The room was full of 8 emergency medicine residents, a respiratory therapist, an EM attending physician, and a critical care fellowship-trained EM attending physician. At the center of the room was the star of the show: the ventilator itself.
We went through the ground rules first. Try to relax. Don't resist the ventilator. And if you feel like your head is going to explode, then remove the mouthpiece.
Next came the obligatory "No one is required…we only want volunteers" speech.
With that, onboarding was complete.
I stepped up to the vent, grabbed the tubing from the respiratory therapist (RT), applied my nasal clamp, and attached my mouthpiece to the biofilter. With my heart beating quickly, I heard the RT ask, "What settings do you want?"
I was momentarily taken aback. While this was not the first time I had heard this question from an RT, it was certainly the first, and hopefully only, time I would be on the receiving end of these settings. I answered with my standard response, "Volume control."
I took a few deep breaths to check my own capacity and felt good, adding, "Tidal volume 6mL/Kg." Then, not wanting to make it too hard on myself, I said, "Peep 8 mmHg and respiratory rate of 12."
The machine was set. Now all I had to do was relax and let a machine do something that I had been doing all by myself for the last 29 years straight.
There was a moment when I looked at the RT, and she looked at me. This was my last chance to back out. No, I told myself, I was ready, and it was go time. My thoughts drifted back to the feeling I had riding a bicycle for the first time without training wheels; at some point I just had to hop on and start pedaling.
At first, I couldn't figure out how to stop breathing for myself. Do I just hold my breath and wait for the machine to take over? Do I try to time my current breathing with the machine? How do I stop myself from breathing? Can I stop myself from breathing?
I decided that starting at the end of my own max tidal volume exhalation would be the best approach. I took 2 deep breaths for luck (and some "breathing room"), exhaled as much air as possible, bit down as hard as I could on the mouthpiece, and waited.
It felt like an eternity.
Possibly secondary to my own residency-related cardiovascular deconditioning, or maybe my tachycardic heart demanding more oxygen, I began to feel that familiar desire to breathe. Suddenly there was a pressure in the tube and my lungs began to expand. The sensation was unique as I felt my lungs being pushed open from the inside. Just when I thought my lungs couldn't expand any farther, the ventilator stopped, and my lungs passively deflated.
To say that the first few breaths were uncomfortable would not be an exaggeration. Luckily, my body adjusted quickly, and then it surprisingly became very easy. I felt almost lazy sitting there without needing to exert effort in breathing for myself. We worked our way through different settings, experimenting with different tidal volumes, respiratory rates, and pressure settings. We even tried more nuanced vent settings, such as airway pressure release ventilation (APRV). Finally, when I had reached the crest of my experience, I removed the mouthpiece and nasal clamp and resumed responsibility for my own ventilation.
The intubation of critically ill patients, and their subsequent placement on mechanical ventilation, is a common scene in the emergency department. In the growing context of hospital overcrowding, the boarding of intensive care unit (ICU) patients in the ED — specifically ventilated patients — is becoming more commonplace. Consequently, emergency physicians are required to manage the vented patient far longer than previously expected.
Having a solid background in ventilator management is becoming something of a necessary skill for the emergency physician. Understanding mechanical ventilation, its different modes and settings, is paramount to providing intubated patients with the proper pulmonary therapy for their individual conditions.
Most ventilator management education for residents occurs during their months spent on ICU rotations; however, familiarity with different vent setting and vent modes is a skill not as easily obtained.
To that end, the actual in vivo exposure of emergency medicine residents to mechanical ventilation allows for a robust kinesthetic learning experience. With a simple mouthpiece and nose clip, residents can experience different ventilator modes through direct connection to an actual functioning ventilator while varying individual tidal volumes, respiratory rates, and pressure settings. This provides a unique understanding of different aspects of mechanical ventilation that are not as well appreciated using other learning methods.
The setup for such an experience is straightforward. All that is absolutely required is a biofilter to keep the circuit sterile for each participating resident, a mouthpiece to attach to the ventilation tubing, and, of course, a ventilator. However, to truly learn from this experience, it is beneficial to have a respiratory therapist present to help with vent settings and adjustments, and an attending physician comfortable with the different vent modes and settings. In our case, this was an EM attending physician with fellowship training in critical care.
During this experience, each resident had a chance to voluntarily “hook themselves up to the vent” via their personal mouthpiece. Starting in volume control/assist control, each resident selected their own personalized tidal volume, respiratory rate, and positive end expiratory pressure, then bit down on the mouthpiece, and tried to relax enough to truly experience mechanical ventilation.
Such experiences certainly cannot replace the more typical didactics-style teaching that provides the required basic understanding of mechanical ventilation common to all EM physicians. These unique experiences, however, can give EM residents a more nuanced understanding of different ventilator modes and build empathy for what our patients actually experience while being treated with mechanical ventilation.