Bad news: Working nights linked with cancer; Good news: research may lead to cure for aging

Now we night shift hospital workers have yet another incentive to get off nights.

According to theAssociated Press, and research that shows an increase in cancer among night shift workers compared to people who work normal shifts, the World Health Organization is now including working night shift among its list of carcinogens. The American Cancer society states it will soon follow.

Some scientists say this is not necessarily true. However, based on my own research regarding melatonin, I'm leaning towards believing it.

Research on this is very new and quite vague, as researchers and scientists don't even know at what point working nights increases the risk of getting diseases, nor whether if one stops working nights his disease risk factors diminish or simply go away, nor if it's even linked to the disease process at all.

I wrote recently that I might try melatonin for my self diagnosed circadium rhythm sleep disorder, but instead of simply listening to my co-workers (and some of you bloggers) who told me it worked well, I decided to research it first. As it turns out, scientists have stated they know so little about melatonin that they really don't recommend that people take it more often than they really need it -- if at all.

The reason is because that while it may help you fall asleep, and while it may help you stay asleep, it's naturally produced by the body, and by you putting artificial melatonin in your body now who knows what effect that might have on your melatonin production in the future.

Not only that, but many studies have shown that people with neuro diseases, cardiac diseases and cancer have proven to have lower levels of melatonin. What they do not know is whether it is the disease process that causes the melatonin to decrease, or if it's low levels of melatonin that causes the disease states.

Older theories believed that melatonin decreased with age, and some scientists theorized that this might be what ultimately causes aging (and diseases). While melatonin is still considered to be linked with aging, it is no longer believed to decrease with age.

Thus, if someone has a low melatonin, something else must be going on other than that someone is just getting older, and lack of sleep might be one such causes of this.

Much research suggests that melatonin might be linked with aging and disease, and as further studies are completed, the study of melatonin might even lead to a cure to aging.

The reason they think this is because melatonin is an antioxident, which prevents the breakdown of cells. And, if we can prevent this from occurring, we can prevent cells from aging and diseases from forming.

If this leads in the direction we hope, this could result in major scientific breakthroughs that will benefit millions of people. Who knows, maybe it will put some of us medical workers out of jobs.

One expert suggested that you get your melatonin tested, because if it's normal you shouldn't take synthetic melatonin pills, because if your body thinks it is making too much melatonin, it will shut down production of natural melatonin. And when you stop taking synthetic melatonin, your body won't know enough to continue making its own.

Another expert wrote that melatonin can't be tested, because levels vary at different times of the day. So, as you can see, the experts vary in opinion regarding how to prescribe melatonin.

My thinking is, if you work a swing shift and are rarely getting enough sleep, you might as well assume your melatonin is low and take a small dose of melatonin to help you sleep. If nothing else, perhaps it will keep your melatonin levels closer to a normal level so you (hopefully) decrease your chances of getting lack of sleep related diseases.

Still, while scientists note that melatonin does not have the side effects of other sleep aids for most people, they still do not know the long term implications of using it.

One site I found had complicated recommendations for using melatonin, and recommend using it every day at different times of day. I'm not a fan of taking it that often.

Another site I found seemed more realistic, and stated that it's best to take melatonin the first day you are trying to adjust to sleeping days. This should allow your body to adjust back to sleeping days, and no further melatonin should be needed to help you sleep.

You should therefore not use it again until you want to adjust back to nights, and then you should (ideally) not need it again until you need to adjust back to a normal schedule.

My thinking is if your miserable due to lack of sleep, you might as well try it. Because having a little synthetic melatonin in your system a few days a week and risking whatever long term implications might result from this is far better than all the negative side effects that come from not sleeping at all.

In a way, it's kind of like giving small doses of steroids to asthma and COPD patients. While the small dose increases the quality of their life, studies have shown that having a small dose of synthetic steroid in your body is relatively safe.

That's my take on it. Let me know if you think otherwise.

Action at Shoreline tonight

We had action tonight at shoreline, but it still wasn't enough to keep me from this blog. And while we may get an occasional gunshot wound, they are usually of the hunting type, and still they are rare. This year seems to be the exception, as we've had more than our fair share.

When I think of gunshot wound, I think of what I might get if I worked at a big city trauma center, not the small town hospital I work for.

"We have a confirmed gunshot wound coming to ER," the ER desk clerk said over the phone. Her voice sounded shaky. "You better get on down here."

I left my paperwork, and found the emergency room was swamped. I looked into our trauma room and saw it had two patients separated by a curtain. It's funny how slow we've been lately and now we have a critical patient coming in and the ER is full.

I could hear the muffled voices over the scanner, but couldn't make out what they were saying over the discordant clamor of voices in the ER. Among those voices was that of the doctor, who was calmly giving orders to discharge some patients in order to make room for the supposed trauma. Even though we don't get this kind of action very often, the crew was mellow as usual.

"So, whatcha guys got going on?" I asked as I leaned up against the counter surrounding the nurses station.

"We're not even sure if we have a patient yet," one of the nurses said nonchalantly. "It actually appears like we have two gunshot wounds."

"Really. Did they shoot each other?"

"No. Actually, they were on separate sides of the county," she said, not acknowledging my feeble attempt at humor.

"You mean we rarely get shootings and now we're gonna get two at the same time." I thought a moment of how I had just sent my co-worker home because it was slow. If we end up working on these patients I might regret that move.

Shortly thereafter the call came in that the rig was only a few minutes away. We quickly geared up with gowns and gloves and made sure our equipment was ready. While we were hoping for the best, we were prepared for the worse.

"We get to wear trauma gowns today, hey," I said, trying to make humor of the situation. In the ten years I had been at Shoreline I think I wore these only one other time, and that was for a chest stabbing years ago. The doctor back then laughed at us because we were all so excited to wear them when we didn't even know what was coming in.

It turned out to be nothing.

"I certainly don't want to risk getting blood all over me," someone said.

A young pale, blue man with his shirt ripped open and blood splattered was wheeled in a short time later, and as soon as I saw that the paramedics were performing CPR I was pretty much certain anything we did was going to be for show.

I grabbed the AMBU-bag and took over that job while the rest of the staff moved the back board with patient to the ER bed. While CPR was ceased during this transfer, I saw the bullet hole on the left side of the stermun. The patient was pronounced dead after a few quick checks for a heartbeat and a flat-line confermation.

"Was it self inflicted?" one of the nurses said.

"That wasn't self inflicted," the doctor said, examining the wound. "He was shot from close range, but it wasn't self inflicted."

"It was murder," another nurse said bluntly. "What we have here is a murder victim."

I said a prayer, and slowly walked from the room. I can't help it but to pray for the people who die in my care. It makes it a lot easier to deal with death when you know the dead are moving on to a better place.

Back at nurses station we discussed the shooting, but nobody had anything further to add. We didn't even have a name. I watched as a lady came in in a rush looking for someone. I could tell right away she knew the victim. The doctor somberly walked up to her. I was glad I didn't have his job. What happened next was not pretty

Once the ER cleared out, and about 20 minutes later, we learned the other shooting was declared as a self-inflicted wound to the head.

"Usually people don't live when they get shot in the head, do they?" a young nurses assistant asked. "You wouldn't think so anyway."

"That's not always true," I said. "I remember a time when we had a patient shoot himself in the head, only he missed and ended up sending the bullet through his mouth." The student grimaced. "As I was bagging I could feel the bullet just under the skin at the back of the jaw just under the left ear."

This man who tried to kill himself tonight didn't fail. He was pronounced dead at the scene.

Well, that was my excitement for the night. I haven't done a whole heck of a lot since then except for a few breathing treatments.

I imagine if I worked for a larger trauma center I wouldn't waste my time making this entry, but since I work in an peaceful shoreline town where most of what you read about in the front page of the newspaper is about how Grandma made a snowman or about the 2nd grade class making a trip to the pumpkin patch.

And while a shooting like this might make page 6 of the Chicago Tribune, it will make page one of the Shoreline Gazette tomorrow I am sure. I'd much rather read about the 2nd grade class.

Rescue bronchodilators: Here are my unfettered answers to all of your questions about them

The following are some questions real patients have asked me recently regarding rescue bronchodilators. The answers here are my humble personal and professional opinions and nothing more.

Keep in mind that your doctor might disagree with me, and that's fine. He can overrule me whenever he wants. But, the answers here are based not just on my 10 years as an RT, but over 30 years as a chronic asthmatic who's abused more than his share of inhalers and lived to tell about it.

Q) What is the recommended dose for albuterol

A) Every 4-6 hours as needed ( no surprise here.)

Q) What if I need it more often than that

A) For most patients, I'd recommend seeing your doctor if you need it more often than every 4-6 hours, because it's a sign that your asthma or COPD is getting worse and needs to be better controlled. However, it's a relatively safe medicine, and some doctors prescribe it to be used as needed for some chronic patients.

Q) What do you think of a doctor ordering Albuterol MDI every four hours?

A) Albuterol is typically a rescue medicine, and should be taken when you are short-of-breath (SOB) due to bronchospasm. It's not going to hurt if you use it more often than when you need it, but I don't see why it would be beneficial.

Q) My doctor says Albuterol will work to prevent an asthma attack, so I should use it every four hours all day. Is this true?

A) I was taught when I was kid to take my Albuterol before I took gym class, and I did. However, it never prevented me from getting SOB. It did, however, make me feel better once I was SOB. So to answer this from my own personal experience, I'd have to say no; Albuterol does not prevent asthma symptoms. However, you can try it to see if it works for you.

There are many doctors who do believe it can be used as a preventative drug. Not only that, it states this on the Albuterol package insert. However, if it is deemed necessary that preventative medicines be taken to prevent an asthma attack, there are far more effective medicines to be using, such as Vanceril, Flovent, Atrovent, Cromolyn, Advair, etc. (this will be discussed in a later post.)

Q. I've had an Albuterol inhaler for the past 3 years. Sometimes I use it more that 10 times in a day, which is more than the prescribed frequency of every 4-6 hours. Can I use Albuterol this much and feel safe?

A. I'm treading on thin water here, but I will say yes. I find from my own personal experience as a former Albuterol abuser, and professional experience giving treatments, that Albuterol is a very safe medicine. The most common side effect is that it might make you jittery, which you probably already know if you've done it before. If you were going to have a negative reaction to the medicine, like an increase in heart rate, it would have happened already.

However, if you have other medical issues besides just COPD or Asthma, then I'd be really cautious of using too much Ventolin. I'd recommend consulting your doctor if you need to do this. Personally, though, I still think Albuterol is safe and effective in most situations where real bronchospasm is the issue.

Q. But my doctor has me on all the right preventative medicines and I'm still finding myself going through an inhaler a week. Will this have long term implicaitons on my life span?

A. I asked my doctor that exact question when I was a kid, and he told me using my inhaler was better than suffering and chancing an anoxic episode. If you absolutely have no choice than to use your inhaler more than every 4-6 hours, make sure your doctor knows about this. Chances are, he will still renew your prescription because he doesn't want you to suffer. However, he may also continue to try to adjust your other medicines to make your life easier. Sometimes, however, as in some cases of COPD or end stage COPD, this is not possible.

Let me answer this question this way. I went through an inhaler a week from the time I was 13 or 14 until about a year ago when I started taking Advair. That was 25 years. I'm getting along just fine now. Will my Albuterol abuse cut some years off the end of my life? Well, nobody really knows. Albuterol has only been around since 1987. Personally, I doubt it will.

Q. My doctor prescribed Atrovent as my rescue inhaler, what do you think of that? Should I be worried if I use it more than four times a day, because I do?

A. Atrovent is not a rescue inhaler. Atrovent takes about 20-30 minutes to work, while Albuterol, idealy, should work almost instantaneously for bronchospasm. Then again, if Atrovent works for you, then that's great. If it isn't, then I'd talk to your doctor about getting an Albuterol inhaler.

Q. Am I safe using Atrovent more often than every four hours, because I do?

A. I don't see what it would hurt. When I was in school ten years ago we were taught never to use Atrovent more often than Q4. However, some new research shows that addtitional Atrovent during an exacerbation does benefit patients. If Atrovent is working for you as a rescue drug, all the power to you. However, if you continue to be short-of-breath, you should talk to your doctor about getting an Albuterol inhaler or (ideally) adjusting your preventative medications.

Q. Can I use my Combivent more than every 4 hours?

A. Again, I don't think it would hurt you, but it's not necessary. Technically speaking, the Atrovent in this medicine shouldn't need to be taken more than every four hours. If you need to use Combivent more than every four hours, then you should talk to your doctor and get an Albuterol inhaler. You can then use your Combivent four times a day, and Albuterol in between if you get short-of-breath. (and still I'd only recommend this only if other preventative medicines weren't working.)

Q. Do you think Xoponex is better than Albuterol?

A. No. I have never noticed a difference. Original studies claimed that Xoponex was stronger than Albuterol, but I've never noticed that to be true in my real life experiences with the two drugs. Not only that, I don't think the claim that Xoponex has fewer side effects than Albuterol is true either. Recent studies have confirmed this.

However, if you have experienced cardiac side effects, or excess jitteriness or nervousness, then you might be a candidate for a trial of Xoponex, if you want to flip the bill: Xoponex costs 5-10 times more than Albuterol.

Q. What if I go through an inhaler a week?

A. Every patient is different. Do you have end stage COPD? If so, you have to do what you need to do. Do you have asthma? Then perhaps you could trial Advair. Advair worked like a miracle drug for me. I went from one inhaler a week and 600mg of theophylin twice a day down to two 300mg pills a week and 4 puffs of Albuterol a day after being on Advair 9 months.

You and your doctor have to find what works best for you. If there is no other alternative, then an inhaler a week might be the best solution.

I meet albuterol abusers at work all the time, and the majority of them are end-stage COPD patients. However, on occasion, I have met a fellow asthmatic who abuses too. Most of them think they are the only one. And, most of them think they are doing this furtively without their doctor's knowing.

Many times I walk into a patients room to give a breathing treatment and find that MDI hidden under the pillow, a sign of a true rescue inhaler abuser.

The admins tried to make us RTs automatons

"The first topic of discussion," Gary, our department head, said to start the meeting, "is what you are going to have to say for now on when you go to do a breathing treatment."

I rolled my eyes. Looking around the room, I observed many eyes rolling.

"Now who's going to volunteer to work on this?"

"I will," Dale, one of my co-workers said, raising his hand.

Well, this ought to be interesting, I thought. Dale wasn't just the biggest complainer about useless breathing treatments, but the biggest joker about it.

At the next meeting, Gary asked Dale if he had a program prepared.

"I sure do," Dale said.

"Go ahead."

"You walk into a room," Dale said, "and you say, 'Hi, my name is Dale, I have your before breakfast peace pipe here. Are you short-of-breath?"

Everybody, including Gary laughed.

"What do we say after the treatment?" Gary asked.

Dale said, "Well, after the treatment you ask them if the treatment improved their work-of-breathing."

"Simple enough." Gary glanced at his clipboard. "But what should we say seriously

Without hesitation, Dale shot back, "I am being serious."

Needless to day, Dales presentation was changed by the next meeting. This is what Gary came up with after verifying the patient:

"Hi, my name is ________. What I am going to do is give you a breathing treatment (explain procedure). Do you have any questions? (answer questions and perform procedure) Thank you for letting me give you a breathing treatment. Is there anything I can get for you? I will see you again at approximately ________ for your next treatment. Thank you."

I watched as Dale's jaw dropped. "You want us to say that?"

"Yes," Gary said.

"What about asking the patient if he is short-of-breath?"

"You can ask that if you want, but you don't have to. Breathing treatments are given for more reasons than just for shortness-of-breath."

There was some grumbling in the room. I looked at Dale and he looked at me: we were both thinking the same thing, "How idiotic." Neither one of us said any more. We just wanted the meeting to be over.
----------------
This happened about eight years ago, when I was still new at this game and still working mostly days in the pool.

Likewise, we were told we had to stick to this, and that the admins would be hiding behind curtains listening to make sure RTs and RN were sticking to their respective programs.

And, needless to say, I followed this line for a few weeks, only because I feared someone might be listening to me. Finally I decided the spiel wasn't working for me, and I went back to my old routine. I was a bit nervous about this, however.

"I feel like an automaton giving that speech," I told Dale one day, "The patients probably think we are a bunch of robots."

"I never do it."

"You don't."

"Hell no. It's not personalized."

"So, what do you say then," I asked.

"Hey, I have your before breakfast peacepipe here?"

I laughed.

They may have had good intentions with the automaton speech as parts of it are well intended, and it's probably still on the records, but it was dumb.

The admins must have realized their folly, for they have never brought it up again.

The six different types of respiratory therapists

There is much resistance to change inside the RT Cave. After much thought on the matter, I have figured out why. It has everything to do with the six different types of Respiratory Therapists (RTs).

Many RT Caves do not have protocols. I've heard every complaint

Very, very slowly I think doctors are becoming more and more receptive to the benefits of adding respiratory therapy patient driven protocols. In real time seems tortuously slow, but I think in ten or twenty years we might be talking about some major changes in the rolls of RTs.

While this is true, there are still many RTs themselves who don't seem to be receptive to change. This became ever more so apparent to me after reading an excellent column over at Snotjockeys Revisited, "Clinician Resistance to Adopting New Practices".

I agree with her, and have my own experience to add to the mix.

A fellow RT, Dale, is very fun to work with. He's intelligent, a great RT; but he is a constant complainer. He complains in a fun way, but nevertheless he is still a complainer.

"I circled all the indicated treatments on the board," he said the other day in report.

"Um," I said, looking over the list of patients, "there are none circled."

"That's my point," he said, and chuckled.

One day he handed me a list. I looked at it thinking it was serious at first, then I started to laugh. On it was a list of 'olins that he made up. (You can view parts that list at the bottom of this blog)

He said, "I bet that 60% of what we do here is absolutely not indicated."

I'm a firm believer that if you're not having fun with your job what's the point. So we make fun of our job. We make fun of doctors, we make fun of nurses, we joke around during a code. I think that's medical humor, and we do it to maintain our sanity.

I check doctor blogs and nurses blogs, and I see their humor all the time.

But humor is one thing, complaining is another. And complaining with Dale is fun, but most complaining in the RT Cave is simply annoying. I avoid it every chance I get. If I have no choice but to give report to a complainer, I give a quick report and scram.

I used to work with Dale a lot. In fact, I'm glad I had that opportunity to work with him because I learned much and he helped me develop my RT humor. However, I was never going to get anywhere via complaining. Complainers rarely get anything accomplished. But they are abounding in the department.

What's that old saying? "Complainers say more about themselves than the person they're complaining about."

I realized this, and I switched weekends. Now all the complainers work with Dale on the other weekend. The RTs who work on my shift are Jane Sage, a very optimistic, intelligent and fun to work with person. And we have Dee, who happens to be a complacent RT (see list below).

Jane had an epiphany one day, and decided the laid back RTs on our weekend are awesome, and she started referring to us at the "A" team. We called the RTs on the other weekend the "B" team. Once the "B" team got wind of this they decided that they were the New "A" team.

"That's fine," Jane said, "We won't tell them that "A" now stands for Anal and "B" now stands for Better than Anal."

Despite the complainers, we have enough "balance" of different personalities to make things work in our department. You need the complainers so we know of our faults, we need the anal people to make sure we get all our work done, we need the content people to boss around, the laid-back people to ease tensions, and the clowns to make us laugh.

I'd even go as far to say we have a great department. I suppose that means we have good balance. I'm sure the members of this RT Cave are no different than any other.

With this in mind, I created the following list. Based on my experience working with many RTs in the past 10 years, these are the six different types of RTs:

1. The stepping stones: These are the RTs who use the career of RT as a stepping stone to a more illustrious medical profession. In my humble opinion, this is the way to go. What better way to learn about medicine than through the eyes of an RT. I'm serious here.


2. The quitters: These are the RTs who don't like to work. Some "Quitters" take a job of RT because they think it will be an easy job and they won't have to do anything. As soon as they learn what RTs really do, they either quit or are forced out the door.


3. The contents: They are the happy-go-lucky RTs who never complain. They are the RTs you love to give report to because they are always happy. They rarely make any effort at learning new information other than what is required. They usually prefer not to work with critical patients, and when they do they never question doctors and they prefer to be button pushers. Usually, you will see these RTs happily knocking off treatments on the floors.


4. The complainers: This composes probably about 60% of all RTs. These are usually very intelligent people who love the career of respiratory therapy in theory, but hate the reality of it. They are usually well up on all the new technologies, and are very quick to question doctors or offer suggestions. However, while they are not happy, they do nothing to better their career field. After working for a while, they become frustrated and content and they give up. One of the reasons they are so frustrated is that they have decided that they are too old to get another job, or have families which makes changing jobs difficult. Yet, while they complain, they do not support change.


5. The optimists (or learners): These are the RTs who write blogs. They may or may not be more intelligent than complainers, but they love to learn. These are the RTs that consistently do research on the Internet and read magazines. These are the RTs that attend every seminar possible. These are the RTs who write the protocols and make recommendations for new equipment, and then write the policy and procedures for this new equipment. These are the RTs who learn about things like Graphics and educate the rest on how to use them. These are the RTs who make the best of their career even though they know there are a lot of forces working against them. Most important, these are the RTs every one in the department loves to talk to because they are good listeners (they listen because they love to learn). More often than not, they work with the leaders to solve these problems as they occur. They often let other RTs take credit for the work they do. They do this to keep morale in the department high. In essence, the optimists are the strings that keep the department together. A department without optimists does not run very well.


6. The leaders: These RTs, while far and few, take charge and lead. They make changes to the RT Cave and they are resented for it. They make sure everything is stocked. They make sure all the i's are dotted and the t's crossed. They are usually opposed to protocols because they don't want to "rock the boat", but they won't say so openly. They listen to the rants of other RTs, but they usually side with the administration on issues. They question RTs who question the status quo. You might hear them at an RT meeting saying something like, "Don't you think protocols might actually create more work for you guys." When they say things like this, they are catering to the complainers, who will work with them to stymie any change. The leaders do no like change because it goes against their philosophy of "do not rock the boat." It is also important to note that while most leaders are good people with normal home lives, they are often hated and revered at work. Complainers often do not get along with them, and optimists are often seen working with them "for the better of the department."

I can give examples galore, but I'll give just one more.

Even though she had several protocols shot down years earlier, Jane wrote a new and updated ventilator set-up and weaning protocol. The complainers in our department all said it would never be approved by the doctors.

Jane trudged on nonetheless. She had the support of me, another optimist, and Dee, the easy going content on our weekend. Finally, with a bit of luck, the protocol was approved.

With our confidence on high after, Jane and I wrote a breathing treatment protocol we thought might work. We were very proud of our efforts. We thought we'd show it to our co-workers and get their support.

I showed it to Dale first. Surely he'd approve of it since he was the most outspoken RT about useless and not-indicated breathing treatments.

I couldn't have been more wrong.

"So what do you think?" I said after he stared at it for several long minutes, grunting and sighing often.

"Well," he paused while staring off, then spoke slowly, "The biggest offenders will still abuse the system. If it does anything it will just create more work."

"Okay," I said. I made no effort to change his mind. I walked away. No point in beating a dead horse.

Jane brought up the protocol at a department meeting. Gary, the department head and quintessential RT leader, said: "It is possible you might just be creating more work for yourselves by doing this."

He may be right; he may be wrong. Either way, Jane and I keep moving forward. And that's easier to do now that we know about the six different types of RTs.

The conundrum of busy emergency rooms

"God, how long are we gonna have to wait. We should have just stayed home."

I hear that often as I walk by the crowded waiting room on busy nights at shoreline, and I think, "If you're even thinking of leaving, maybe you shouldn't be here in the first place.

Trust me on this: RT Cave Rule #7: if you are having a true emergency, you will not have to wait to be seen by the ER physician. If you are suffering from anything critical, you will find yourself in an ER bed faster than you can say ER.

"It's ridiculous I have to wait this long," I hear.

And I think to tell them, "So, do you want us to treat you before the man in room F who's having a heart attack, or should we treat you right away so you can get back to your beer and cigarette."

Being the good boy I am I usually keep on walking.

I had a discussion with an elder doctor who told me that 20 years ago he didn't even stay in the ER at night, he simply went home. If he was needed he was paged. And, he said, that when he came in he knew it was for an emergency, which is what the EMERGENCY room used to be for.

Not anymore.

So why are todays ERs so busy?

Anonymous over at Respiratory Therapy 101 wrote an excellent post on this today. I encourage you to read it, because he is right on. I can honestly say I agree with him 100%.

He writes that ERs are busy because the government does not reimburse independent doctors enough money, so these doctors have no incentive to accept Medicaid patients. This leaves Medicaid patients with no option but to flock to the ER for their non-emergent medical problems.

That, coupled with the threat of a lawsuit, has resulted in doctors ordering a bunch of tests that aren't' even indicated just to "cover my ass." This makes for a long ER visit.

There's another factor involved here, and that's the idea of FREE. It is a natural human tendency that when people hear that something is free, they flock to it.

And, since it's illegal for ERs to turn people down, they have no choice to accept Medicaid patients, and even uninsured patients they know will never pay up.

Like Anonymous RT, I'm not proposing that we throw these patients out of the ER. I do, however, believe we have a serious conundrum here that needs to be addressed.

Here is my 2 cents worth of ideas that should get the ball rolling:

1. Do not go to a Federalized Health Care system. Giving away more free stuff will only make the matter worse.


2. Force doctors to do the procedures they order. Frivolous orders would soon be a thing of the past. The ER will clear out faster.


3. End frivolous lawsuits by forcing people who file them to pay all court fees if they lose. Doctors will no longer have to order procedures, "just to protect myself."


4. Encourage RNs and RTs to chart when they think a therapy is not indicated and hope that insurance and government agents read that charting. When agencies stop paying for these not indicated therapies, hospital administrators will be forced to crack down.


5. Encourage politicians to spend a day shadowing in the ER. I bet it wouldn't take long for them to catch on.


6. Have mandatory health education classes for anyone using government health care programs. Here they will learn what constitutes an emergency.

Good night at Shoreline

I have to admit that despite getting called STAT to ER a few hours ago to do a sputum induction, I'm having a pretty decent night tonight.

The patient load yesterday morning was down to only five patients, so Dee worked solo days. And, which usually happens when one of the day shifters is called off, all hell broke lose.

"Why didn't you call Tom in?" I asked her in report.

"I wish I would have," she said, and sighed.

"Other than this one, none of these patients need these treatments," I said, "And besides, you knew I was coming in, so you could have just left stuff for me to do, no point in being overwhelmed."

"I know, I should have, but you know how it is."

When you have a shitty day like I know Dee had, it pays to know you have a good RT relieving you. We good RTs aren't nit-picky when the day shift leaves us things to do, especially if there is a good reason.

I grabbed the stack of 20 EKGs Dee did during the day and filed them despite her objections that I was doing her job, and told her to go home.

I had a little rush in ER right off the bat, and (get this) I was called STAT to ER to do a sputum induction. Not only that, but the doctor wanted me to NT suction the patient to get it.

"You really want me to traumatically suction this patient," I asked the doctor. How about if we do this to you to see how you like it, I wanted to tell him, but held my thought to myself.

The doctor looked at me like I was an idiot, and said, "Yes I do. We need to bla bla bla bla."

Okay, so I did it.

Afterwords, the RN, who happened to be a rental RN, cornered me and explained why he ordered the STAT sputum induction: "We have a pneumonia protocol and we have to have the antibiotic given within four hours or I get written up."

"Okay," I said. "That's fine." Well, I wasn't really fine by it, but I wasn't going to debate with a rental nurse who's done working here in a few weeks.

However, after asking many questions, I leanred the pneumonia protocol does require a sputum induction prior to antibiotic, but it says nothing about having to be done in a certain amount of time. He must have been thinking of someother hospital protocol.

This RN, I am certain, pressured the doctor into getting this induction. What a moron. I'd like to suction him.

Despite that episode, I'm having a decent night tonight. While not all my treatments are indicated, I have no gomers, and no sundowners and no outrageously crazy patients. They are all nice individuals who appreciate my time.

I have two real COPD patients who really need the treatments, and both want to be awakened, so I don't have to worry about being snapped at (one of the things us night shifters worry about).

I have one patient who has septic shock secondary to pneumonia secondary to COPD who is probably on the verge of STD (Swirling the drain). But her Q4 breathing treatments are supposed to cure all these ailments (see Holy Water or Scrubbin-bubbles on right side of blog.)

I believe she is a full code, as there is no "plunger" at the bedside (a little inside humor there).

The best part is that I've been called on three occasions tonight by nurses for me to assess their patients and give my opinion. One patient appeared to be fine, but the RN wanted me to listen and give my opinion "just to be on the safe side."

Cool.

I love it when I work with nurses who respect my opinion this way. I love it, and I make sure they know I appreciate it.

Good patients + great nurses + a decent doctor in ER + an ideal equilibrium of the planet = good night for the night shift RT.

The saddest part of the job

There are a lot of tough parts about working in the medical field, but by far the worst is when you have to face the death of a boy or girl.

So the story goes, his mom thought he was watching TV with his brother. But, what he was really up to was riding his quad. It was snowing out, so he probably thought it would be fun to ride in the snow. But the fun turned on him, as the quad landed over his little 9-year-old body.

He was rushed to the hospital by ambulance, but he was probably already gone. Nonetheless, our staff worked on him for over 45 minutes hoping to defy the odds. Our general surgeon rushed in to help at the code, and we are thankful for his efforts, but in the end there was really nothing any of us could do.

I was told he didn't have any cuts or scrapes on his body, so whatever got to him must have been internal. Perhaps the pressure of the quad on his chest didn't allow him to breath and he suffocated. Perhaps he broke his neck. We're praying he broke his neck, because that would be the quick way to go.

While most of us are bagging, or inserting IV lines, or deciding what recommendations we could give to the doctor, the Doctor has the job of telling the child's mom that her son is not going to make it, and the rest have the job of consoling her. That, I think, would be the saddest job in the world. I'm glad I don't have to do it.

I've been in too many situations like this, and I can tell you the worst part is when you are still bagging and the family comes in to say their final good-byes. A rare person will walk from that room without a tear in his eye as the doctor says, "Okay, time of death 12:05."

The silence as everyone slowly sets down what they were doing and stares at the lifeless child, all saying their silent prayers. They stare at the child, sweet and innocent up to the end, even in his last daredevel act.

He was in the prime of his childhood. He will never to go on a date. He will never explore the world on his own. He will never again sit on his mom's back porch and feel the cool, fresh breeze upon his face. He will never hug his mom again. He will never play with his brother again. He will never play catch with his dad again.

But that's not the worse of it. The worst part is thinking how his mom is going to cope. Because I can't imagine anything that would be more difficult in this life than losing a child.

In an older person's death we find some solace in knowing they had a full life. In a middle-aged person we have solace knowing they died in their prime. There is no solace when a boy dies, only anger and regret.

Knowing the child is now with Jesus does little to make a mom feel solace, I'd imagine. Yet, that's where solace will come from in time.

I can't imagine anything worse than losing a child.

RT to RN, BA in RRT: is it worth it?

I had a discussion with my coworker, Tom, who is working here while still attending school. Tom said he wanted to go on to get an RN and then proceed to getting a BA in nursing and perhaps move up even higher.

You have to realize that Tom is my age, and he has a wife and kids and bills and debt just like all of us hard working RTs.

"I told my teacher that I thought this would make me more marketable," Tom said.

Tom said his RT teacher tried to explain to him his options from a different angle.

He said, "He told me that an RN is basically on the same level, or same playing field, as an RT. And going on to get a BA in nursing isn't any different from going on to get a BA in respiratory. "

His teacher told him he'd be better off getting his RRT and moving on to getting his bachelors, rather than spending the extra time getting an RN. He'd save two years of his life and lots of extra money.

And from there he'd still have the benefits of increased pay, and an increased opportunity of moving up the ladder.

I agreed with Tom's teacher on everything here except the idea of an RT going on to getting a BA. There is no increased pay for BA's in this part of the state. It might work to help him move up the ladder, but there are a very limited number of RT department head jobs available. Would it be worth the investment?

"Besides," I added, "our boss doesn't have a bachelors degree."

"Good point."

"And do you think that piece of paper is going to make our boss a better leader? Do you think it would make him smarter?"

"No," Tom said.

"Well, it would make him smarter, but it wouldn't make him necessarily a better boss. Yeah it might help him get hired, but if he doesn't have what it takes to head this department, he certainly isn't going to be hired, regardless of what papers he has."

"True."

"So, technically speaking, is it worth sacrificing the two years to get a RT bachelors? I'm not convinced. I'm not trying to talk you out of doing this either. I'm just saying: is it worth it? "

"They do pay extra for BA's at some hospitals," he said.

"You'd have to move. Is that what you want to do?"

"I'm thinking about it."

We spent some time on Google trying to find advantages to an RT BA, but failed to find anything before we gave up.

Now, for an RN to get a BA is another story. There are a ton more opportunities on that side of the isle.

Another reason Tom said he wanted to go on to be an RN from RT is he could use his RT skills and he could be hired as a nurse and could fill in as an RT on occasion.

His teacher told him there really is no added benefit to having both an RT and an RN degree because you can only concentrate on one or the other, and whichever one you are doing you will forget what you know about the other.

That sounds veritable to me.

I can think of some really good reasons for someone going from an RT to an RN, and I think the experiences gained while being an RT will very much so make that person a much better nurse, especially when it comes to respiratory patients. For one thing, they certainly won't be calling for treatments on people who don't need them, unless their mindset changes that much.

Not only that, but there would be a pay raise, considering RNs make better money; and there are more jobs available.

However, I can think of no reason why someone who is an RN would want to become an RT, unless they work at a small hospital and they want to watch more TV. But trust me, while you may see me watching TV from time to time, I do my fair share of running. In fact, I think most RNs will agree that when I'm busy, I may be busier than a busy nurse.

Why would an RN want to take a pay cut? Why would an RN want to go from a job with many opportunities even within the hospital, to one where there are only a few RTs in the entire county?

That is, unless you are miserable as an RN and you think you'd enjoy sucking snot far better than wiping butts.

He also talked about being a physician's assistant. His teacher told him he'd be far better off taking the RN route if he were going to do that. But that's a lot of schooling, especially considering he still has to go through the RN program to do that.

Whew, he's gonna be real tired of school if he gets through all that, and very much in debt. But considering he has a wife and kids to support, he's probably better off just working as an RT.

That's my opinion. I think he should stick with what he has already committed himself to. Then, later on, if he's financially stable and still wants to be an RN, he can study instead of watching TV at night while getting paid as an RT.

But that's just my opinion, and I've been prone to be wrong from time to time.

Happy Thanksgiving

Part of being a productive respiratory therapist one must maintain a happy home life. Me, I have a good home life and I'm thankful for it.

I'm thankful for my kids: Here's a couple entertaining kid stories. Some of these happened a few years ago, but regardless I'm thankful for the memories.

1. My son was probably 2 or 2.5, and I cleaned out the fridge and placed a small bottle of stale 7-up on the kitchen table. I went to work and my wife took a nap (with one eye open) on the couch.

My son woke her up. "Mommy, mommy, I was thirsty, but don't worry because I got myself something to drink. I didn't want you to know about it, so I put the cap back on."

My wife looked up and the 7-up bottle was emptly.

2. I let my daughter run around naked to air out herbutt, and while she was doing this I went to the computer to play a little game.

"Yook Daddy, yook, yook," my daughter said just moments after I got involved in the game. At first I tried ignoring her, but she’s too darn cute to ignore. Then she stuck this gift that she had for me right up to my face and said, "Yook, daddy. Yook, yook."

I looked down at her little palm, and thought, "What the heck is this?" Before I realized what it was, I went to grab it:

"Woah!!" I said to myself, "It’s a big poop."

I thought, "What the heck do I do with it?" So I decided, having no other choice, to pick it out of her hand.

"Baby," I said, "Where are these supposed to go?"

"Daddy dot it, Daddy dot it."

Fortunately for daddy, it was a big, solid poop.

3. One of us left the back door open, and we had a little visitor. A few days after placing poison behind the fridge a little mouse was sitting, squeeking, on the rug by the padio door in the dining room.

"Look, daddy, a little mousy. I'm going to pet it."

"No, that's okay," I said, stopping her.

I donked the mouse on the head, because I didn't want to chance it getting away. My daughter was all excited and laughing at this.

I took her into the back yard, and together we dug a hole and burried the little mousy. Moments later I noticed she was digging with her little toy shovel where the mouse was burried.

"What are you doing?"

"I have some peanuts for it," she showed me the acorns in her hand. "I want to get it back up so I can feed it."

Perhaps it's time to try melatonin again

See that picture to the right? That's me. It's 4 a.m. in the morning and I'm awake. I assured myself by going to bed early last night that I'd be able to get that one nights worth of great sleep, but that's not going to happen tonight.

My wife and kids assured me yesterday that I was a grump. I am aware that kids normally have a tendency to side with their mother against their dad, but I can assure you that this wasn't one of those times: I confess I truly was grumpy to them too.

If you knew me you'd know I'm usually a very laid back person, and even the most critical things don't phase me. So when I start getting grumpy you know there's something wrong. Of course I refused to admit it at the time, but I was grumpy because I haven't been sleeping.

"What's that number?" my high school buddy would say, "It's 1-800-Waahwah."

He was also famous for, "Cry me a river."

I told my brother about my new self-diagnosed disorder, and he said, "It's probably just another one of those fake diseases people make up so they can use it as an excuse, like in court."

He's probably right. Kind of like how people started accepting Post Election Stress Disorder (POSD) as a real illness after the National election.

"Yep, your honor, we can justify that bad behavior because he had POSD."

In my case, it would be, "Yep, your honor, we can justify Rick's forgetting to turn the oxygen on because he has Day/Night disorder. It's a societal problem so he shouldn't have been fired for killing that patient."

Okay, so I didn't screw anything up yet. But I suppose I could if I don't watch myself. And I certainly don't want to be grumpy again today -- no way. Today I'm going to be sweet as pie to my kids and wife. I don't care how tired I am. No excuses.

For once my brother was wrong. While people do have a tendency to make up some diseases, mine is real. I didn't say anything to him though, because I'm just that way. And also because he works nights too and he doesn't have a problem.

But he is also ignorant of the medical field, which is why it's difficult to discuss anything regarding work with him. That's one of the reasons it's nice having a nurse as a wife, and you guys to blog to (if you're still there).

I still think this is a legitimate disorder. The circadian receptors in your brain are for real, not fake. When a normal person's brain senses light it stops releasing melatonin so you can wake up. When a normal person's brain senses dark it starts releasing melatonin so you can sleep.

Since I stay up 3 nights a week when my circadian receptors are supposed to be releasing melatonin, my brain is out of whack. So tonight, when I got up to go to the bathroom and my brain saw that bright light, it instantly stopped producing melatonin, and I was awake for good, while most people's brains would have allowed them to fall right back to sleep.

One of my sources recommended I place a night light in the bathroom. That's as good as done today.

One of you guys recommended I try melatonin. I tried it once before, but I quit because my wife told me she heard that if you take it to sleep in the day, your body won't release it in at night when you really want to sleep. So I quit taking it.

However, I have found no research to support or deny that claim. All I've found is 80% of the articles claim it's save, and 20% claim it's not safe. Until I hear otherwise, I think it's about time to support the use of melatonin.

I'm going to keep researching it though. If anybody reading this knows of any further research on the stuff let me know. If you think this is all in my head, let me know that too.

Need STAT reform STAT

Aside from the need for bronchodilator reform, I've been thinking lately that we also need some major STAT reform. It's getting the the point that the word STAT has lost all credibility.

"RT STAT to ER," wailed overhead. I had a SOB patient in need of a treatment, but what was I to do? I rushed down to ER to find a kid in no respiratory distress. He didn't even need a treatment. I rushed back up to care for my SOB patient.

When I hear that word "STAT" that's what I think: drop what I'm doing and go (with a few exceptions.)

RT Rule #6: STAT means that you need to get to the patient's side right now. We are talking about a life and death situation.

I've been called to a room stat to do an EKG, only to find out the doctor wanted it done so he could go home. I consider that abuse of the STAT system.

I've been called to pre-op STAT to do an EKG prior to surgery on a scheduled surgery. Those EKGs should be completed way before the surgery so they can be inerpreted.

I've been called STAT to induce a sputum. Once I was called to STAT NT suction patient for this.

After I very reluctantly performed this not indicated and traumatic procedure, the nurse cornered me. He said, "I called that STAT because of the pneumonia protocol, and we had to give the antibiotic within four hours."

"That's a silly reason to call me STAT," I said. And you're lucky I didn't have anything else to do, or I wouldn't have come down right away either. I'm not letting my SOB patients suffer for this.

I was even called to do a STAT Halter Monitor once, but that ended up being the ER staff fooling around with me because they knew I hated doing Halters in ER. I suppose I deserved that one.

The first thing you learn as an RT is that a page to ER is considered a STAT page. I was told that I should be down in ER in about 5 minutes.

When I first started working here I was told by the ER staff how impressed they were at how quickly I got down there to do EKGs and treatments. "You get down here almost twice as fast as any other RT."

I was perplexed. I thought we were supposed to be in ER within 5 minutes. I thought we were supposed to drop whatever we were doing and get down there.

Then I caught on. I realized that I was quitting in the middle of a breathing treatment, rushing down to ER, and doing an EKG on a patient who had leg pain, or abdominal pain, or bad fingernails or something stupid like that. Or I'd get called down there to do a treatment on a kid with a cold.

Either that or I'd get down there and the nurses were putting in a catheter and tell me I had to wait. After a few months of waiting 10-15 minutes each time this happened, I decided I could better utilize my time.

I tried to go to my boss, but they had more pressing issues to deal with. That was a dead end. I learned that other RTs had done the same thing when they first started as RTs. Now we are all slow. According to some ER RNs, we are slow getting to ER because we are lazy.

That's fine, call me lazy, but you guys need to learn how to use the word STAT. I would like a reform of the ER paging system. When I think of STAT I think of running. I think that if I don't get there right away the patinet might die or have prolonged suffering.

One day an ER nurse was blunt with me. "What took you so long to get down here?"

"I'm sorry, I'm swamped," I said. It was true.

"You should at least call so we could do it."

"I was at a code."

Twenty-minutes later I received another page to ER for an EKG, and this time I really was busy and called. An hour later I made it down to ER and the EKG was still not done.

To be fair, most ER staff at Shorline are very understanding that sometimes RT is busy, and that we have to prioritize. And, as it turned out in this case, the nurse that did complain was a rental nurse not familiar with our hospital.

And, even while ER procedures are considered STAT, the people who order them are simply following the current protocol and, thus, doing there jobs.

To correct this problem, we at the RT Cave wrote the following letter. It was signed by all my fellow RTs:

To whom it may concern:

To speed up time from door to EKG for critical patients in the ED, and to allow the respiratory therapy staff leeway in prioritizing EKGs with important therapies on the patient floors, we propose the following paging protocol be instituted for all EKGs ordered in the Emergency Department (ED).

1.EKG Priority One: This page will be sent out for all EKGs ordered on highly critical patients such as obvious MI’s, life threatening arrhythmias, failing patients, etc. Upon receiving this page, the RT will drop what he is doing and run as fast as he can to the ED. If RT is unable to complete the EKG within 5 minutes, the ED will be called and the ED staff will complete the EKG.

2. EKG Priority Two: This page will be sent out for all EKGs that fit under the ACLS protocol where the EKG must be completed within 10 minutes of the patient’s arrival in the ED. Upon receiving this page, the RT should be in the ED within 10 minutes to complete the procedure. If RT is unable meet this time frame, the ED will be called and the ED staff will complete the EKG.

3. EKG Priority Three: This page will be sent out for all EKGs that do not fit under the ACLS protocol, the patient is stable, and a time frame from door to EKG is not essential. Upon receiving this page, the RT will have leeway to complete other
essential procedures prior to arrival in the ED. This page will also be utilized for all pre-op patients, and any patient currently unavailable due to use of commode, bathroom, gone for x-ray,CT, etc.

Ideally, priority three EKGs should be completed within 20 minutes from time of page. If RT is unable to meet this timeframe, the ED will be called with an estimated time of arrival. In some cases,the ED staff may decide to complete the EKG and, if this occurs, RT will be notified the procedure has been completed so they don't have to rush down when they finish the task at hand.

If the ER staff is called to do an EKG, and the EKG is not completed in a timely manner, the RN will have to order pizza for all the RTs on duty. If this is not possible, the total sum of $50 will be extracted from the RNs paycheck and set aside for an end of year RT party.

We believe the implementation of this protocol is essential to improving staff time management, and, more important, improving patient care.

Sincerely, The RT Staff

We understand it's a hell of a lot easier to be called lazy (we're used to that) than to try to change policies and procedures that make no sense. But we had to try with this letter.

If this works, we will tackle STAT ER treatments ordered on patients not having bronchospasm next.

Defining a successful vacation

When I was a kid and we went on vacation as a family, I never wanted to go back home. It always seemed that mom and dad were happier, more likely to agree with us kids and let us do things our way, and, of course, we didn't have to do any homework.

My dad owned a car lot, so on the way we'd usually have this nice sized van to loaf in, and most of the time we'd turn the table and chairs into a bed and rest comfortably. We did not worry about seatbelts back then. And, of course, there was a TV. While it wasn't hooked up to cable, there always seemed to be at least one channel we could pick up.

Sure we got into some fights, and mom would yell at one or all of us or dad would smack us with the back of his hand if one of us got way out of hand if he could reach us while maintaining his grip on the wheel, but for the most part we all seemed to enjoy ourselves.

If we went to visit a relavite there were always new toys to play with that were far better than the old boring ones that we had at home. And there usually were other kids to play with. And when we weren't visiting we were doing something cool like going to Mammoth Cave on the way to Florida or mini-golfing when we visited grandma in Florida or going to someplace.

Maybe my siblings didn't enjoy it as much as myself, but to me it was fun just to get away from the reality of home life for a while.

I suppose a successful trip as a kid is one where you have so much fun you don't want to go home. My parents succeeded in accomplishing this many times, as I hope I did with my kids this past weekend.

Now, as an adult, I remember those trips. Now I feel joy in knowing I'm the dad, the one who gets to decide what cool things we do. So last weekend when my wife decided she was going to have a girl weekend with her friends, I asked the kids what they wanted to do for fun.

"I want to play with Arlan," my son said.

"Okay," I said.

"Really."

"Sure. Pack up your bags and let's go."

They were so excited I can't put it into words. When I asked KK to get dressed in the morning she didn't fight me one bit. My son packed his own bags.

There is some kind of joy in traveling in a car for 2 1/2 hours, stopping at McDonalds and not worrying about the diet, lettting the kids get whatever they wanted because mom wasn't there to tell them they couldn't have something. And drinking pop and eating donuts and chips the rest of the way.

And while we were at my brothers both my son and daughter had a cousin their ages to play with and they played non-stop. And my brother and I talked sports and politics without worrying about what we said because we don't judge one another. There is nothing better than hanging out with people you know won't judge you.

Then my older brother showed up with his kids and we watched the Redwings, played live-aciton sports on the Wii. The new Wii has a motion sensor where you actually have to swing the golf club or the baseball bat to hit the ball. It's amazing how far these games have come since the Atarii we played with back in the 80s.

When we were hungry we ate hamburgers or ordered pizza without worrying about price or about eating too much. We rehashed some old memories, and listened to the kids giggling late into the night, way past bedtime. My daughter came to me on her own accord finally and said, "Daddy, I'm tired."

Finally, my dad showed up with another one of my brothers and we watched the Lions. The game was a bust, but it was cool to have all us brothers together again, even while it was only for a few short hours.

We dads love vacations. Dad was vacationing here from his winter home in Florida. He was happy to be with his kids; he didn't need to say it. Just like he didn't need to say he was happy to be on vacation with his boys when we were kids.

Dad never even asked why I didn't go to hunting camp with him this weekend, for he just knew.

My youngest brother, Trin, did. "Why didn't you come out to camp with us."

"Kids!" I said, bluntly. "This was my weekend with the kids." He smiled. Some day he and his wife will have kids and he'll know how I feel, if he doesn't have a clue already. I bet he does because he loves to play with his nieces and nephews.

As an adult, no matter how long a vacation lasts, a successful vacation is one in which you are equally excited to get back home as you were to leave. My trip to the big city this past weekend accomplished that.

So we were all happy. Now we are home, me and the kids, and we're all happy and well rested -- and so is mom.

It was a nice weekend.

Good patients go to be with the Angels

Patients who believe in God are often far better patients than those who don't. This is a theory that my friend Sin over in the CCU Cave and I discuss once in a while. And more often than not our patients prove us right.

Last night was a perfect example. I walked into a patient's room to give him a breathing treatment and he said, "I don't want that damn thing." He flailed his arms and tried to hit me.

I was blunt with him: "I have kids that behave far better than you do."

I left and charted a refusal. I don't care if he was short-of-breath or not. Fortunately for him he wasn't SOB, but he did have a harsh, audible, prolonged and forced expiratory throat wheeze when he was all worked up, which he was at that time. And for that reason the patent's nurse, Wren, called me to the room.

"I think he really needs his treatment," Wren insisted.

I studied the patient again. "What he needs is s spanking."

"You shouldn't talk like that in front of the patients."

"This guy isn't having anything close to bronchospasm. He sounds bad and that's about it. Even his doctor told me he's like this at the nursing home. As soon as he calms down he'll fall asleep and he'll be just fine, just wait and see. And if you guys just leave him alone he will calm down."

"Why don't you just give him a treatment?"

"Because I have patient's who want my services and I'd like to live to give them. I'm not going to stand there and risk my life and force a treatment down someones throat when he doesn't want it or need it." My voice trailed with that last part.

"All you have to do is put a mask on."

"And he keeps ripping it off. The day RTs gave him a blowby all day, and he won't even tolerate that now. Besides, like I said, he keeps trying to hit me."

I paused a minute while she tried to insert her syringe into the IV port, and the patient jerked his arm away. "GO AWAY!" The patient ordered. I grabbed his arm forcefully and held it down while she did her job.

"See what I mean. I'm not trying to be mean, it's him. I know this guy, he's been here all weekend. I've studied him. Trust me when I say he's not short-of-breath, he's simply anxious."

Wren smiled. "I see."

Later on we had time to discuss the patient, and laughed. I told her about my God theory and she agreed with me.

Later in the night I visited Sin who took care of the patient a few days earlier, and Sin told me he had a tryst with the patient, who shouted, "I don't have no use for your f#$%ing God! Get the F#%^ out of my room!

Sin said, "He has no reason to be good. He didn't believe if he was good he'd go some place good, like Heaven. There's no incentive for someone like that to be happy at the end, so they take it out on everyone around them."

"So you're saying he's scared."

"Yes. And people who believe they are going to Heaven do not get scared. I mean, they get scared, but you know what I mean."

"Yep, I agree with you."

"Whether you believe in God or not, it's a proven fact that people that believe in God, for the most part, are good as Angels. And I think most patients fall into this category."

I told him my favorite end-of-life stories are when people go out still doing something they love. I remember this one lady who loved doing Genealogy, but her computer broke down just prior to her coming to the hospital."

"Do you know how to fix computers?" she kept asking me. She was in CCU and I know she knew she was going to die. Doctors told her her heart was going to give out any time. She was cheerful and happy as ever. And she simply continued to work on her little projects.

I know they say it's not good to get close to your patients, but I'm telling you that's not always possible, especially when they are so sweet and innocent.

My grandpa, I was told, checked out while he was making a to-do list.

Many ladies whittle to the end. I'll never forget this one long-time patient of whom I participated in many interesting conversations. A couple days after she was discharged I was called to the front desk. Her husband was there holding an afaghan.

"She wanted you to have this," he said. I smiled and waved to her out in the car. I didn't have time to visit at that time.

A few days later I read her obituary. I think of her every time I use the afaghan.

I see many terminal patients reading books. I think, "What more could there be for you to learn? What good would this knowledge be?"

I know the answer now. God can use the knowledge.

At the funeral of a my wife's uncle last spring, his son spoke through tears and said his dad gave him a book in which the author claimed to have studied the Bible and was convinced that "what we learn in life we use in Heaven."

He said, "I guess God needed a carpenter. I'm sad that it had to be my dad, but I'm happy for him too."

Circadian rhythm sleep disorder: I have it

Until a few days ago I thought I only had one disease -- asthma. Now I've learned that the 12 hour shifts I work three nights a week have caused me to develop a new disease -- Circadian rhythm sleep disorder.

From what I've read, Circardian rhythms are the signals you get during the day from the sun light that tell your body what time of day it is. Your body actually increases or decreases hormones based on the time of day.

If you work night you screw this whole process up. So, when you're night shift friends tell you you're chemically screwed up, they are right.

So my being completely exhausted at around 3 a.m. is due to the fact that I'm supposed to be in deep REM sleep at that time. Then, when I get home, I am in and out of sleep all day. I cannot sleep for five straight hours. When I wake up it takes me hours to get back to sleep. Then, when I start my six day off in a row stretch, I can't seem to adjust to a regular sleep pattern.

That's a sign of insomnia. What I have, according to what I've read, is a classic sign of a sleep/awake disorder called Circadian rhythm sleep disorders. (I think I have that right.)

Over time us night shifters become more and more sleep deprived and symptoms start to develop:

• Headaches (absolutely)


• Increased irritability & being moody (I have to admit it)


• Overly emotional (snapping or losing your temper. Just ask my son.)


• Too sensitive and defensive (getting all worked up over nothing)


• Contrary behavior (seeing problems that aren't really there)


• Forgetful (My wife will contend to this)

Who would have imagined there would be a whole scientific effort to study nothing but us poor night shifters, and that they'd even have a disease named in our honor. I don't know if I feel better now or worse.

I suppose I feel a little better because since it's a disease experts have an actual list of things one can do to make it all better. I'll get to that in a bit. But What I'm most concerned about are all the side effects to working nights:

• Fatigue/ tiredness (Yep, had that)


• Loss of energy (have this)


• Loss of sex drive (ummm)


• Broken sleep after shift (definitely)


• Constipation (never had that)


• Stomach problems (I'm on Provoloc)


• Dehydration (yes)


• Cardiovascular disorders (I'm not there yet)


• stymied career advancement (no energy)


• Eating more junk food junkies (can't keep the weight off)


• Increased obesity (always having pot-lucks)


• Staying out of social loop (Never feel like doing anything)


• increased medical errors (50% caused by lack of sleep)


• Miscarriage


• Getting injured at work (I've been lucky)

Dehydration they said is another problem for us night shifters. So I drink a lot of water. Now I have to get up every two hours even when I am sleeping good to go pee. We just can't win .

Serotonin is an important chemical in our bodies that allows us to control our moods and emotions. Research shows that night shifters produce a lower level of serotonin than normal people, because serotonin is only produced during sleeping hours. And, as we get older, our body becomes slower at producing serotonin as it is, which doesn't help. (No, Melitonin won't help either.)

So no wonder we're so out of wack.

What can we do to help ourselves improve our sleep habits. Unlike my asthma the problem would simply go away if I went to days. But that's not an option right. I've tried all these at one time or another, and some work and some don't; and sometimes it doesn't matter what I do. Anyway, here's what the experts recommend to resolve this disease:

1. Go to days (I've been next in line for 8 years)


2. Keep room dark (no problem there)


3. Avoid caffeine (haven't had any in 4 years)


4. Eat healthy (I am, but don't know how long it will last)


5. Exercise (I do)


6. Avoid sedatives (I do)


7. Try to keep sleep patterns consistent


8. Pay attention at work (I keep double checking myself)

Good news guys. My friend Milt was wrong, and I will not have 7 years cut off my life. Studies show there is no evidence that working nights has an effect on lifespan or cancer. Yipee.

Driving home exhausted

You can't expect to get much out of me today, considering I'm on the final leg of an 8 day journey here at Shoreline hospital. My brain is about fried. But I still think I have enough energy to complete one post here before I go out to knock off my 10 p.m. treatments.

I love working nights. I've been doing this since before my respiratory days, and for a total of 16 years now. In fact, I've been working nights so long that if an opportunity to work days ever came up I think I'd be stressed about it. At least that's how I thought until recently.

I don't know about you other night shift RTs and RNs and DRs, but it's been catching up to me lately. Not only am I utterly exhausted at night, but I can't sleep when I get home. I sleep four hours sound from about 8 a.m to 11 a.m, and then I wake up feeling like it's about 5 p.m. I roll over and look at the clock to find out it's only 11 a.m.

I usually try to stay in bed until at least until 2 p.m. no matter what, but even that's been a challenge lately. It's so bad that this morning I was so tired I thought I was going to fall asleep giving my treatments after 6 this morning.

When my boss came we talked about driving home exhausted. She said one day she was taking her usual journey home when she used to work nights, and all of a sudden had no idea where she was.

I told her I've had similar experiences. I'll be driving home, and all of a sudden I find I have no clue where I am. I mean, I know what neighborhood I'm in, but know that somewhere I took a wrong turn. And once, funny thing, when I was on a wrong road, the road curved back and actually crossed the road I was supposed to be on and I didn't even realize it until later.

Jep, the guy who works nights opposite me, said he doesn't fall asleep while driving, but said he has fallen asleep at stop lights before.

Now that's driving home exhausted.

I've read that driving home exhausted is worse than driving home drunk. I wonder how long it will take for a group like MADE gets started: Mothers Against Driving Exhausted.

A couple days ago when I was leaving work a new RT here, Milt, asked me if a day job came open would I take it. I said, "Hell no, I love working nights." What the hell am I saying, I thought. That's what I used to think, but haven't things changed?

"Good," he said, "Because I don't want to work nights."

"On second thought," I said, yawning, "I'm thinking a day job might be nice."

"No! No! You cant change your mind," he said, smiling.

"You know, I can think of 200 things I really love about working nights, and one reason I hate working nights, and they both balance each other out."

"What's that one thing?"

"Lack of sleep."

"Well," Milt said, "You do know that working nights takes seven years off your life."

"Is that true?"

"Yes, you can Google it."

I went home and I did Google it. There is actually a disease that specifically refers to hospital workers who work 12 hour shifts and then completely adjust to days for their days off. It's true.

Now, I didn't see anything about seven years, but there are a bunch of other diseases directly linked to working swing-like shifts. It's scary.

Despite being able to blog, to surf the net, to watch TV, to read books or pay bills or whatever else us night shifters get to do because the bosses aren't around, I think I want to go to days now.

I'm tired. I'm exhausted. I'm ready for bed and it's only 9:15 at night.

I'm going to go out now to knock off my 10 p.m. treatments, and then I'm gonna loaf on the couch in the waiting room in front of the TV and pray to God my beeper doesn't go off.

Super RT

I came into work today and saw that there were 15 patients on the board. Then I sat down to get report and "Respiratory therapy stat to ER!" rang out over head.

I yanked off my sweatshirt and left for the emergency with Jane Sage.

"You look like superman there.," Jane huffed on the way, "You pull off your hooded shirt and now you have your Super RT suit on."

"Yeah, I feel like superman here sometimes," I said, "RTs are useless dummies unless there is an emergency. What's the old saying, 'In case of emergency break glass.'

Upon entering the ER we were told we were needed "promptly" in room 76. Jane entered first and I was right behind. The patient was a 10 YO boy lying supine in no respiratory distress. Jane listened to the boy while Dr. Carr asked questions to the parents.

"Do you need anything from respiratory?" Jane casually asked the doc as she plucked the stethescope from her ears.

"No, I think we'll be fine," the fine doctor said.

"Wow," I said behind the nurses station, "You guys sure know how to wake us up." The nurses back there laughed. "I'm all pumped up now."

"Well, I'm sorry to make you rush down here," the secretary said, "but the pager system was down. I was told he was having trouble breathing."

"He was," one of the nurses said. "He just got better fast."

"Hey, no problem," Jane crooned, "The next time you need the Super RTs you know who to call."

So what started out looking like it was going to be a rotten night, now doesn't look so bad at all. While we have many on the treatment load, most of them are prn and not indicated or are Q4 and refusing.

I think many RTs might be worked up and stressed about now, but with my Super RT ability to prioritize, I get to sit here while I wait to check on all these patients at 10. And, if these patients are as fine as what I was told in report, I should have plenty of time for all the fun things us Super Night Shift RTs get to do.

Of course I'll keep my ears pealed for the sound of the Super Beeper that chimes when someone is in need of the many services provided by the Super RT.

Albuterol is a bronchodilator and nothing more

Some of the posts on this site, including my list of 'olins on the bottom of the page, are my humble attempts to make a humorous account of why doctors order Albuterol on patients having absolutely no signs of bronchospasm.

RT Cave Rule #5: There is only one purpose for bronchodilators, and that is to treat shortness-of-breath due to bronchospasm

In no way do I think I am smarter than a doctor, for they have knowledge in far more areas than I will ever imagine to have. It is their job, after all, to fix patients. And, when they order therapies I disagree with, I will still do them without complaining.

I have to say, however, that this is difficult not to complain when I know a treatment is not indicated, especially considering I have been using Albuterol since it was invented in the 1980s, and before that I used Alupent, and never once used either one for anything other than SOB due to asthma. In this way, I have over 30 years of bronchodilator experience.

Likewise, I have given many breathing treatments to patient in the hospital the past 12 years as a registered respiratory therapist, and have seen first hand for whom they have a beneficial effect and for whom they have no effect.

Plus I believe my opinion is in concordance with nearly every other RT on the planet.

If you are an RT or suffer from diseases like Asthma or COPD, you know how wonderful a drug Albuterol is. I can tell you from personal experience it's a life saver. In fact, without the drug I'd probably would have died many years ago.

And that brings up my next point. Bronchodilators of the past, such as Alupent and Bronchosol, did have some bad side effects. Alupent was proven to be a great bronchodilator, but had the side effect of making the heart thump. I remember abusing it when I was a kid and fearing that I might now wake up in the morning.

Alupent was a good drug in it's time, and was used for many years, but in 1987 a new refined bronchodilator was invented that was proven to have very little effect on the cardiac muscle, and thus rarely causes the heart to thump or increase. I'm not saying it never does, but very rarely, and usually only when it's given in huge quantities all at one time.

I can tell you from my personal experience as a "Rescue Inhaler Abuser" that I have gone through an entire inhaler in a day and still not had my heart thump like it used to when I used Alupent. Now, I wouldn't recommend using that much Albuterol outside the hospital setting, but my point is that Albuterol is that safe.

When patients come into the hospital, and you are having bronchospasm, we quite often give you an aerosol of Albuterol. If that aerosol doesn't do the job, we have been known to give as many as 10 in a row back to back to back. Again, I wouldn't recommend doing this at home, but I bet many of you chronic asthma and COPD patients have at one point or another. Hey, back me up here.

Now, understanding how quickly and magically Albuterol can get an asthmatic or COPD patient breathing easy, and considering how safe it is, many doctors choose to try it for other respiratory illnesses, even illnesses that are not bronchospasm in nature

I find that some doctors order Albuterol because a patient is short-of-breath because of pneumonia (fluid in alveoli), atelectasis (collapsed alveoli), pleural effusion (fluid in lung) and pneumothorax (collapsed lung) . All of these diseases are in the alveolar sacks, and the aerosol particle of Albuterol are too large to deposit in the alveoli, and thus have no effect there.

If, however, a patient has a bronchospasm component to their disease with any of the diseases listed in the last paragraph, then I'd recommend Albuterol. But if there is not bronchospasm, then it has no benefit to the patient.

Other diseases that Albuterol does not benefit that it is often prescribed for are: Croup, upper airway congestion or excess secretions, CHF, pulmonary edema, post-operative, obesity, cancer and many more.

Let's tackle croup. The harsh inspiratory noise kids make with this illness is because their throats become swollen. The key word here is throat. There are other medications that might help here, but not a bronchodilator. Hence, Albuterol is a bronchodilator, not a throat dilator.

Chronic Heart Failure (CHF) causes fluid to build up in the lungs called pulmonary edema. This does not occur in the bronchioles, but outside them. When this fluid overload causes the pressure inside the lungs to build up, this can cause the fluid to in effect squeeze the bronchioles and causing a wheeze. This is called a cardiac wheeze. Yes, it does cause the bronchioles to tighten, but, since the cause is outside the bronchioles and not inside, Albuterol will not work to solve this problem. This patient will need diuretics like Lasix.

Nonetheless, a cardiac wheeze is very often confused as a bronchospastic wheeze, and treated like bronchospasm.

Many times in the hospital setting I give a breathing treatment the same time a nurse is giving Lasix. The patient is severely SOB. My treatment has no effect on the patient's WOB. But, an hour later when the Lasix has worked, the patient is no longer SOB. Since the patient actually participated in taking the treatment, he or she often thinks the treatment is what eventually solved the SOB.

So, what happens the next time we get a CHF patient? The doctor orders Albuterol back to back to back to back until the Lasix works. Can you see how I can easily make comedy out of this.

Cancer will not be absorbed and broken up by a bronchodilator, nor will it absorb a pleural effusion, nor re inflate a collapsed lung (that's what a chest tube is for). Even if it did get down into the alveoli, it will not remove fluid in the alveolar sacks caused by pneumonia.

Now hopefully by you reading this you understand RT humor. Since doctors use Albuterol for all these diseases, we RTs (me in particular) have a choice between grumbling and griping about it, or making humor of it. We at Shoreline Hospital choose to make humor, and thus our list of 'olins came to be.

One of the reasons I made this post was because I've received more than one emails or comments from patients who wondered if I was being serious or funny when I wrote "Xoponex now a humidifier." I will confess: I was being facetious.

While Dr. Krane is a brilliant doctor, and while I enjoy working with her, and while I have no problem trying one Albuterol treatment with patients with croup just to see if it works, it is not a humidifier. In fact: Albuterol given via nebulizer treatment is a mist.

Just so you know, any post on this site where I'm using RT humor will be labeled on the bottom as "RT humor" or "funny."

Again, I am in no way proposing that RTs know more about the human body than doctors, but we are the experts in the hospital on the respiratory system -- that's all we do. We study respiratory, we learn respiratory, we learn the other systems as they pertain to respiratory, we keep people alive with our respiratory machines, we sleep respiratory, we breath respiratory. We give breathing treatments all day long, and we see how they work first hand. Doctors can only order them. And, when they do, we have to give them. We have no choice.

Now, if you are a medical staff at a hospital other than an RT, or if you are a patient viewing RT sites like RT Cave, it is important that you know that there really is only one true purpose for Albuterol, and that is to treat shortness-of-breath due to bronchospasm.

To determine if someone is having bronhospasm, it requires an assessment of lungsounds and/or a quick review of the patients history, which usually can be provided by the patient. Most of the time, true bronchospasm is very obvious.

In the insert inside the Albuterol inhaler or aerosol solution you will find an insert. Go ahead and pull it out if you have access to one. On that packet it says: Indication: "(Albuterol) is indicated for the treatment and prevention of bronchospasm in adults and children under 12 years of age and older with reversible obstructive airway disease." (emphasis added)

It is a a fact, proven by much research, that Albuterol is a medications that becomes a particle size of 5 microns and fits perfectly into the size 0.5 micron bronchioles of the lungs to relieve bronchospasm. Five microns is too big to go into the alveoli level (which is 0.1 to 0.2 microns wide) and too large to deposit in the throat (although some of them will deposit there).

It is not a cure for any disease. It will only resolve the symptom of bronchospasm. This is my humble personal and professional opinion. And as long as doctors continue to abuse this most wonderful drug, we will continue our effort at bronchodilator reform. And while we may never get it, we will continue our feeble effort at RT humor here at the RT Cave.

I encourage you to challenge me.

Here is a great column that might explain it better than me.

This article describes what bronchospasm is.

Here's a basic definition of bronchospasm.What are bronchodilators?

Here's how to check if a bronchodilator is indicated.

The indications for Albuterol are listed right here. If you're really bored you can read the whole thing.

Boring study on the particle size of bronchodilator. I just don't want you to think I'm making this stuff up.