Advancements in Respiratory Therapy Roles & Training: Expert Interviews
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We have come a long way from how I cared for patients who were critically ill 45 years ago to how we care for them today. Certainly, medical technology, medical techniques, and medicines have changed significantly. It’s much more complicated than it was when I first started and I think it’s changed for the better. We’ve improved outcomes in many areas of critical care.
Stephen G. Smith, Clinical Associate Professor of Respiratory Care at Stony Brook University
During the height of the pandemic in New York, Lisa Shultis was assembling ventilators and equipment as fast as she could to send up to the intensive care unit at Maimonides Hospital in Brooklyn.
“I saw the chaos: the tents outside and the body bags and the trucks. It was mind-disturbing, that’s for sure,” she said. “You saw [respiratory] therapists wearing rubbish bags and surgical masks. There were no safety shields. People were wearing swimming goggles into work.”
The cases in the metropolitan area had skyrocketed over a period of a few days in late March, the number of deaths tripling in the 24 hour period between the 28th and 29th. Hospitals were quickly reaching capacity and medical teams were hooking up patients to ventilators as a last resort to save many fast-deteriorating patients’ lives.
Shultis, who is the director of Long Island University’s (LIU’s) health science and respiratory care program, said that these kinds of critical care scenarios are what respiratory care practitioners (RCPs) are trained for. But no amount of training could have fully prepared them for the situation that they were confronted with.
“There was no breakfast, no lunch, and often people didn’t even go to the toilet because you couldn’t break your bunny suit and your mask,” she said. (A “bunny suit” is a hazmat suit.)
Shultis was one of many healthcare professionals in the medical reserve community that were called to action during the onset of the pandemic in New York. On top of her job as the director of the RT program at LIU, whose students were getting ready to graduate and hit the ground running in the workforce, she began to build equipment at various hospitals that didn’t have enough machines and began working at a drive-through site to administer coronavirus testing.
While she was stationed a few floors down from the heart of the chaos at Maimonides Hospital, she was witness to the challenges that direct care workers were grappling with on the frontlines.
“Imagine a hospital where there are 500 cases and there are four [respiratory] therapists,” Shultis said. “Imagine these are all critical patients, they all need your one-to-one care. Usually we’re dealing with, at most, 20 patients on ventilators per therapist, and that’s even a huge number. It’s usually only around 12. To come into work and have 76 patients per one person? It was overwhelming.”
Putting a patient on a ventilator is an extreme step that is only used when patients with respiratory diseases can’t breathe on their own, as is the case of the particularly ill coronavirus patients.
The treatment is effective with diseases like pneumonia and acute respiratory distress syndrome (ARDS), a type of respiratory failure usually brought on by an injury to the lungs that causes the organs to flood. What medical professionals didn’t realize was that even though some of ARDS’ x-ray images and symptoms showed similarities to the coronavirus, the treatment didn’t work with as much success. In fact, New York City officials said in early April that 80 percent of coronavirus patients who were on ventilators in the city died.
“We had to stop treating it as an alike disorder [to ARDS]. We always try to keep patients off of invasive mechanical ventilators as long as possible. It’s not the first therapy we go to, but sometimes we have no choice,” Shultis said.
With so much ambiguity about the nature of the new virus, trial and error has been a part of the treatment process‚ as it is when any new, life-threatening virus has emerged in the past, such as HIV, SARS, and swine flu.
Now that medical professionals have gained a few months of experience treating coronavirus patients, they’ve discovered other treatment modalities, such as turning ventilated patients onto their stomachs to open their lungs, a technique called proning; giving patients oxygen through nose tubes; and adding nitric oxide to oxygen treatments to increase blood flow, among others. Between April and July, death rates decreased by 75 percent.
What Do Respiratory Care Practitioners Do?
Because of the significant role that RCPs (also known as respiratory therapists, or RTs) have played during the Covid-19 crisis, the significance of their role in critical care has gained more attention. And members of the RT community feel that it’s about time.
These healthcare professionals are generally unknown outside of the medical community; at hospitals, they are often mistaken for doctors or physician assistants by patients, and in the media, they have often referred to as ‘the people who run the ventilators,’ which is just one aspect of their wide scope of practice.
Part of the misconception that RCPs are simply technicians is rooted in the fact that the profession started out “almost as a trade,” Shultis shared, but the role has changed over the last since its inception in the early 1950s.
“It’s been an evolving profession. But remember, we were at the forefront for polio with the iron lung—and it wasn’t nurses who were in the contaminated tents with AIDS patients; it was respiratory. We were there for SARS, for MERS…we’ve been there every time, but I think people just don’t know who we are because nobody’s calling us by our names. We’re just ‘the people that run ventilators.’”
While RCPs do monitor equipment, they are above all patient care advocates. Their duties include performing diagnostic testing, helping physicians make their official diagnoses, and administering and monitoring patient therapy. They listen to breathing sounds and take blood to check PH, oxygen, and carbon dioxide levels. They work with patients of all ages with cardiac and pulmonary diseases, in both acute and critical conditions.
The Demand for Respiratory Therapy Professionals
Similar to other schools, Long Island University’s RT programs instruct students in emergency care and critical care techniques. However, training can only go so far when hospitals don’t have enough healthcare practitioners on staff.
RCPs were already spread thin before the pandemic, with only 150,000 across the U.S., but once the crisis hit, the true value of these healthcare workers came into focus. Hospitals were offering therapists, including Shultis, double the hourly pay of current staffers. “When we were faced with the chaos that this initial phase of the pandemic hit, it was really hard,” she said.
The scientific community is concerned that in our globalized world, Covid-19 may just be the first major episode in a series of others in which new diseases emerge and pose a threat to society. So, while the pandemic will eventually die down, the need for respiratory therapists won’t.
Although we don’t know if the next major health crisis will be respiratory-related, the need for RCPs is already projected to grow by 21 percent between 2018 and 2028 due to our aging population, which is much faster than average, according to the Bureau of Labor Statistics.
“I think our biggest mistake was that we didn’t pay attention to what was coming our way, so when it came, we were just kind of swept off our feet a little bit,” Shultis said.
“We will likely see this again in a different fashion, and hopefully, we will have learned we need to get ready. I’m hoping that we maintain our health professionals—that we don’t lose people from the field and that we keep establishing a pool of young people going forward so that we can keep the momentum and be ready for the next time, the next pandemic or bioterrorism event or whatever it might be.”
Education for Aspiring Respiratory Therapists: Will a Bachelor’s Degree Become the New Standard?
At present, the minimum requirement to become a respiratory therapist in all 50 states is an associate’s degree. This may come as a surprise because most medical professions require four years of school or more.
Bachelor’s degree programs in respiratory therapy (or BSRTs) are offered by many schools across the country because the additional education appeals to employers and expands the possibilities of one’s career, both in hospital settings and in the outpatient arena, as well as increasing graduates’ earning potential.
But in New York, there is a movement to make a four-year degree a requirement to practice within the state. Their stance is that increasing educational requirements is a necessary move for the RT community because of the evolution of the role and its expanding scope of practice.
The effort is being headlined by the New York State Society for Respiratory Care’s ad hoc committee of which Shultis is a part. She’s working alongside co-chair Stephen Smith, who is facilitating a task force that is in the process of writing the legislation, and Lisa Endee, the committee’s secretary. Smith and Endee are clinical associate professors in the respiratory care program at Stony Brook University in Long Island.
The RT community feels that their lack of recognition and relatively low pay are rooted in the associate’s degree requirement to enter the profession.
“Our survey research showed that a large percentage of NY licensed practitioners want more autonomy, an increased scope of practice, a higher salary, and reimbursement for their services,” Endee added. “All of that goes back to the profession’s academic standard. We can’t achieve these benefits without raising it.”
Shultis echoed these sentiments: “I tell my students, we deserve more pay. We don’t get paid as much as nursing or as some of the other professions.”
In the U.S., the median pay of a respiratory therapist is $61,000 per year, while nurses make a median of $73,000 per year. But RCPs take on a significant level of risk in their day-to-day lives working in critical care.
“We’ve earned [higher pay]. We earn it every time we go in and work critical care,” Shultis added. “And that goes back to the legislation. We’re working on that.”
The movement has the support of the New York State Society for Respiratory Care (NYSSRC), as well as the American Association for Respiratory Care (AARC).
In a survey from the latter organization, it found that only 42 percent of associate’s degree programs teach integrated evidence-based medicine (versus 80 percent of bachelor’s degree programs), writing that “strong evidence supports that in 2015 and beyond, respiratory therapists will need to master 67 competencies in eight major areas and understand the scientific evidence because healthcare is increasingly driven by evidence-based medicine.”
How New Educational Standards Can Fortify The U.S. Healthcare System
The move is not just about increasing RCPs’ earning potential and career opportunities. It’s about preparing for the future.
“With Covid-19 and the enormous responsibility placed on RTs during this crisis, I think the greater skills that they develop in [baccalaureate programs] with the autonomy to manage the critically ill patient could have potentially improved outcomes in New York,” Smith added.
“We have come a long way from how I cared for patients who were critically ill 45 years ago to how we care for them today,” he continued. “Certainly, medical technology, medical techniques, and medicines have changed significantly. It’s much more complicated than it was when I first started and I think it’s changed for the better. We’ve improved outcomes in many areas of critical care.”
Endee shared, “The other [allied health] professions have already done this because they realize the importance of greater education and strengthening their knowledge and skills in terms of practice. We have to do the same thing.”
The NYSSRC ad hoc committee is aiming to potentially introduce a bill at the beginning of the legislative session in January of 2021. Although new educational standards would not affect currently credentialed and licensed RTs, this could usher in a new era of bachelor’s prepared—and hopefully better compensated—respiratory care practitioners.