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Monday, May 30, 2016

It's time to stop the war on salt

So, New York City has now received permission to fine chain restaurants for serving up too much salt, or for not using icons to warn customers of salty food. This ruling allows me to segue into a topic I've been meaning to get into for quite some time: What if they are wrong? What if too much salt is not harmful? If salt is proven to be safe, will New York change this ruling?

This subject kind of touches home with me because my mom suffered for many years with hypertension, and still does. She used to have to drink these horrid tasting drinks to keep her blood pressure in check. I think they were potassium drinks, but I'd have to ask her. My mom was also encouraged not to eat foods that contained salt, so she never added salt to anything she cooked. She never ate foods like potato chips, and used a salt substitute.

The science makes sense. The theory has it that eating salt raises the level of sodium chloride in your bloodstream, and this salt is absorbed into cells lining the bloodstream. This, in turn, causes these vessels to constrict, thereby raising blood pressure.

Even before I became a respiratory therapist, which was prior to 1995, I remember reading studies showing that, while this theory seems to make sense, it might not be true. Since then various studies show that cells only take in so much sodium chloride, and what is not used is simply excreted by kidneys. So, the evidence seems to show that too much salt does not cause hypertension.

In fact, even more recent studies show that, to the contrary, too little salt is more likely to cause hypertension than too much salt. Too little salt increases your risk of stroke and heart disease, not too much salt.

So, this brings me back to my original question: will this new evidence cause New York to change this ruling? Will evidence showing that too much salt will not cause high blood pressure, and that too little salt might, cause progressives to stop their push to limit salt intake? Or is there so much at stake here that they will not stop their quest no matter what the evidence shows?

Recently I was diagnosed with hypertension. My doctor prescribed a blood pressure medicine for me, told me to take one pill every day and then he said, "Well, you should probably limit your salt intake. In fact, the evidence seems to show it doesn't matter. So, if you want to continue to add salt to food to make it taste better, and your blood pressure is under control, go for it!"

So, my doctor seems to have caught on to modern wisdom. He understands that while the science shows one thing, analytical data shows another. This is one more old medical myth that appears to be out the window, and yet progressives continue to push for laws to make food taste worse. So, my argument is for progressives to stop the war on salt, and find something else to do with their time.

Friday, May 27, 2016

Why get a Bachelor's Degree in respiratory?

I like the idea of respiratory therapists being better educated. I like the idea of having us obtain a Bachelor's Degree. However, the way it is set up right now, there is not really an incentive to do this. Here, allow me to explain. 

Right now, I'm a respiratory therapist. I have an associates' degree. Every other RT I know has the same qualifications that I do, including a license. Most of us are great at what we do, and further education will not make us better. However, further education "might" garnish more respect for us. 

However, that said, I actually thought about getting a BA. Two colleges near where I live now offer the program. I discussed this with a good friend of mine who said this:
"Why would you get a BA in respiratory therapy when you are not going to get paid more. If you are going to get a BA in something, you might as well choose a program that, when you graduate, you can get a job that pays you $75,000 a year."
That point stuck. I mean, really, there is only one reason to get a bachelor's degree, and that is if you are planning to head your department some day. And that's taking a great risk, considering there are many great therapists to choose from to run any department. And, quite frankly, I'm not sure I'd want that job.

Now, if I decided to get a BA in respiratory the institution I work for would probably pay for it. Still, to participate will involve the sacrifice of a lot of time, and probably some of my own money, as I'm sure there would be many related expenses along the way. Plus there will be a rise in my stress level, and less time with my wife and kids. All this for, what, respect? Pride?

So, that said, what is the current incentive to take the time, and spend the money, to get a BA? I do not see any. It will not make me a better therapist. It will probably give me a better overall understanding of how hospitals work (maybe), but it will not make me better at doing my job, and it will not earn me more money (unless I joint the small number of therapists who move into administration or some other similar job).


Saturday, May 14, 2016

How to know if its science or consensus

I like the idea of best practice medicine. These are the recommendations or guidelines by which we live with when treating patients.  The problem with these is that many of the guidelines are based on consensus and not science.  This results in healthcare providers offering profligate or surreptitious treatment to our patients, and often with the side effect of frustration, burnout, and apathy.

If you know that what you are ordered to do is a complete waste of time and money, and you have no choice but to do as you are told in order to keep your job, chances are that you are well aware that medicine is not based on science but consensus.  As John described a while back, a consensus is not science.  If it comes to a vote, it's not science, it's a consensus. If it's believed because it's popular, it's not science.

Science is infiltrated with consensus.  So how do you know if it's science or consensus?  When you go to school, teachers must teach you the consensus view.  It's then up to you to form an opinion.  So how do you form opinions?  There are basically two ways.  When posed as a question, you can ask one of the following two questions.
  1. Does it feel good?
  2. Does it do any good?
So, let's pose a question.  You have a 72 year old male admitted to the emergency room with pink frothy secretions coming from his nose and mouth.  The doctor orders a bronchodilator.  

  1. Does it feel good?  Yes.  It makes me feel like I'm doing something to help this patient
  2. Does it do any good?  No.  All it does is add more fluid to the airways. 
You see. Now, let's pose question #2: You have a 48 year old man who is not in respiratory failure but is suffering from kidney failure. In order to prevent pulmonary edema from developing, the doctor orders intermittent BiPAP. 
  1. Does it feel good? Yes. I believe the increased intrathoracic pressure will assure that fluid is not forced out of pulmonary vessels. The increased pressure forces fluid that seeps out back into the vessels. Believing that it does this makes me feel good.
  2. Does it do any good? No. There is no science that shows that BiPAP in any way will prevent heart failure and pulmonary edema. 
Example #3:  Okay, so you have a patient with pneumonia. The doctor orders an albuterol breathing treatment. The patient feels no different after the treatment. The patient has crackles in the left base before and after the treatment. But the patient is admitted, and treatments are ordered every four hours. 
  1. Does it feel good? Yes. I believe that the albuterol will somehow cause the patient to cough up that pneumonia. It makes me feel good to know I'm doing something.
  2. Does it do good? No. The treatments do not make the patient feel better, so they are a waste of time. There is no science that shows albuterol goes into alveoli, let alone that it reduced inflammation in alveoli enough to fit in and join to beta adrenergic receptors that do not exist in alveoli. 
See what I mean. Science is not a consensus. If it's up to a vote, it's not science. If 99.9% of doctors believe albuterol cures pneumonia, that does not make it true. Science means that it either is or it is not. It does not matter what doctors think. Either albuterol treats pneumonia or it does not. See. 

Monday, May 9, 2016

Chronic Cough: Causes and Treatment

A giveaway sign of COPD is the development of a chronic (it’s always there) cough. So what makes a cough chronic, and what can be done about it?

First, what is a cough?  It’s a natural, primitive reflex. When foreign irritants and mucus enter the back of your throat it causes a tickle.  The Mayo Clinic says this causes nerves in the area to send an impulse to your brain to cause muscles in your abdomen and chest to contract and push a strong force of air through your airway to expel the unwanted particles or mucus. The force of air in a healthy person can reach up to 500 miles per hour.

A cough is part of a complex immune response that also involves:
  1. Goblet Cells: These are cells that are scattered throughout your airways. When foreign particles get into your airways, your immune system sets off a series of reactions that cause goblet cells to produce sputum. This helps to ball up particles.
  2. Cilia.  These are  fine hair-like structures that wave in rhythmic fashion. They work together and act like an escalator, moving mucus to your upper airway. Once in your upper airway mucus is called sputum.
  3. Expectorate or Swallow.  Sputum tickles your upper airway. This causes you to cough and spit it out. Swallowing is also acceptable, as acids in your stomach will destroy the sputum.
Random Coughing.  It’s good because it helps keep you healthy by keeping your airways open and free from infection. It makes sure your breathing stays easy.

Frequent Coughing.  A frequent cough can become annoying and even burdensome. Colorful sputum (yellow, brown, red, etc.) indicates a lung infection you should see a doctor for.

Chronic Coughing.  It’s defined as a cough and increased sputum production at least three months a year for two straight years. It can be diagnosed as chronic bronchitis, although when it occurs with loss of lung function it’s usually diagnosed as COPD.

What causes a chronic cough? A common cause is chronic exposure to tobacco smoke. Chemicals in the smoke cause airway changes, such as:
  1. Cells lining airways become inflamed This is caused by your immune system attacking harmful chemicals year after year after year.
  2. Chronically inflamed airways become thicker. This is due to scarring. Thicker airways become chronically narrowed, resulting in airflow obstruction. This may make it difficult to generate enough flow to produce an effective cough.
  3. The number of goblet cells increase This increases the amount of mucus produced in response to irritants.  
  4. Cilia are destroyed.  This makes it difficult to bring up sputum. This, along with increased sputum, can cause a constant tickle in the back of your throat triggering the cough response.
  5. Excessive secretionsThese can block already narrowed airways causing increased airflow obstruction and flare-ups. They can also create breeding grounds for bacteria, resulting to pneumonias and flare ups.
  6. Chronic cough.  All of these combined cause constant irritation of airways, resulting in a cough that’s seemingly always present. Some call it a smoker’s cough.
How do you treat a chronic cough  Again, it’s important to understand that a cough keeps airways clear and breathing easy. If sputum is present in your airway, you’ll want to cough it out. That said, there are things your doctor can recommend to help relieve your cough and improve the quality of your life.  These include:
  1. Quitting SmokingWhile this will not undo damage already done, studies suggest it will slow the natural progression of the disease.  We offer tips to quitting smoking in our post, “6 Tips to Quitting Smoking.”
  2. Coughing Techniques. Various techniques are available that can help you produce a more effective cough.  These are discussed in our post “Best Coughing Techniques for COPD.
  3. Medicinal Options.  Various medicines are available to open your airways, release trapped secretions, keep airways open, and reduce the amount of sputum produced. Some of these are discussed in our post, “Top 10 COPD Medicines.”
  4. Staying Hydrated.  Dry mucous membranes are easily irritated resulting in flare ups. This is especially true during winter months when the air is dry. Drinking plenty of water can help keep them moist and less sensitive. Water also helps to thin mucus so it’s easier to cough up. As a general rule, most experts recommend 8-10 cups of water every day.
  5. Humidifier Dry air, or air with a humidity less than 30%, can trigger flare-ups. This is especially true during winter months. For this reason, most experts recommend you keep humidity in your home between 30-50%.
Conclusion.  Knowing that smoking can cause a chronic cough is a good reason to discourage kids from ever lighting up in the first place. For those who already have a chronic cough, the good news is that there are some nice options to help you live better with it.

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Saturday, May 7, 2016

Why regulations increase healthcare costs copy

There have been accusations, including some by our president, that doctors sometimes order procedures just to make a profit.  For instance, that doctors are more likely to cut out tonsils, or cut off legs, or perform c-sections, just because these make more money and are easier than trying to find out why the tonsils are swollen, why a leg is rotting off, or waiting for birth to be natural.

They say the cure for this is supposed to be government run healthcare and not for profit healthcare, as these evils are the result of capitalism.

Yes, if you are a doctor, and you are cutting out tonsils or cutting off legs just to make a profit, than you are a despicable doctor.  Still, government run healthcare will not solve this problem, only make them worse.  I can give you some real life examples to make my point.

According to modern healthcare regulations, if you come to the emergency room with generic dyspnea, and the doctor even thinks you should be admitted, you will receive three breathing treatments.  This is because, if you don't need at least three breathing treatments, then you aren't sick enough to be admitted and therefore do not meet criteria for admission nor for reimbursement.

The same is true once you are admitted.  One of the best ways to assure reimbursement criteria is met is to order breathing treatments on a frequency, such as Q6 or QID.  This way an auditor can looking back on the patient's stay and see that, well, at least the patient was sick enough to need breathing treatments. So, he must have been sick enough to be admitted. So, in that case, we will reimburse the hospital.

Okay, so this is true whether breathing treatments are needed or not.  Breathing treatments cost over $100 each, and therefore rack up quite a hefty charge.  You add into this other procedures that are ordered just so the hospital meets criteria, and this adds up to a lot of money. And you know who eats this charge? Hint, it's not the insurance companies nor the government.  It's the hospital. This is because the hospital is reimbursed per diagnosis and not by procedure.

However, to assure reimbursement criteria is met, these procedures must be ordered. I know this sounds silly, but it's the way it is in our current healthcare system. This might explain why some patients receive breathing treatments even when they admit themselves that they are breathing fine and question the need. But, because the doctor ordered it, they don't refuse. Of course this would be different if they were paying the bill and not a third party.

There's one other not anticipated aspect of Obamacare.  The authors did not expect that hospitals would actually hire people to make sure the above is done.  These people, what I like to call Obamacare workers, go over charts to make sure the correct diagnosis is written, and to make sure enough procedures are ordered (like breathing treatments for pneumonia, even though breathing treatments do nothing for pneumonia, but I won't rock that boat again).

And when they see a diagnosis the doctor did not write, one that would charge better, they (the Obamacare workers) call the doctor and tell them to write it.  When they see breathing treatments aren't ordered, the call to get the order. This is what they do.

This is how hospitals operate today. It's crooked. It's seems like fraud to my friends and me, but it's the way it is. It's even heralded as good. It explains why doctors who have historically fought cookbook medicine (treating all patients the same) now support them. And, to be honest, I don't think most doctors support order sets that order doctors what to order. I think they have just conformed out of need to get paid and keep their jobs. But I digress.

These Obamacare workers make a lot of money.  And when you figure that over 30 of them work at every hospital, this adds to the cost of medicine.  So in order to pay for all these extra workers, hospitals have to make choices.  They have to cut back on the number of nurses they hire, or pay lower wages and salaries, or raise prices. Yes, they have to raise prices. They have to charge higher prices for all those frivolous breathing treatments, or those not needed EKGs or X-Rays to make a profit. I mean, there's more to it that what I describe here, but that's the jist of it.

So, in this way, government healthcare raises healthcare costs, it does not lower them.

They tell me I'm short of breath

You know, among the respiratory therapy community you often hear grumbling about breathing treatments being ordered that aren't needed. Sometimes we're overburdened by them, although, for the most part, we're fine with it because it allows us to keep our jobs.

What becomes a problem is when patient's question the need for treatments. For instance, recently I walked into a patient's room, and I said, "How are you feeling? Are you short of breath?"

The patient said, "They think I am."

I said, "What do you mean?"

She said, "Well, I feel fine. But the doctors keep telling me I'm short of breath."

So I stayed with the patient long after her treatment was done and reviewed her chart with her. The patient truly was no longer short of breath, and various doctors noted this fact. However, one doctor noted that he suspected the patient was in heart failure and was very concerned about it. He offered a variety of treatments, including diuretics and a move to critical care. It all seemed logical to me. I reported my findings to the patient.

"Yeah," she said, "And they are going to move me."

"Why," I said.

"I don't know. The doctor scared the crap out of me. He asked me what I wanted if my heart stops"

I said, "Well, I can't fault him there. That's something they need to talk to you about. That's something you need to think about."

"Yeah, I guess you're right," she said. "But I don't see why I need to move to a different room when I feel fine."

I said, "I don't know the answer there. Do you want me to have the doctor or nurse come in and talk to you?"  I might have had theories, although I certainly didn't want to step on anyone's toes. I certainly didn't want to create a wedge between patient and doctor. I do not do that. Essentially, when I'm in a patient's room, I'm just a mediator.

"Sure," she said. So I did. I talked to the nurse, and she promptly came in to talk to the doctor.

We never did figure out why the doctor convinced her she was short of breath when that same doctor charted that the patient noted to feeling better. Some things in medicine elude even me.

Bottom line here is that the patient questioned the need for treatments, but she did not refuse it when I offered it. She knew she was not short of breath. She knew past treatments had no effect on her. However, she did get to enjoy the presence of her friendly neighborhood respiratory therapist. And, by the way, I gave Palbuterol (see #56)

Monday, May 2, 2016

World Asthma Day

The following was originally published at on May 4, 2015.  While it was published for last years event, it still applies today. 

World Asthma Day is May 5, 2015. This is an annual event sponsored by the Global Initiative for Asthma (GINA) since 1998. This is one day of the year specifically dedicated to improving asthma awareness and care throughout the world. This year’s theme is “You Can Control Your Asthma.”

Asthma, or asthma-like symptoms, were recorded in some of the earliest writings. The disease was relatively ignored by the medical profession, mainly because it was considered more of a nuisance (like a head cold) than a serious disease. So they ignored asthma in favor of diseases like tuberculosis and diptheria.

So now that those diseases are tackled, it’s our turn. Since the 1950s researchers have made great strides in asthma research. In the late 1980s and early 1990s, asthma guidelines were created -- such as GINA’ Guide to Asthma Management and Prevention and National Heart Blood and Lung Institute’s (NHLBI) Asthma Guidelines -- to arm doctors with the knowledge they need to help YOU control your asthma.

In 1998, the first World Asthma Day was sponsored by GINA. In 2003, GINA released the Global Burden of Asthma Report showing “the prevalence and impact of asthma around the world.” The theme for World Asthma Day 2004 was the “Burden of Asthma.” They just wanted to get the word out that, “Hey, our disease is important too. We would like some attention here.”

Yet despite all the progress made since then, all the evidence suggests that too many asthmatics continue to suffer; too many asthmatics continue to be victims of their disease and they don’t have to.

The American Academy of Allergy, Asthma and Immunology (AAAAI) estimates that about 300 million people worldwide have asthma, which is about 10 percent of the world’s population. Of these, about 53 percent have asthma attacks in a given year. So there are still many asthmatics who struggle with their disease.

So, as you can see, it’s a big deal that we get our own day, once a year, on the first Tuesday of May (National Asthma Month) to get the word out about our disease. And considering all those who continue to suffer from the effects of asthma, it’s only fitting that this year’s theme is “You Can Control Your Asthma.”

Most asthma experts now agree that most cases of asthma can be controlled by working with a doctor and creating an asthma action plan. This plan tells you what to do daily to control your asthma, and what action to take when you recognize asthma symptoms.

The goal of asthma control, as noted by GINA, is:
  • No (or minimal) asthma symptoms
  • No waking at night due to asthma
  • Rare use of asthma rescue medicine
  • Ability to do normal physical activity and exercise
  • Normal lung function
  • No (or infrequent) asthma attacks
These goals should be realistic for most asthmatics. For the 10 percent of asthmatics with severe asthma, the goal of asthma control might be satisfaction with your current qualify of life, or being able to do the things you love to do.

These guidelines arm physicians with the knowledge they need to help their asthma patients obtain and maintain good asthma control. No longer do asthmatics need to suffer as victims of their disease. Yet, as the evidence shows, many still do.

So, the goal of this year’s World Asthma Day is to get the word out to every asthmatic: You Can Control Your Asthma. To get started, check out my post “How to Obtain Good Control of Your Asthma.”

Further reading: