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Deana Orth, RRT-ACCS, a respiratory therapy lead at Harborview Medical Center and acute critical care and ECMO specialist, has worked at UW Medicine for 15 years. Working at a regional Level I trauma center, she sees all types of respiratory issues, but she hasn’t seen anything like COVID-19.

Comprehensive respiratory care

Respiratory therapists treat and manage airway and breathing problems. Orth sees all types of patients, including pediatric patients, and commonly treats breathing problems related to chronic obstructive pulmonary disease (COPD), spinal cord injuries, pneumonia, trauma and burns.

Orth says respiratory therapists have to look at all these types of patients differently in order to successfully manage the ventilator.

“If a patient is not on a breathing machine but in danger of it, we try and prevent that from happening,” says Orth. “For example, for someone with COPD, we treat them with a nebulizer, or using non-invasive ventilation. If that doesn’t work and they do end up on a ventilator, we manage the ventilator and look at blood oxygen and carbon dioxide numbers and do breathing tests.”

Orth spends a lot of time optimizing settings, doing spontaneous breathing trials and assessing what treatments a patient might need in order to get off of their ventilator. This information is then shared with the medical teams during daily rounds.

Many patients are able to successfully wean off the ventilator, while others, like patients with spinal cord injuries, might be on a ventilator for the rest of their lives and need the assistance of a respiratory therapist to learn how to breathe, speak and eat with their ventilator.

“We also manage tracheostomy tubes,” says Orth. “We work with a team to manage the tracheostomy, get it to a smaller trach tube and eventually get the trach out.”

As an extracorporeal membrane oxygenation (ECMO) specialist, Orth helps put patients who are experiencing severe respiratory failure or acute respiratory distress syndrome (ARDS) on an ECMO machine, which she describes as similar to a lung bypass. The surgeons insert a catheter into the femoral artery or vein to remove blood. Then the blood circulates through the ECMO machine and back to the patient. ECMO can be run by a specialty trained respiratory therapist, nurse or perfusionist.

“It’s a tiny machine with a salad plate sized oxygenator. The oxygenator membrane puts oxygen into the blood and pulls out carbon dioxide,” says Orth. “The blood is circulated back in and you have freshly oxygenated blood with the carbon dioxide removed.”

Orth’s favorite thing about her job is seeing positive results from ECMO treatments and helping patients come off ventilators. But she does have to manage end-of-life care as well.

“Most people think that doctors come in and do end-of-life care, like taking patients off a ventilator,” says Orth. “But oftentimes it’s the respiratory therapists and nurses supporting the patients and their families through that process.”

COVID-19 changed everything

Orth says that since the first case of COVID-19 was discovered in Washington, everything about being a respiratory therapist has changed. And much of this is due to the way COVID-19 spreads — through respiratory droplets — that makes it challenging to safely treat patients with COVID-19 who are also on breathing assistance, which turns respiratory droplets airborne.

As a respiratory therapist during COVID-19, she sees two categories of patients: droplet isolation, patients without a breathing tube; and airborne isolation, patients on a Bilevel Positive Airway Pressure (BiPAP) machine, intubated or on a nebulizer.

These categorizations are important in determining what level of personal protective equipment (PPE) is needed for a care provider to treat their patient.

When working with patients in airborne isolation, care team members need to be in full PPE because the ventilator generates aerosols (tiny particles that can spread the virus).

“We wear a positive air pressure respirator (PAPR) with a hood, hose, belt, gowns and gloves,” says Orth.

This suit keeps providers safe, but it also takes about five minutes to put on and 10 minutes to take off, and requires additional staff members to help with the don and doff process.

“When exiting a patient’s room, you have a trained observer, or ‘dofficer,’ because you can’t safely get the PAPR off by yourself. It has to be wiped down while it is still on you,” says Orth. “But it is so important for you to be safe — you can’t help patients if you get sick.”

Orth says that she didn’t anticipate the high levels of stress that came along with COVID-19.

“You are operating at such a high level for 12 hours and the amount of time it takes you to do things has had a big effect on the ability to staff efficiently,” she says. “You can’t take care of six patients on ventilators if you are donning and doffing. It takes more staff to manage every situation.”

In these stressful times, Orth relies on her team for support.

“Work is the only place I have the support of people who understand what we do, especially with end-of-life care. When we have to assist in letting a patient pass, having co-workers that understand what that’s like and to talk or cry with is so important,” she says.

COVID-19 has reinforced the need for self-care

“You also don’t realize the amount of responsibility you feel for your family and friends,” says Orth. “I live by myself and I don’t feel like I can safely see friends or family because I take care of patients with COVID-19.”

If she hasn’t taken care of a positive COVID-19 patient for a couple weeks, she’ll allow herself to go for a walk or a physically distanced meal outside with friends.

As much as Orth feels a sense of responsibility to be masked and physically distanced to protect others, she also recognizes her own responsibility to take care of herself.

Orth recently took a vacation: a solo camping trip through 10 states. And every day that she is not working, Orth and her dog go for long walks.

“Something I have always said while working at Harborview is that you have to stay in touch with your feelings,” she says. “Reminding yourself of the beauty in the world is helpful when you have a stressful job and when you see a lot of death.”