE against antigens to which T cells were exposed. IgE attaches to mast cells and eosinophils. When mast cells are re-exposed to antigen, they secrete preformed and newly formed mediators, leading to production of more mast cells, differentiation of more Th2 lymphocytes, and differentiation and chemotaxis of eosinophils. The end result is bronchospasm, inflammation, and mucus production.

Figure 1. Cellular mechanisms of airway inflammation. Adapted from National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health Pub. No. 98-4051. Bethesda, MD, 1997; 9.

When the immune response is no longer needed, a control mechanism is activated to check it and return the tissue to a state of homeostasis. If control elements are lacking or insufficient to down-regulate the inflammatory response, a condition of generalized inflammation will exist. Inhaled corticosteroids, the most effective long-term control medications for asthma, suppress generation of cytokines, recruitment of airway eosinophils, and release of inflammatory mediators. Research is currently underway to develop anti-IgE therapy, as well as various interleukin soluble receptor antagonists.

Another important inflammatory pathway that is a target for asthma pharmacotherapy is the arachadonic acid pathway, mediated by 5-lipoxygenase. This pathway is responsible for the formation of leukotrienes, another mediator of inflammation, from arachidonic acid. Stimulated mast cells, eosinophils, and neutrophils can produce leukotrienes. The pathway (Figure 2) begins when a phospholipid, a cell membrane component, is converted to arachidonic acid by a cytosolic enzyme called phospholipase A2. The ultimate product of the arachidonic acid pathway is a leukotriene designated LTD4, which leads to airway narrowing, bronchovascular leakage, and mucus secretion. Montelukast (Singulair) is an LTD4 receptor antagonist, which blocks LTD4 from binding to its receptor on airway tissue cells.

Figure 2. The arachidonic acid pathway of leukotriene production.

New information about inflammatory pathways and the cytokines that regulate them is being elucidated almost daily. While it may not be necessary to impart detailed information about these pathways to our patients during disease management sessions, it is critical that we, as health care providers, understand the role of cytokines in disease so we may impress upon our patients the importance of using their medications appropriately to effectively manage chronic inflammatory diseases such as asthma.

References

* Firestone, GS and McInnes, IB. Role of cytokines in the immune system. Available at www.uptodate.com.
* National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health pub no 98-4051. Bethesda, MD, 1997; 1-146.
* Vedanthan, PK, Mahesh, PA, Holla, AD, Vedanthan, R, and Liu, AH. Lower prevalence of asthma, rhinitis and atopy in rural India is associated with higher house-dust endotoxin levels. J Allergy and Clin Immunol, Online Vol 109, No. 1, Jan 2002.[Top]

Presentation

The magazine, Presentation, published monthly, offers a wide variety of articles on giving an effective speech, talk, or lecture. Monthly updates on education technology and software are also provided. Several feature articles include how to improve PowerPoint slides (before and after illustration), speaker's notes, and articles related to public speaking and teaching. Presentation is a good resource for RC educators. It is free and can be obtained at http://www.presentations.com.

Other professional journals to assist RC educators

The American Physiological Society publishes the quarterly Advances in Physiology Education, which offers a wide variety of resources, including innovations and ideas for new teaching strategies, reports and critical reviews of experimental and observational research on teaching and learning, and real-life situation articles that reorganize the content of physiology and other health sciences topics for problem-centered learning. Yearly subscriptions can be obtained by calling (301) 530-7180 or visiting http://www.the-aps.org.

Academic Medicine is another scholarly journal addressing medical school education. A peer-reviewed monthly journal, it serves as an international forum for the exchange of ideas and information about policy, issues, and research concerning academic medicine, including strengthening the quality of medical education and training, enhancing the search for biomedical knowledge, advancing research in health services, and integrating education and research into the provision of effective health care. Subscription information can be found at http://www.academicmedicine.org/.

Clinical simulation software

The section e-mail list recently featured information regarding the availability of commercially available clinical simulation software. C&S Solutions offers a range of respiratory self-evaluation software and other programs that may be of interest to educators. They can be reached at (812) 735-3505 or on the web at http://www.cssolutions.biz/. Another product in this arena is WinSim, a software program that allows educators to author their own tests, either simple true/false or multiple choice, or more advanced branching-logic clinical simulations. The obvious advantage of the latter is that an instructor can tailor exam questions to a specific course or skill. For information about WinSim contact: sinopoli@instruction.com

What's up at the AARC for RC educators

* A list of AARC educational programs for 2003 can be found at http://www.aarc.org/education/meetings.
* Options for earning continuing education credit include the Professor's Rounds. Check out http://www.aarc.org/education/professors_rounds to learn more about these programs offered via C-Band satellite broadcast.
* AARC members can join the new polysomnography e-mail list by logging on at http://www.aarc.org/community/sleep_mailing_list/.

Student financial aid information

To assist students with financial aid RC educators are encouraged to have them visit the American Respiratory Care Foundation Awards Programs page at http://www.arcfoundation.org. Information on Education Recognition Awards, Research Fellowships, Achievement Awards, and Research Grants is available. Another good site is http://www.ed.gov/offices/OSFAP/Students/, which provides information on federal assistance programs.

Teaching aids for RC educators

Two excellent sites worth visiting are listed below. The first is an excellent resource for new teachers to obtain assistance with developing a course syllabus, evaluations, test construction, classroom management. The second is a great interactive site on anatomy that includes an excellent section on how to teach patient assessment:

*http://www.hcc.hawaii.edu/intranet/committees/FacDevCom/guidebk/teachtip/teachtip.htm
*http://numedsun.ncl.ac.uk/~nds4/tutorials/

Also consider visiting http://www.merlot.org. This site is dedicated to multimedia educational resources for learning online. It is a cooperative effort of individual members and institutions of higher education interested in improving teaching and learning. The site offers a free resource for faculty and students. A free online registration allows the member to browse a large number of related articles and contribute material. Links to online learning materials provide a wealth of information for those involved with online instruction. Another excellent teaching and learning site is The Virtual Medical Center, located at http://www-sci.lib.uci.edu/HSG/Medical.html. Grand rounds, case histories, teaching files, tutorials, journals, and movies can be found at this site.

AMA survey for RC program directors

RC program directors have been asked to complete and submit the 2003 version of the AMA's Annual Survey of Health Professions Education Programs. Access the survey now at http://www.ama-assn.org/go/hpsurvey. Data from this survey is used to update listings for more than 6,000 programs. Deadline for submission is August 31. More information can be obtained by calling Dorothy Grant (312) 464-4936 or e-mail hpsurvey@ama-assn.org.

Keeping up with research across the disciplines

The U.S. Department of Health and Human Services offers a free monthly publication called Research Activities, which is published by the Agency for Healthcare Research and Quality. This journal offers summaries of research articles covering all aspects of health care. It is an excellent means to obtain a brief overview of health care research being published across the country. Subscribe for free by calling AHRQ Clearinghouse 1-800-358-9295 or e-mailing ahrqpubs@ahrq.gov.

AHRQ also offers a supplemental electronic newsletter highlighting research findings, conferences, and more. To join the AHRQ e-mail list send an e-mail message to: listserv@list.ahrq.gov. In the subject line type: Subscribe. In the body of the message type: sub_public_list-L your full name. Additional information can be obtained by e-mailing hholland@ahrq.gov.

A call to the Education Section e-mail list members!

What are you doing to encourage your students to celebrate RC Week, October 19-25? Please consider submitting your responses on the e-mail list so an exchange of ideas can occur!

Allied health information for RC educators

http://www.alliedhealth.org offers a comprehensive source of information related to allied health, including related links, educational material, and ideas for allied health promotion.

Community Campus Partnerships for Health

Community Campus Partnerships for Health (CCPH) is a nonprofit organization that promotes health through partnerships between communities and higher educational institutions. Founded in 1996, CCPH is a growing network of more than 1,000 communities and campuses, with members throughout the United States and the world who are collaborating to promote health through service-learning, community-based research, community service, and other partnership strategies aimed at improving health professional education, civic responsibility, and the overall health of communities. This site can be accessed at http://www.futurehealth.ucsf.edu/ccph.html.[Top]