Your Respiratory Therapy Search Engine Queries: Here are the responses from the RT Cave

I don't really spend a lot of time checking my stat counter, but about once a week I check it out for fun just to see who's been clicking on my blog. One of my favorite things to do while I'm there is click on "Recent Keyword Activity."

This is where my stat counter records what was typed into a search engine, such as Google or Yahoo, that led someone to clicking on my website. A few of the searches have nothing to do with respiratory, such as "Scratchy Neck," but the majority are respiratory related.

As I glance through the list, I wonder if that person had his question or concern answered. And, I think, they should just email me and I'd give them a legitimate reply, or at least I could tell them I don't know.

The reason I think this way is that some of these questions could only possibly be answered by an RT. So, with that in mind, I have listed some of the "recent keyword activity," and my humble responses.

1. "blowing into computer for respiratory": Um, I have no clue.


2. "Itchy neck pain": Um, how did that cause Google to link you to me.


3. "Duoneb pediatrics": Some studies show it works well in ER. Other than that I'd recommend just Albuteral. Personally, though, I don't see what it would hurt.


4. "Doctor doesn't believe in Peek flow meters: The doctor is a fool to disregard the benefits of a peek flow meter. It's a great tool to use in asthmatics to measure the effect of a breathing treatment, and to be an adequate tool to determine when to use a rescue inhaler, go to the doctor, or come here to the ER.


5. "Persistent croup": You can try the shower. You can taking the child outside in the cool air because many times it goes away on the way to the hospital. But don't be afraid to come in and get checked out. That's why we are here.


6. "Will Ventolin harm you if taken unprescribed": NO. However, I would not recommend it. If you have a need for Ventolin, you should go see your doctor.


7. "Does Albuterol Help Crackles?": No. The medicine particle size is too large to even get down in to the colapsed alveoli, and even if it did it wouldn't be able to re inflate it. But this is a great question, because often doctors prescribe Albuterol for this.


8. "Needle shot stings": Yes.


9. "How to write BiPap orders": With a pen in the doctors order section. It works best if you write the doctor's name followed by your signature. Plus I'd write "RT to set up BiPap to patient tolerance." Seriously, every patient is different, and every patient tolerates BiPap differently. That's how we write the order where I work.


10. "House filled with smoke from fireplace fever coughing": I would recommend not having the fire in the fireplace if it causes you to have trouble breathing due to it. It may cause you to cough, but it will not cause the fever. However, if you do have a respiratory illness, it may exacerbate your problem. Also note that it is not uncommon for smoke to bother people with respiratory illnesses.


11. "Respiratory therapy one treatment at a time": I would recommend it, but sometimes you will have no choice. If your patient takes nebs at home, or if the nebs are not indicated, then you should be okay doing more than one treatment at a time, just make sure you are only one or two rooms away. This is where it really comes in handy to know your patient. However, if you are new at this, or not sure, then you should definitely do one at a time.


12. "I hate respiratory therapists": What's your point.


13. "Breathing treaments for pneumonia": Same as for the question on atelectasis above: Albuterol does not get down to the alveoli. Besides, Albuterol relaxes bronchiolar muscles, and there are no bronchiolar muscles in the alveoli anyway. However, if the pneumonia causes bronchospasm, the treatment might work. Usually the first treatment in ER does the trick. If I were a doctor, I'd order Albuterol Q4 prn for these patients so we can give a treatment if indicated.


14. "Coughing spasms albuterol": If it's caused by bronchospasm then Albuterol is a good idea, othersise what's the point. Albuterol will not cause someone to stop coughing if it is not caused by bronchospasm. Personally, I'd try one and see what happens. It's a safe medicine.


15. "COPD on BiPAP": It works. And if it keeps them off the vent, you'll be happy and so will the patient. I've kept many patients off the vent by using a BiPaP. The big problem here is patient compliance. You will have to do a good job of explaining and be very patient with the patient.
    
16. "How long are patients intubated for": Depends on how long it takes them to recover. Depends on how sick they are. Many times, with the new microprocessor ventilators, it takes only one or two days. But every patient is different. If you are the family of someone currently on a vent, you should talk to the RT for an explanation.


17. "Do you give breathing treatment for cough congestion?": Yes, many doctors do. But Albuterol is technically speaking indicated for bronchospasm only.


18. "Where should one live with asthma": While there was once an advantage to living in dry areas like Arizona, research shows that this is no longer a benefit due to air polution.


19. "Why do people need to be intubated": I like to tell people that they, or family member, need to be intubated to get over the hump when they are really having trouble breathing. It allows their lungs to rest. Unlike in the movies, it is also indicated when someone goes into cardiac arrest. It is also done during certain surgeries, if someone is comatose to prevent aspiration, bronchoscopy, or you can check Wikipedia for more information.


20. "Tips for being a great respiratory therapist: Be patient. Don't be afraid to let other people take credit for your ideas. Do your homework. Most important, have fun with your patients and enjoy your job.

Well, I could go on, but I figure I had best stop at 20. There were many that I chose not to list here just because I saw via the stat counter that the person was linked to one of my articles where I know they would have found the answer if they read it.

Perhaps I'll make this a regular feature on this blog.

Keystone Project to improve patient outcomes

For a more updated and thorough post about the Keystone Project, Click here.

As I have mentioned before, we at the RT Cave believe it is important for each respiratory therapist to be involved in the entire process of patient care as much as possible, as opposed to simply focusing on the respiratory side of the patient's needs.

The main reasoning for this is that, as we learned in respiratory school, "all the organs of the body combined effect the respiratory system in one way or another." Not only is it important for nurses to pick up on the early signs that a patient is failing, it is the job of the respiratory therapist. After all, we are a team, we are all responsible for taking care of the patient.

Most doctors agree that most people do not go into respiratory failure without showing early signs that this is going to happen. It is our job as part of the hospital team to pick up on these early signs and prevent a patient from getting so bad that he or she has to be moved to the critical care unit (CCU).

And, once in the patient is admitted to the CCU, it is our job, along with the nurses, that we continue to monitor the patient for signs of impending failure, besides treating the patient for the critical issue that landed the patient in the CCU.

According to the MHA Keystone Center, "It is estimated that, "over 5 million people are admitted annually (to the CCU) in the U.S., consuming approximately 30% of acute care costs or $180 billion annually. In addition to consuming health care costs, these patients suffer preventable morbidity and mortality. Previous studies suggest that nearly every one of the 5 million patients admitted to an ICU suffer a potentially life threatening adverse event (emphasis added)."

It was the goal of the Keystone Project make recommendations based on the most up to date research to improve costs and, most important, recommend steps that hospitals can take to improve patient outcomes regarding illnesses that do show early signs. And the project recommends each hospitals voluntarily create its own Keystone Team to implement these recommendations.

One of the early recommendations was to create a rapid response team , which would get nurses and respiratory therapists on the patient floors to be on the look out for early signs, and to call the rapid response team into action, to generate early intervention, and thus to prevent the patient's illness from progressing to the point that a move to the CCU is necessary.

Creating ventilator protocols is another recommendation of the Keystone Project in order for the doctors and the respiratory therapists to begin thinking about weaning the moment the patient is placed on the ventilator. Since we have initiated our ventilator protocol, we have seen patient length of time on a ventilator decline sharply.

The Keystone Team at Shoreline where I work has decided that the next step they want to tackle is creating a Sepsis protocol.

I'm not sure what steps we will take, but a few years ago I went to an MSRC conference and one doctor gave a presentation "Everything a respiratory therapist needs to know about Sepsis." And he made us aware that the number one killer in the CCU is sepsis. But people do not get spontaneous sepsis any more than they get spontaneous DIC or ARDS, so it is very important for nurses and RTs to pick up on the early signs.

I couldn't remember everything this doctor said because he went so fast I couldn't keep up with my notes, so as soon as I had a slow night at work I looked this up on the Internet, and was surprised at how much I found.

I found that the MUST protocol was created to make hospital staff aware that sepsis, according to aacnjournals.org, "affects more than 750,000 patients and accounts for more than 215,000 deaths in the United States each year at a cost of $16 billion. Mortality to septic shock has decreased only slightly between 1970 and the late 1990s; it remains the most frequent cause of death in noncardiac intensive care units (emphasis added)."

The MUST protocol makes recommendations in making hospital staff aware of the early signs of sepsis and what to do in the event these signs are prevalent. And while sepsis is not necessarily a respiratory illness, if it progresses, it may result in respiratory failure. Thus, when the RT is present with the patient, or part of the rapid response team, it is essential that he or she knows what the early signs of sepsis are.

While I'm not going to get into the nursing end of sepsis (and you RNs can check out the links above if you are interested), I will address everything that an RT needs to know about Sepsis in the next few days. It's also to know which patients are at risk for Sepsis, ARDS, DIC and PE so they can be closely monitored. At some point in the future I will address all of these as well.

We have met resistance in every step of the way in initiating these protocols, but so far at Shoreline we have managed to create our own rapid response team and a ventilator protocol, and we are currently in the process of creating a sepsis protocol.

While it's not the RTs role to insert catheters, central lines and pulmonary artery catheters, the Keystone Project believes it's the role of every person at the bedside to make sure nurses and doctors are in compliance with infection control techniques to "reduce or eliminate catheter related blood stream infections in ICUs." Since we RTs are often at the bedside, we need to be aware of proper technique.

And, while it's not our role to check sugars, an RT must be one of the team members thinking about this, especially when a patient has sudden mental changes, which may also be an early indicator of sepsis. Does the patient all of a sudden have significant change in respiratory rate, heart rate and blood pressure? Is the patient suddenly filled with Rhonchi or crackles. These are not things to be ignored, as they may be signs of impending failure.

As a respiratory therapist, I like to see the big picture above and beyond my role as an RT. Due to the recommendations of the Kestone Team, I know that it is important to do oral care on a regular basis to prevent VAP (ventilator acquired pneumonia), and to have inline suction as opposed to bag and suction, and to make sure the head of the bead is up 30 degrees, and to make sure the patient is still rotated from side to side even though he or she is on a vent.

And, while it was once recommended not to exceed 20 cwp of cuff pressure in the ETT, , it is now recommended not to let the pressure become anything less than 20. The reason for this is to prevent aspiration and VAP.

I'm not sure if this was a recommendation by Keystone or not, but while I was taught to use 1-15ml/kg ideal body weight when I was in RT school in the mid-199s, it is now recommended to go with a lower tidal volume of 6-10ml/kg ideal body weight to prevent barotrauma. And, in cases of chronic or severe pulmonary illness, it is recommended to start on the low end.

If these things are not being done, it is my responsibility as an RT to either do them, or to at least make sure the nurses or other RTs are doing them.

Not only is is a good idea to generate these teams, and these protocols, but it's also a good idea for respiratory therapists to continue to research, to attend seminars and in services, to stay up to date on all the latest research and recommendations to improving patient care. I think this is necessary even if protocols are not available.

Personally, I don't need a protocol to make me participate in the patient's care this way, but the use of protocols provide RTs with more leeway in what we are allowed to do regarding the patient, especially regarding early intervention. If the patient looks bad now, why not get a quick ABG, EKG and, perhaps, order a STAT x-ray while the nurse is calling the doctor.

When we RTs are called to the patient room to give a breathing treatment, and we observe that the patient is not having bronchospasm but is wet, and then we notice that the IV is running at 500, we would naturally make the RN aware of this. And then we would recommend a diuretic, instead of a bronchodilator.

It's not that the nurses are incapable of finding this out on their own, because they are and they do. But if we are a team, we all must be vigilant all the time. What one of us does not pick up on right away, the other hopefully will.

By keeping up on our research, participating in protocols, and making recommendations that work to benefit the patient, we are not just helping the patient, we are using the skills and education that we have accumulated. This is good for our RT morale.

We are a team, and we must all work together to the benefit of the patient, and to the benefit of ourselves and our institutions.

The doors to the RT cave are still open

The Respiratory Therapy Cave opened its doors to the blogging world just over three months ago, and we have reached our first milestone: 10,000 page impressions.

This technically speaking is not a big deal, except for when I started this blog I figured I'd just be writing to myself. I never expected to pick up regular readers, let alone have 10,000 page impressions three months later.

When I started this I had no clue what a blog even was. By looking at statistics a few days ago, I know now that I was not in the minority, as 92% of Americans that have access to the Internet do not blog. Or, if they do blog, they don't know they are doing it.

In three months I've learned quite a bit about the blogging world, and still have a lot more to learn. I'm still not quite sure what RSS feed is, but I know I use it. I thought I was simply out of the loop, but yesterday I asked my brother, who creates web sites, what RSS feed was and he said he had no clue either.

As far as I know, I'm the only person in Shoreline County who blogs. Not one person I've asked at work blogs.

My brother said people who blog are nerds. I thought that was kind of ironic considering he spends 12 hours a day in front of a computer. If anyone is a nerd, it's him. Hear that Lucky, you're a nerd.

I think it was some character on the Simpson's who defined nerd on a recent episode. NERD: Not Even Relatively Dorky.

So I digress, As far as I know, I am the only person in Shoreline who blogs. That's why I'm not too worried about my boss finding out I'm writing about her on this site. Well, I haven't written anything bad about her yet, but I could.

When I started this I figured I would write something, oh, maybe once a week if not every two weeks. Somehow, to this point, I've managed to find something to write once a day. On days I'm tired I think the writing tank will run dry, but when I'm wide awake ideas flow form my pen like balls on a billiards table.

Am I interesting? Is my writing unique? Is my writing any good? I don't care.

That's the neat thing about having my own blog: I can write about whatever I want.

As a former marketing and journalism student I know I could better target my writing to one specific audience and gain more readers, but that's not the point of this blog.

The point of this blog is to have fun writing about things I'm passionate about. If people are entertained, or learn something in the process, that's a bonus. If I wrote for any other reason than to entertain myself this would cease to be a hobby, and would become another job.

That I definitely don't want.

So I had no clue I'd be here three months later. I thought I'd write a few weeks and then move on to something else. So, for the fact that I'm still here, I have to thank all of you who have clicked on my blog.

Honestly, I didn't have a clue what would happen when I opened the door to the RT Cave to the blogging world. So far, it's been a cool ride.

The five different types of COPD patients

In RT school we are taught that there are three different types of COPD patients: emphysema, chronic bronchitis and asthma.

In the hospital we tend to leave asthma out of the COPD definition, and the general consensus is that if they smoke it's not asthma.

However, some doctors still diagnose smokers with asthma. I suppose that's their prerogative.

Personally, I am under the belief that if you are an adult with asthma, it is chronic asthma, and falls under the category of COPD.

Emphysema patients are referred to as pink puffers, because they tend to have smaller frames are are not cyanotic. Chronic bronchitis patients are referred to as blue bloaters, because they tend to have larger frames and are often cyanotic.

However you want to define COPD patients that's up to you. Based on my experience working with COPD patients over the years, I have come up with a list of the five different types:

Happy: About 80% of COPDers fit this category. These patients tend to be among the most pleasant of all patients, more so because they are professional patients with a chronic illness and have accepted it. They rarely ask, "Why me?" Happy COPDers generally are of two types: they are either talkative or phlegmatic.

Talkative: About 80% of Happy COPDers are talkative. Some of the best conversations I've ever had with a patient have been with a talkative COPDer. Before their "time is up" they want to share as much of their experiences and knowledge as possible.

When you give a treatment to one of these patients they might not let you leave. They will talk openly about their illness and family life. By the time the patient is discharged you will have a pretty good idea of what kind of a person he was, and what kind of a life he led, prior to getting sick. Usually they are very interesting and intelligent.

If you are talking with a COPD patient, and the patient starts describing an event that occurred in 1945, he is probably a talkative COPDer.

Phlegmatic: About 20% of Happy COPDers are phlegmatic. Whatever you want to do, they don't care. They talk little and have very pleasant and modest dispositions. The majority tend to be men.

If you walk into the room and find the patient has his feet up on the end table while watching TV, you know he is a phlegmatic

If you walk into the room and find the patient is moderately labored and still appears cool and calm, he is most probably a phlegmatic.

Melancholy: About 20% of COPDers fall into this category. They love to be waited on hand and foot. These patients have not accepted that they are sick, and have a tendency to be unpleasant
and very bossy.

When this patient wants a drink, she will say something blunt like, "Drink!" or, "Gimme a drink." Many might pretend they are incapable of lifting the glass so you have to do it for them. If you hear the words like please or thank you, you are probably not dealing with a melancholy COPDer.

Exaggerated: Would you believe it if I told you that a certain percentage of patients actually WANT to be in the hospital. The exact percentage is unknown, but it is estimated to be around 20%, and includes both Happy and Grumpy COPDers.

What happens here is that family members are tired and need a break, so the patient feigns his symptoms to get admitted.

If you need to give a series of Duoneb treatments in ER, but once the patient is on the floor she declines a treatment because she wants to sleep, then you should think exaggeration.

If she is lying in low fowlers and appears to be in no respiratory distress when you walk into the room, but as soon as you grab your stethoscope you hear an audible forced expiratory wheeze, you should think exaggeration.

If she is so bored the day after her admission that she is assisting her elderly room mate walk to the bathroom, then you should think exaggeration.

There are two different types of exaggeration of COPD. When emphysema and chronic bronchitis patients are faking it, the diagnosis is generally exaggeration of COPD. Faking asthma patients are referred to as exaggeration of asthma.

It is important that exaggeration of COPD not be confused with exaggeration of asthma. The differences may not be easily identified once the patient is in the hospital, but must be obtained through questioning, or it may simply be assumed.

Now, I know your science teacher told you not to assume, because when you assume you make an A-S-S out of U and ME. But in this rare instance, it is often necessary in order to make a proper diagnosis of the type of COPDer.

Exaggeration of COPD is when the patient is faking because their family members taking care of them are tired and need a break. So it may be assumed that 100% of exaggeration of COPD patients do not come from nursing homes or assisted living centers.

Exaggeration of Asthma is when the patient is faking because he is stressed and in need of a break from his family. He loves it that when he comes to the hospital he receives special attention and sympathy, and gets waited on hand and foot.

Now, while most of my opinion in establishing this data was obtained at one small town hospital, I believe my sample size and length of study (12 years) was large enough to obtain an accurate stereotype of all COPDers.

However, it must be noted that their is a +/- 6% margin of error on my percentages.

If you disagree with this assessment, or you have an observation of your own, please feel free to let this RT know.

See the 11 types of asthma patients

Lexicon (Dictionary of RT Vocabulary)

Choose your lexicon

Basic Termonology:

1. Respiratory Therapy Lexicon
2. Medical Center (Hospital) Lexicon
3. Physician Lexicon
4. Abbreviation Lexicon

Diseases:

1. Asthma Lexicon
2. COPD Lexicon
3. Congenital Heart Anomalies Lexicon
4. Neonatal Abnormalities Lexicon
5. Near drownings lexicon
6. Neurological Lexicon
   

Respiratory Procedures Lexicons:

1. Lungsound Lexicon
2. Sputum Lexicon
3. ABG Lexicon
4. PFT Lexicon
5. Medicine Lexicon (Coming soon)
6. Pulmonary Toilet Lexicon
7. Respiratory Failure Lexicon

Other:

1. Philosophy Lexicon

Hardluck Asthma

It's time to form that fantasy baseball team

One of the things I do to stave off boredom when the patient load is low is by participating in fantasy sports.

I noticed about six years ago my brother was rooting for the wrong team.

"No I'm not," he said, "I have Terrell Owens on my football team."

"Well he just caused the Lions to lose," I said.

"Rick, you should join a team next year, it's fun."

"I'm not doing anything that will cause me to root for that team."

The next year he convinced me to "just try it," and now I'm hooked. In fact, not only do I play fantasy football, I play fantasy baseball as well.

Fantasy sports is neat in that it causes you to look at sports in a whole new way. And, most important, even when your team is doing poorly, you can still get enjoyment out of the game.

While I used to just watch the Lions on Sunday, I now find myself sitting on the couch with a bag of Doritos every Sunday during football season flipping through the channels and keeping up on my players. It's fun.

Fantasy baseball is different in that I hardly find myself watching any games except for the Tigers, but when I have a Yankee pitcher on my team, I now find myself cheering for the Yankees, of whom I hate.

I don't watch every baseball game like some sporting geeks do. In fact, I don't really watch any games other than the Lions. And that's the neat thing about fantasy baseball -- you don't have to watch the games.


Like I said, fantasy sports has you seeing sports in a whole new light.

With all the acquisitions my Tigers have made in the off season, I'm starting to get Tiger fever; I'm starting to get baseball fever; and fantasy baseball fever. I got the bug.

For any of you baseball fans out there who have access to the internet and the bosses don't care or aren't around, this is a great way to keep your mind busy.

The student who was told he would fail as an RT

There was a RT student about 13 years ago who was told he wasn't going to make it as a respiratory therapist. What made this particularly distressing to the student was that the person telling him this was one of his RT teachers

The incident that lead up to this encounter with his teacher occurred during his first clinical rotation as a student. This was actually supposed to by his oxygen rotation where he was to learn about oxygen and oxygen rounds, but was also allowed to do treatments if his preceptor felt he was ready.

After he had followed his preceptor, an elderly choleric lady named Ellen, around for two rotations, he was finally given his own assignment of doing oxygen rounds on his own, and one patient to give a breathing treatment to.

This seems like a simple assignment to any seasoned RT, but it could be quite daunting to new student. And, once he was set free by his preceptor, he set out to do his oxygen rounds. He was so determined to do a good job, and so intense in concentration, that he forgot about the treatment.

Several hours later he was feeling pretty good about another good clinical day's work. He listened as Ellen gave report on her patients, and thought nothing of it at first when she paused and looked at him.

"You give report on this person." Ellen pointed at the student.

"Who?"

"You were supposed to do a treatment on this person right?"

"ummm... Gulp!

The next day Ellen watched the student like a hound as he did his oxygen rounds, and later as he did ALL of her breathing treatments. She stood behind him so close as he put together the nebulizer that he felt faint by the rancid odor of her breath, and this made him nervous, and he fumbled immensely.

It's not that he couldn't do treatments either, because he had asthma his entire life and gave himself treatments at his home when he needed them. Such a choleric person might have caused stress on a seasoned RT, let alone a new student.

And, after he finished doing ALL of her treatments and had returned to the RT Cave at this hospital, the RT student felt a sense of joy as he knew he would be going home soon. He actually felt good about what he had accomplished. He was bound and determined not to be swayed in his desire to be an RT by this evil woman.

Yet, just as he thought things were starting to go well, and just as he thought he was going to be able to rest a bit, Ellen plopped an oxygen tank in front of the RT student and gave the student a petulant glare that would have caused an experienced RT to stay away. But this student had no such option.

"Turn that on and off and on and off again," she growled. The student looked at her. Are you joking?

She did not blink. The corners of her lips moved just slightly, and he thought for a moment her face might crack. He thought he might turn to stone by her wicked glance, but unfortunately he didn't.

Instead, he plucked the key off the top of the tank and fumbled terribly in his attempt to do this simple task. It was as though that cantankerous old RT had a spell on him.

The next morning at school the RT Student was called to his teacher/clinical coordinator's office. Oh, boy, he thought, Here we go.

"Student, grades aside, I'm not sure you have the personality to make it as an RT. You just don't have the bubbly, outgoing personality like the other people in this class."

His heart skipped a beat. Okay, what's coming next? I can take it. I'm out of the program aren't I?

"The people you worked with at Happy don't think you are capable of being an RT. I know you're new at this, so we're gonna give you some time. But, I'm not quite sure about you at this point." He paused and stared at the paperwork on his desk, then looked at the student. "We'll see."

Fortunately, that RT student never had to follow that witchy preceptor again, probably more so because she refused to work with him than anything else. But the other preceptors weren't any better the rest of that six week clinical.

And, likewise fortunate, every six week rotation was at a different hospital, so he was exceptionally happy that his next assignment was far, far away from the wicked withch of the west. And everything went perfect from then on, well, aside from the few bumps in the road.

And, a year later when he applied at the hospital of his choice, one of the RT's from the hospital, we'l call her Tara, where he did his first clinical just happened to work there. And she was not nice to him. Right off the bat she put in a bad word about him, and she recommended he not be hired because "he's incompetent."

Fortunately, he had made a far better impression at his later clinicals, and had made some great friends along the way. And, despite the bad word from that one RT, he was hired.

And while all the other RTs at this new hospital were great, that one lady was just as bitchy as Ellen. This student love his new place of employment. But Tara continued to bad mouth him. It got so that the now former student was only scheduled to work when Tara wasn't working.

Then one day Tara quit because she couldn't handle the workload of working at a small town hospital. Things get pretty hectic sometimes.

You see,he was bound and determined not to let one stupid mistake, two cows and one teacher's comments stand between him and success. If anything, these people lit a fire under his butt.

That was more than ten years ago, and now I'm still here working as one member of an elite RT staff. That's right: I am the student who was told he would never make it as an RT.

Now you know the rest of the story.

Holter monitors not emergency room precedure

I was just sitting here when I was called STAT to ER to do a holter Monitor. Normally I wouldn't gripe about ER calling me no matter what the reason when I'm just sitting here, but it was a STAT holter Monitor, so it warranted a groan and a gripe.

I don't know if all RT departments do holter monitors, but I know that most of the ones in this area do. However, we have other staff do them during the day shift, and RT just has to do them at night.

Which, one would think, would cover all holter orders, considering holter monitors are an outpatient procedure. But, lo and behold I get called to do at least one STAT holter monitor a week.

And, usually, it's during a time when I'm really busy.

When you are the only RT working, you learn to prioritize your therapies, and I can find very few things, aside from a STAT IS, that a holter set-up should be ahead of. Occasionally, I've been known to take over an hour just getting to the holter.

"This is the ER," one doctor told me once, "nothing in ER deserves to be put off for over an hour."

My short-of-breath patients on the floor are more important than this holter, that I shouldn't have to be doing in the ER in the first place, I thought. Yet I smiled and said, "Sorry."

If there are any readers of this blog out there who can think of one reason why a holter needs to be ordered in ER, please let this RT know. I can think of none.

Because the patient has chest pain?

Hardly. If he has that symptom he should be admitted.

What about if the patient had a fast heartbeat, but when she got here we didn't pick up anything on the rhythm strip or EKG?

If that patient is symptomatic, admit them. Otherwise, schedule them for an outpatient holter.

Another goofy thing we do after giving a patient a holter is give them this little log book for the patient to record any symptoms they might have such as chest pain, palpitations, etc.

If the patient is having these symptoms, they shouldn't be recording it in a log book, they should get themselves back to the ER.

Does a holter need to be ordered stat? Absolutely not in my humble opinion.

On the other hand, if the ER doctor called me and said, "Hey, if you guys have the time, and a holter monitor available, we would love it for you to put one on a patient so she doesn't have to come back in two days to get one."

If that happened I'd be ecstatic about doing the holter. In fact, it might cause me to have chest pain, and then I'd need a holter set up on me.

A world where doctors are trained by RTs

I wonder sometimes what the job of RT would be like today if doctors were required to work a day as an RT as part of their doctor training.

If we had RT doctor students, then we'd most definitely need a doctor RT student lounge, and in that lounge we'd have to have a bed and a TV for the doctor students to enjoy between passing out peace pipes.

BEEP.

Knock-knock.

"Wake up, you doctor student," Larry the RT said, "we gotta give another neb to Mr. Edgington."

"Wha...hugh..." The doctor smacked his lips together, rolled over, and snuggled back up under the blankets.

"Come on!" A sound of knuckles rapping on a wooden door. "Get out of that bed; it was ordered stat. Doc. student, come on! we gotta--"

"All right, all right... I'm coming." The doc. student swung his feet from under the covers and sat on the edge of the bed. His eyes were still glued shut. "The nerve of them stupid bla bla ordering more stupid bla bla treatments. When I become a doctor--"

"Yeah, that's what the last generation said. Come on!" He held the door and motioned for the doc. student to follow. Very, very slowly the doc. student managed his way to his feet. He opened his eyes, blinked several times to get used to the light, and followed the RT.

"I just want you to know," the RT said as the duo rushed down the hall, "Is this is one of my favorite patients. He's one of the coolest guys I've ever met."

"Really," the doc. student said.

Upon entering the room the RT observed a patient sitting on the edge of the bed facing away from the door. On a table by the window he saw a comode, and he watched as an elderly nurse replaced the tray of the comode, and rushed past the doc. and RT, into the hall, disappearing around the corner. The smell of bowel was redolent in the room.

The RT walked around the bed and faced the patient.

"You got like this because you went to the comode, hey?"

"Yep," the patient ghasped. "The usual." He was leaning on an end table like short-of-breath COPD patient are famous for, and had his shoulders hunched. While he looked like a COPD patient, the RT knew this patient also had an extensive cardiac history. He was got this way, he knew from experience, not due to bronchospasm, but due to his heart.

"You're a little wet too, I bet," The RT said.

The patient coughed up some of the wet stuff from his lungs and swished it in his mouth. He grabbed a tissue with one hand from a small box and hacked up a good one, but the sloppy wet, white secretions was overwhelming for the cheap tissue paper, and dribbled down his chin and onto his gown. He made no effort to clean his mess.

The doctor student plucked a pair of rubber gloves from a box on the wall, and slid them with some difficulty onto his large hands which, the RT thought, were probably too big to perform small operations. But, then again, what do I know? The doc. plucked several tissues from the box, and cleaned the slobber from the patient's chin.

"Thanks," the patient snuffed between breaths.

"We're going to give you a breathing treatment," the doc. said. The RT observed a bit of sarcasm in the doctor-to-be's voice, but he ignored comment on that as he observed the subject, who was obviously pale, drenched in sweat, and had audible rhales that could be heard across the room. He was laboriously breathing for sure. "Go ahead and listen to him.

"What the heck do I need to listen to him for," the doc. student grumbled. "It's obvious he's wet. What he needs is some Lasix and to pee."

"Um," the RT patted the doctor-to-be on the shoulders. "Doc. student, just do as you're told. If the real doctor orders a treatment, then it's a treatment the patient needs. What's so hard to understand about that. What this patient needs is a breathing treatment. One vial of scrubbing bubbles and the patient will be cured in an hour."

"Oh, come on," the doc grumbled as he put together the neb and squeezed a vial of Scrubbing Bubbles into it. "We've done 20 treatments tonight, and about 5 of them have been indicated. I could be in dreamland right now, instead my feet are killing me."

"Did you look at that vial you just poured in. You certainly don't want to give Xoponex when Scrubbing Bubbles is the ordered medicine."

The doc. student rolled his eyes. "Yes! What do you think." He closed his lips tight and concentrated intently on his task. You're mad aren't you. This oughta teach you to order useless therapies when you grow up.

"I could be sleeping." The doctor placed a mask over the patient's face that was connected to some O2 tubing, which the doc. pluged into a flowmeter on the wall, and turned up the flow on the flowmeter. The nebulizer spun to life, hissing. The magic mist instantly filled the mask and billowed through the holes in the mask into the room. Heressed his fingers around the patients wrist and stared at his watch.

The Rt laughed to himself as he stepped around the bed and stood by the door. "Doc. student," he said, smiling, "There will be plenty of time for sleeping on the job when you become a real doctor. You should just be happy our bosses let you practice for that part of your job with that bed in the student doctor lounge. If it were up to me you'd have to stay suffer with staying awake like us RTs and RNs have to."

A fresh, sweet smelling breeze suddenly wafted over the RT as a pretty young dark haired nurse came into the room. The doctor let go of the patients wrist, stepped back and the RN gently positioned the syringe into the port on the patient's IV line. "I have something that will make you pee."

"Good," the patient said.

The RT sat in a chair by the door so he was facing the back of the patient, but could observe his student closely. He crossed his legs, and set his clipboard on his lap. He watched closely as the patient inhaled the magic mist. He knew the treatment wasn't the solution to the patient's ailments, but he enjoyed bossing the student around, because he also knew in a few years it would be the other way around.

"You know what," the RT said on a whim and looking over at the doc. student. "When you are a real doc., you'll get paid $200,000 more a year than me, and you'll get the privelage of us catering to your every whim. And , when your work is done, you'll be allowed to sleep all you want, while we lowly RTs will have to stay awake no matter how slow or tired we are."

The doctor looked at the RT with deep, dark glaring eyes. His eyebrows curved inward so they were snug over the base of his long, narrow nose. Then he relaxed his face, plucked the nebulizer cup from the mask, tapped it a few times, and pressed it back into place. More mist sputtered another moment, then the mist was gone.

All the RT could hear now was the familiar hiss of oxygen, and of course the patient's harsh, gurgling breathing. "It's done."

"I know," the doc said. He removed the mask from the patient, stuffed it into its bag, and set tossed it onto the windowsill. He listened to the patient with his stethescope.

"Do I sound better," the patient said, with a choppy breath between every second word. "Because I sure don't feel better."

"We're working on that," the nurse said, and left the room.

"You guys... are... pretty funny," the patient said, smiling despite his predicament. "You are... a pretty... good duo. Lasix works far better for me that that treatment."

"We'll come back and check on you in about ten minutes," the RT said.

"Ten minutes," the doctor on the way back to the RT cave. "So, after we get him fixed, how long before the next scheduled procedure."

"Three hours," the RT said. "Time to get some charting done."

"Well, I'm going to take a nap first."

BEEP

The doctor jumped at the sound. The RT observed the swear word that crossed the doctor's lips.

"Well, let's see what that is." The RT nonchalantly reached into his pocket and pulled out his pager. "Ah," he said, "Another ABG in ER. Well, how about that."

"ANOTHER ABG" "I hope it's not the same as the last ABG, where the patient was NOT labored, and had a sat of 98 percent on room air."

"Look doc. student, it doesn't matter. Our job is to do what we're told."

"Well, that's gonna end when I'm a real doc here."

The RT rolled his eyes. "Yep, I've heard that one before."

Fast forward two hours.

The doctor student grabbed a donut from a stash of treats provided complimentary by the hospital cafeteria for doctor students only to ingest and not for RTs to enjoy (however they've been known to sneak one from time to time), slammed the door to the RT Cave doctor student lounge, and flopped onto the bed. He groped blindly to one side of the bed for the remote control. When he failed to find it, he stuffed the donut into his mouth.

Through the door he heard a muffled beeeeep, followed by a knock on the door. "Come on, doc, time to go do another ABG."

"Argh."

Not working hard and appreciating it

I woke up early today, and the first thing that popped into my mind was the image of a little boy we had taken care of a while back. I decided as soon as I got to work I was going to check on him via his mother's blog.

Now here I sit. It is freezing cold here in the RT cave. Even with the thermometer turned up to 85 I can still feel a draft coming from the window. And, considering we only have seven patients on our RT list, I have plenty of time to sit here at this computer, which sits on a table right in front of that window with the draft.

Seven patients seems like a lot these days, considering when I came in Thursday night we only had 2 patients. By the end of that night we were up to a whopping three patients, the third of whom actually took up some of my time during that night, but it was still a major task staying awake by morning.

Last night our patient load escalated all the way up to four, but two were QID and one Q4 W/A, so I ended up not giving any of them treatments all night because I'm certainly not going to wake a patient up whose sleeping comfortably. So, what I ended up with was a hell of a lot of time on my hands.

By six in the morning, after spending the majority of the night right here completing some projects and, of course, just a little blogging, I was feeling very sleepy. This wouldn't bother me so much if I were actually doing something, but since I was sitting around so much I needed tooth picks to keep my eyes open, and what I looked forward to more than anything was going home for no better reason than to give my butt cheeks a rest.

I really haven't had an interesting case worth writing about lately, which is unfortunate because I have the time to write. The ironic thing is, if I worked at a larger hospital like some of you other RT and RN bloggers out there, I'd probably have many interesting cases to write about, but no time to write. So, I suppose, that's life.

Last night around six, eyes burning, I slouched back in a chair behind the critical care desk and had a real philosophical discussion about God. It seems when you are most tired, like say after 2 a.m., is when these discussions occur. The discussion seemed really enlightening at the time, and I thought I might write about it later, but, for the life of me, I can't remember the details.

Oh, I suppose this might have something to do with the fact that at around 6:30 it seemed the discussion rested mostly between my two RN co-workers, and I decided to rest my eyes a minute. I will do this just a few minutes, I thought, and then I'll go out and do my QID treatments."

I opened my eyes and looked up at the clock: it read 6:55. My co-workers were still rapt in their discussion. I don't think they even had a clue I had fallen asleep.

Here I sit; the cool draft causing me to shake slightly as I click away these words. I'll eat my lunch soon, finish off my two treatments, and then I'll end up right back here for a few hours unless the emergency room finds other things for me to do.

And I feel fortunate nonetheless. When I have nights like this, at work, I think of how many 18 hour days my dad put in, and his dad before him. And I think how many people have sacrificed their lives over the years so I can have this. I thank them.

Thinking of this makes me appreciate all the more how wonderful a life I have, especially to have a great job like I do.

This reminds me of the little boy again, so I clicked on his mother's blog.

He was transferred from out services to the Big City hospital and placed on an ECMO machine within a few days. If you're not familiar with ECMO, that's a machine that removes the blood from your body and oxygenates it, giving your lungs and heart a rest and time to heal.

She wrote how she was informed by the doctors that there was a chance the boy would survive, but it would be a long and difficult road.

Going on an ECMO machine is nothing like the ECMO machine used in an episode of ER that I watched two nights ago, where the patient was put on an ECMO machine right in the emergency room and taken off five hours later. This boy's doctor said it would be a minimum of three weeks.

I know very little about ECMO other than what I was taught in a brief two hour lesson when I was in RT school. I did see one once when I was an RT student at a large University pediatric hospital in our state, and what I remember is a roomful of machines, IV's and other machines and, right in the middle, this tiny patient.

In doing my research, I learned that there were other children who had swallowed kerosene and survived. Two I read about were placed on ventilators, and another was on an ECMO, and all three of them survived.

This mother was well aware of this, and this gave her hope.

I read today the child passed away.

Now I didn't know this child, as I don't know probably 99% of the people who walk through these doors, but it's very nice when a family keeps us updated on people we cared for, even patients we stabilize in a few short hours and ship out.

While I feel for the child, and especially the mother, this situation acts as a reminder to us all how fragile life is. It provides me a greater appreciation of how wonderful a life I have, and how great a job we have, even while I sit here freezing.

Relearning what we learned and learning more

After I had worked in the hospital for about five years I realized I had forgotten many of the basic things I was taught in school. The old saying that if you don't use it you lose it rang true with me.

One day we had a new RT hired here right out of RT school and he was still studying for his exams. He asked me if I knew what the alveolar air equation was. Of course I knew what it was, but I couldn't think of the formula nor how to apply it for the life of me.

Then one day I was called to talk to the hospital's lawyer because a man who was diagnosed with pneumonia died of something else "coincidentally" and the hospital's lawyer wanted me to be a witness to testify that the patient had obvious signs of pneumonia.

The lawyer said, "How often do you take care of pneumonia patients?"

I said, "I would say that probably about half of all our patients have pneumonia. So we take care of pneumonia patient's quite a bit."

"So you should be an expert in identifying pneumonia."

"Yeah, I guess."

"Okay, to make the jury impressed with your knowledge, I want you to rattle off the signs of pneumonia as fast as you can, like they are second nature to you."

"Okay," I said.

"So rattle them off."

"Ummm, pain with deep inspiration, brown sputum, isolated crackles, ummm..." My mind went blank. I could think of no more, however I knew there were more.

"No problem," he said, "When I talked with your co-worker he rattled off a list. I want you to memorize them in case we go to court."

I looked at the list; studied it. I added a few more signs that my co-worker missed, and the lawyer wrote them down.

I went home, looked up signs of pneumonia in one of my RT books, and discovered that we had both missed a couple more signs.

That was the day I decided I was going to re-learn what I had forgotten that I learned in school. I think you lose it not just because you don't use it, but because you get so used to just doing whatever the doctor tells you to do.

Not only that, but when you're a new RT, you are focused so much on just doing your job and doing it right, you tend to forget the most basic of RT knowledge.

When I was in school I took all the best notes. In some classes I wrote nearly word per word what the teacher said, and then went home and re-wrote all my notes into the computer and printed them off for studying.

But once I passed my registration test I put the boxes of RT class notes in the trash. Man that was dumb. So, instead of reviewing my great notes, I had to start from scratch. Thank God for the Internet.

Fast forward: I relearned what I learned once before and then I learned some more.

It's cool when a nurse calls you to assess the patient, and you know what is wrong right off the bat by your assessment. It's cool when you see signs not of bronchospasm, but of a pulmonary embolism. Or you see a reason to worry that this patient is at high risk for PE, or ARDS, or DIC.

Or, you look at the chart, and at the labs, and learn that the patient is probably a CHF patient as opposed to pneumonia based on the BNP of 30,000. And that the patient is in renal failure, confirmed by the high BUN and creatinin, and GFR of only 18.

Or you assess the patient and observe a high respiratory rate, high heart rate, normal BP, and learn the patient is on an antibiotic and you are the first to think sepsis. You talk with the nurse to see if she agrees with you, and when she does she calls the doctor, and a crisis is nipped in the bud.

In an ideal world you'd think anybody would be able to spot a sign of an illness and know right away what is wrong with the patient, but we all know it doesn't work that way in the real world. That's why we work as a team.

For that reason we at the RT Cave continue to do research on the Internet, to read the opinions of other RTs on the Internet, to listen intently when a doctor or nurse is patient enough to explain something we had no clue about that might come of some use at a later date. Who knows, we might be able to impress someone some day.

Being a small hospital, our bosses can't afford to send us to many RT seminars, or so they claim. But when we get the chance we go. When there is a free in service, and I'm not working, I'll be there with my pen and pencil -- especially if there's a free lunch.

While I'd like to think that this is the way all RNs and RTs think, I have had people tell me, "Why? You are an RT, so why do you need to know about sepsis? Why do you need to know about lab values other than ABGs? Why do you need to know about hemodynamics?

And sometimes I hear things like, "Well, I'm not getting paid anything extra, so I'm not going to learn anything new."

That's fine. I don't have a problem with people thinking that way. That's their choice.

That type of thinking isn't good enough for me though. I want to be more than just a body passing nebs, or doing some odd procedure.

Peak flow meter compliance in question

I always forget to do peak flows when I 'm working in the emergency room. In fact, I've been cornered by my boss more times regarding this than anything else. I admit I should remember to do them, but I still continue to forget.

We used to have to do peak flows on all patients, but one of my co-workers complained that we were wasting our money doing peak flows on patients other than asthmatics. And this might be part of my problem, as if I did them on everyone I'd never forget.

Still, occasionally, we have a new doctor order a peak flow on a COPD patient, but it is my experience that the peak flow number on about 90% of them goes down after the treatment as opposed to up. And then the doctor thinks he has to admit the patient based on the peak flow alone.

In fact, while the American Lung Association states they may be used for COPD, some lung organizations, like the National Lung Health Education Program, note point blank, "This device SHOULD NOT be used to diagnose or monitor COPD."

I don't know how credible that second website there is, but I agree with it.

The idea of using the peak flow meter is something that has been taught to child asthmatics for about 30 years now. From all my hospital visits when I was a kid, I have probably 30 of them crammed into a bag in my basement. Some might even be antiques by now.

The general idea behind peak flows is that the child will use it as a guide or "tool", according to NationalJewish.com, which has a great tutorial on using peak flows.

"Your peak flow meter is only an aide," the site states, "to you. Do not rely on your peak flow numbers alone when deciding whether to take your rescue medicine or call your doctor. Your symptoms also need to be considered."

The general idea is that they go home, blow in the meter morning and night for two weeks to obtain a normal value or "personal best". After that, they are taught to blow in the meter once a day, or if they are feeling asthma symptoms.

If the peak flow number is 80% of the patient's "personal best," the child is expected to use his rescue inhaler. And, after 20 minutes, if the peak flow is not back to normal then the patient is expected to call his or her doctor.

If the inhaler doesn't work, the patient is supposed to go see his or her doctor. If the number is 60% of normal, the patient is supposed to consider this an emergency, take the rescue medicine, and go the the doctor or emergency room.

The problem I see as an RT is this: very few asthmatics are compliant with their peak flow meters. In the past year, I remember one patient who used her meter on a regular basis, and knew what her normal value was. But she was an adult, and didn't need the peak flow to know she needed to be in the emergency room.

As far as I an remember, that was the only compliant patient I've ever had here.

When I was a kid I never used my meter. When I was breathing good I had better things to think about than blowing into that darn thing, and I suspect most kids are the same way. However, it probably would have been a good idea had I done so, may have even saved me some stress.

I did find one study about compliance, and it showed that about 80% of asthmatics were indeed noncompliance, however the study must have been inconclusive, as it called for more studies on the matter. I think that would be a good study.

So, while the peak flow meter is an effective tool for asthmatics, especially asthmatic children, I will continue to question patient compliance with the device.

Signs of an impending asthma attack

Considering we spend quality time on this blog writing about how signs of nasal drainage, chest congestion and excessive secretions are treated as asthma, I thought this would be a good time to make a list of the signs of an impending asthma attack.

While RTs and doctors should know these signs, I also believe it is the responsibility of parents of asthmatics to be educated on and be vigilant for the signs of an impending asthma attack. Likewise, I also think it's important for anyone in contact with kids to know the signs, including teachers, baby sitters and day care moms.

So, just for the heck of it, I've created this list of the signs to be on the look out for. I will follow each sign with a brief description based on my own experience either as a former child asthmatic, current dad of one, and an RT:

1. Itchy neck and chin: I have no clue why this happens, and as far as I know scientists don't either, but this is a classic, and quite often overlooked sign. For me, when I was a kid, this most often occurred when I forgot to take my preventative medicine, and this was my cue to take it, and fast. So, if you see an asthmatic kid scratching his neck and chin, or if you see scratch marks there, you should think asthma, or at least rule it out. If he's an older child responsible for his own medicines, you may want to question his compliance.
2. Mood change: All of a sudden your child is quiet, suddenly moody, appears to be anxious, or stressed.
3. Coughing: I remember a friend of mine telling me about his mother getting annoyed with him for coughing all night, and even making him turn on his side and put his head in the pillow when he coughed so his mother didn't have to hear it. I'm not providing this information to make fun of a mom, but to show that she was missing one of the classic signs of asthma. There might be other reasons for a cough, such as sinus drainage, but asthma should at least be considered, especially in an asthmatic child.
4. Audible Wheezing: This is usually caused by increased secretions in the upper airway, which is a symptom to asthma. This is usually an early sign, but it may also be a sign that the lungs are opening up after bronchodilator has been used.
5. Wheezing (not audible): This is the classic sign of bronchospasm, or that an asthma attack is occurring. In the hospital we use a stethoscope to listen for this, but my dad used to put his head to my chest. Hearing wheezing is a good sign, for it means there is still air movement.
6. Chest tightness: This is something the asthmatic will feel, so it's less likely to be a sign for a parent to pick up on, but if your child complains that his chest hurts, you should think bronchodilator.
7. Increased respiratory rate: Even to this day when I'm around an allergen that really irritates my asthma, I notice an increased respiratory rate. If you notice this, especially when the child is sedentary, you are observing a classic sign of asthma.
8. Itchy, burning feeling in chest: Another classic signs that's difficult to pick up on by pure observation. However the child may tell you he feels funny in the chest.
9. Feeling of breathlessness: Again, more subjective than objective, and you may need to ask a few questions to find out if this is the case. Or, you may pick up on the signs that follow, which are indicative of breathlessness.
10. Leaning on things to breath: This is a sign that an asthma attack is occurring, and a definite sign of shortness-of-breath.
11. Hunched shoulders: This may be coupled with #10 above. Asthmatics do this in an attempt to increase lung capacity so they at least feel like they are getting air in (although getting air in is not the problem, it's that they are not getting it out.)
12. Paradoxical breathing: Normally people have no chest movement with each breath, and their abdomen goes in and out. When a person is having bronchospasms, he will breath more with his chest, shoulders and upper body.
13. Retractions: This is a classic sign especially with small children and babies that are having bronchospasm. When I'm assessing these children in the hospital I place my palm on the child's chest. If I feel the chest being sucked in, I know that child is retracting, and thus having bronchospasms. Thus, while it is impossible for a baby to tell you he is short of breath, his retractions will talk for him.

When my 4 YO daughter was having an asthma attack last month, she showed many of the classic signs of bronchospasm, and, perhaps if I wasn't educated, I might have missed the signs. She had obvious retractions, increased respiratory rate, and wheezing. One dose of Albuterol did the trick for her.

However, every child is unique. So keep in mind the signs provided by each child will be unique as well.

And, while your initial reaction might be the use of a rescue inhaler, there may be other options that work best for your child when you see one or more of these signs. It's up to you to know what's best for your child.

For example, when I was a kid and my neck itched and my chest had the itchy, scratchy burning feeling. The first several times this occurred this caused anxiety, especially when my rescue inhaler didn't work. However, in time I learned this feeling was caused because I forgot to take my Theophylin. And, within 20-30 minutes of taking it, I started to feel relief.

I've never heard of any other asthmatic who observed this, so I'm assuming it was unique to me. Thankfully, however, I've since been weaned off that nasty stuff.

Another good example was provided to me by Asthma mom. She said that her doctor wanted her to give Albuterol to her child when her daughter coughed. But later, as an observant mother, she learned that the coughing often occurred due to throat irritation or sinus problems, and Albuterol was not indicated.

My friend whose mom was annoyed by his nocturnal coughing that I mentioned above told me, in retrospect, he remembers his doctors telling his mom not to give him cough medicine, nor allergy or cold medicine, due to what it says on the box, "This medicine should not be used if you have... asthma."

The theory here is that it may cause bronchospasm. I remember when I was a kid having the sniffles and feeling miserable, and my parents were told the same thing about cold and allergy medicine. When I got older one of my new doctors told me to go ahead and take the stuff, and it worked wonders. Thank God for new doctors and updated research.

My point is that most of the time Albuterol might work fine, but it's good to be observant for other options. If your child has a cold, then that's probably the underlying problem causing the problem. Same thing with allergy signs, which often accompany the signs of asthma.

Same thing with child compliance.

Regardless, when you see these signs, you should have a plan that you and your doctor have pre-arranged. And, if this doesn't work, or you still don't know what to do, then you should take your child to his physician or to the hospital where he or she will be treated as appropriate.

And please keep in mind this is just an extemperaneous list based on my humble opinion. After all, I am just a lowly RT.

Webkins take over my Internet time

Santa Clause made a mistake this year, and gave both my kids Webkins. Now, in their spare time, they are constantly begging to get on the Internet.

Then again, kids have a lot of spare time, so there's a lot of begging going on here, especially by my 4 YO to go to Webkins.com.

My wife decided to be nice to her yesterday and let her play on the site, and then she told me she was leaving to go shopping. I figured while she was so entertained I'd just continue with my task of cleaning the basement.

"Dadda, I need your help," she shouted down the stairs. So much for getting this done.

"What now?" I said, feigning annoyance.

"I have something on the 'puter that I don't know what it is. I need your help."

It's hard for a dad to say no to a cute little girl, so I proceeded up the stairs. I stood behind her, leaned over to look at the screen. At first the screen appeared overwhelming, as there were about a hundred different things going on at once, but then I saw what her dilemma was.

"Um, if you want to buy stuff you need to have money."

"Money?"

"Yeah. Money." I knew a little bit about the website. That she had an online room that her pet lives in. And she has to buy various stuff for the room, such as furniture, windows, decorations, beds, toys to entertain the animal and even food. Oh, and the cat gets sick sometimes, so she had to take it to the Webkin's doctor.

Anyway, I guess it's a whole world there for that kitty. And, to make money, you have to play games. And, based on points made during the various games, you earn money.

"Do you want me to make some money for you?" I was in a good mood.

"Yeah."

So here I sat for the next half hour playing games. I got addicted to one game I thought was cool. In case you've ever been to the site it's called Cash Cow.

"Daddy, can I play now," she finally said.

"No! I'm busy."

"Please, daddy. I want to play."

"Oh, all right, as soon as this game is over." I plucked myself away from the game and let her play, and proceeded to my project in the basement.

Three minutes later: "Daddy, I'm ready to buy stuff now."

Oh, all right. "I'll be right up."

If you know four-year-olds, she wanted to buy everything in stock. Finally she settled on buying a window -- a window of all things.

"Are you sure that's what you want," I said, not wishing to sway her decision, even though I was thinking she should, perhaps, buy food to feed her pet.

"Definitely," she said, "That is absolutely, definitely what I want." She smiled.

I showed her where to click to finish the process, and then she urged me to win her some more money. I got addicted again.

Thanks Santa.

Asthmatics can be normal and have fun too

If all goes as planned, today's the day I get back in the swing of maintaining a sound mind and body. While it seems a ton of people make this their New Years Resolution, it's something we asthmatics have no choice but to think of, though I'm not necessarily the best at it.

Last summer I let myself get out-of-shape, so in the fall I started doing the Body for Life workout program. Which is one of the reasons it didn't make sense that I got sick last month, because I was being 100% healthy at that time. Go figure, hey.

When I was released from the hospital after being diagnosed with a duodenal ulcer, I felt vulnerable, and was going to do whatever I needed to keep my body healthy.

However, while I was recuperating, I wasn't really able to hit the treadmill, especially considering my hemoglobin was low. And then, once that period of vulnerability wore off, I started eating normal again. So now I'm starting to feel out-of-shape once again.

I like working out. I love how good it makes me feel. However, when I stop for whatever reason, say a vacation, a holiday, or, as was the case this time, a hospital stay, I find it easier to stay off the wagon than get back on, and I end up feeling like a do today -- sluggish.

I don't know if this is the case with normal people, but when I go so long without getting any aerobic exercise, I start to feel winded -- not short-of-breath as in bronchospasm, but simple windedness.

I observe some obese people I meet being winded as they walk, but I don't think that's the norm. In fact, I'm convinced it is not. So, when I see someone winded like that, I think chronic lung illness.

How can these people live like that? How can these people stand being winded all the time? I hate it, and that's why I work out. I'm definitely not muscular, and I'm definitely not skinny, but I'm definitely not obese either.

I have learned, both via asthma eduction when I was a kid and the hard way after I failed to listen, that excersise makes your lungs work better. It's true. It really works. It may even make your asthma better.

This is one reason why having asthma might be good for me, and why I don't regret having it. Because it forces me look at things from a different angle.

It forces me to at least keep trying to get my body in shape. And one good thing about having a stomach ailment is that it forces me to limit what I eat. Sometimes I wonder if perhaps God gave me these ailments for this reason -- that, and the fact I have the ability to share my experiences with other people.

I come from a family that loves to eat and drink and have fun when we get together. And I've never been shy about joining in. It's fun. However, one thing that people with asthma have to be aware of is this: alcohol dries out your lungs. Usually, on the day after drinking, I have at least some trouble with my breathing.

When I was younger and still participating in the bar scene, I used to blame this on the smoke. Now I know it's not just the smoke that caused this, because no one smokes around me when I'm in my home. So, if I'm using my Albuterol more than usual the day after drinking, I know it was the alcohol that caused this.

I wonder how many asthmatics don't know this. Most asthmatics, like most COPD patients, learn this by trial and error. Some people never learn, and continue to suffer.

Now that I'm an adult, it's easy for me to avoid things that I know will bother me. Sometimes, however, I intentionally walk into enemy territory because I want to be normal. I'm allergic to my brother's house, for example, but I went there recently to socialize, to eat, to drink.

I got the sniffles. I had the prototypical mild windedness the day after due to the alcohol and whatever I was allergic to at his house. But I had a great time none-the-less. While I try to stay away from irritants, I don't want to live in a bubble either.

In a previoius post, I wrote about how when I was a kid I used to play football despite the fact I'd be having an asthma attack. I did this because I didn't want to let my brothers down, and because I wanted to play football; I wanted to be normal.

I don't get that bad anymore, but then again I don't play football in the cold anymore either. And I have adult sized lungs, am compliant with my medicines now, and have a good routine of preventative medicines, which is why I don't have so much trouble when I rough house outside in the cold with my kids these days.

When I was a kid I remember wanting to be just like my dad, but my dad never once had to think twice about what he needed to grab or avoid in order to go camping. I still envy him for that. And when he took me with him once when I was a kid he had to take me home before midnight because I was so miserable.

Later I learned I couldn't be normal like my dad. For years, when I left the house, I had to make sure I had all my medicines, and especially my rescue inhaler. And no one but me would be thinking this way. It was just something I had to learn on my own.

Likewise, I had to be thinking of where I would be going, because I had to prepare for the worse. For example, if we were planning on going camping, I had to make sure I took something for allergies -- just in case.

I no longer have to rely on my rescue inhaler so much today because I know what places to avoid and we (RTs and doctors) know a lot more now about medicines that allow asthmatics to live normal lives.

And I've learned that there is only one person who knows when I'm entering enemy territory, and that is myself. No other person will notice the warning signs but me. While I'm aware of this, I think this is a major challenge for other people with pulmonary illnesses, particularly people with adult onset asthma or COPD.

Me, I've had this all my life, and when I realized I had to make life changes, it was easy for me because I was young. I bought a new house instead of an older one with allergens. People know not to smoke within a mile of my house. I learned to excercise and eat right, and got into the habit of it (well, sort of).

However, for others, I can see how hard it would be to change their surroundings.

When I was a kid doctors and scientists weren't sure about the safety of keeping asthmatic kids on steroid inhalers, now they know they are safe. And, by using the appropriate preventative therapies, there is no reason any asthmatic should not live a normal life.

When I was a kid I never tried to get out of anything because of my asthma, as my football experience should prove, but I did get out of physical education classes in high school. Now-a-days, there is no excuse for asthmatics to not excersise. Jackee Joyner Kersee has asthma, and it didn't stop her from participating in the olympics.

If you can't run, then you can walk, like the Bay City Walker, if nothing else.

Asthmatics can be normal and have fun too, they just need to pay attention to certain things, that's all.

It's good to have fun. I could not imagine going through life without social gatherings that involve a lot of great food and drinks. And I couldn't imagine going through life without relaxing at the end of a long day with two or three nice cold beers, or a glass of wine, or a whisky and diet soda. Those are just some of the things I enjoy.

We all get out of shape. We all have bad habits. But it's especially important for those with chronic illnesses to do some form of exercise, and to at least pay attention to what they eat, even if it isn't always health foods.

But, as with most people, there comes a time when the "get the body back in shape" mode comes back on. That day, if all goes as planned, is today.

I'm going to do this. I have to do this. And, as usual, it will probably last for about three weeks, at which time I'm going on vacation in Florida. When I get back I'm certain to have trouble hopping back on the wagon.

That's normal, I bet.

Albuterol a cure for annoying respiratory ailments

As part of my usual two week schedule I end up with 6 days off in a row every other week, and right now I'm on day three. To be honest, I'm still not recuperated.

It's not just the burning feet and eyes, but ridiculous doctor orders. It takes 2 days to recouperate from tired feet burnout, and 5 days to recouperate from doctor order's burnout.

I don't have a problem with doctors, but I wish they would actually assess patients rather than looking at them, determining they have no clue what to do, and deciding to annoy respiratory therapy by ordering a breathing un-needed breathing treatments.

I'm telling you guys, if you check out my post, "Physicians creed: how to take care of pesky RTs", you'll see that this is all planned out.

Just before I was called to intubate a patient I honestly didn't think needed to be intubated, I finished doing a second breathing treatment in ER on a 1 YO boy of whom the doctor stated "has obvious signs of RSV."

Upon finishing the treatment, I charted, "Patient happy and playful, no signs of respiratory distress, has audible rhonchi and congestion and runny nose, no observable difference with this treatment."

I had to leave to do an EKG in another ER room, and then, when finished with that, I just happened to walk by the room where the RSV boy was stationed. I overheard the doctor, "He's looking much better. I'll come by in a half hour to see if we need another treatment, and about getting set up for home nebs."

Home nebs? Since when does this child need home nebs. He's full of junk. He needs suctioning if anything. Home nebs? Where the bleep do we get these doctors from?

I rolled my eyes to no one but myself, and waited for the doctor to leave the room. When she did, I proceeded to assess the patient again. He sounded just as junky as the first time I listened to him.

He grabbed at my stethoscope and tried to put it into his mouth. I pulled it from him, and handed him the little blue corrugated tubing from the nebulizer, because I had already discovered he loved to play with it. He smiled at me and placed one end of the tubing into his slobbery wet mouth.

While he was so entertained, I placed my palm on his chest, and I could feel no retractions. With the blue tube, he smacked me on the back of the hand, and smiled at me.

I went to the nurses station, chose a seat in front of one of the computers, and pulled open a charting screen. I did this while two nurses stood behind me, and I made sure they watched what I charted.

"Re-assessed patient at this time. RT notices no signs of respiratory distress. Patient very happy and playful. No breathing treatment indicated."

I was tired, and I wasn't going to dink around. If the doctor is going to order therapy that isn't indicated, the insurance company can read about it via my charting.

Home nebs for this kid! How ridiculous! Why couldn't the doctor have asked me what I think. I've been taking nebs for 25 years; I've been an RT for ten. If I don't know who needs home nebs, nobody does.

Then again, I am bias. And, of course, I'm lazy. I'm lazy because I want to get out of doing work. I'm lazy if I tell the doctor a treatment isn't indicated. I'm lazy because doing the treatment involves actually doing something.

I would love to tell that doctor to look on the Albuterol insert, where no where does it say that irritating lung sounds is an indication for this medicine. But that would involve actually doing research. That would involve going into the room and actually assessing the patient for real signs of bronchospasm.

Then again, another doctor ordered a breathing treatment on the floor. The patient told me she was not short-of-breath and, upon assessment, her lung sounds were clear with good air movement.

She said, "Well, I did tell the doctor I had a little cold."

After doing this treatment I charted: "Patient denies SOB, NARDN, no signs of bronchospasm, no indication for therapy, no difference with therapy."

Read that, Dr. Astro. Read that insurance company, and think about why you have to put out $80 for this procedure.

I would love to tell that doctor to look on the Albuterol insert, where no where does it say that clear lung sounds is an indication for this medicine.

Later I had a patient in ER who was very short-of-breath. I noticed this while doing an ordered EKG, assessed the patient, and thought a treatment might benefit the patient. However, the doctor told me the patient didn't need one.

Whatever! I left the ER and went to my cave, where...

...five minutes later the phone rang. Oh, come on!

"Yeah, respiratory," I grumbled into the receiver.

"We need another treatment down here," the ER desk clerk said.

Okay, fine. So the doctor came to his senses on the patient I thought should have a treatment.

In ER I observed that there was not one order but two, and neither was for the guy I wanted to give a treatment to. Upon assessing the patients I learned that one was coughing too much, and the other was not coughing enough, and the doctor wanted a sputum.

Ah, I just want to go home.

It's amazing a world where the same medicine that can be used to make someone cough can make someone not cough. And the same medicine that can get rid of rhonchi can make clear-er clear lung sounds. And, yet, a patient that's really having bronchospasm has to wait.

You'd be proud to know I was a good boy and kept my mouth shut, but I charted "No treatment indicated," on all of them. Is this legal. I really don't care.

No wonder the cost of medicine is so high. I wish that doctors would look at my charting, at least then we could have a good debate about it. And, of course, I'd lose. I'd lose because these doctors are following the "Doctors Creed: how to take care of pesky RTs."

Doctors are not on a mission to annoy RTs. They are taught in med school that Albuterol nebs are a cure all for all annoying respiratory ailments. Understanding this should help us RTs who study research that shows bronchodilators are for bronchospams and bronchospasm only.

In other words, doctors don't think in terms of "does this patient have bronchospasm or does this patient not have bronchospasm." Heck no. That technique is simply too hard and would involve a full assessment and doing reasearch.

They don't think this way becasue bronchospasm is covered under "annoying respiratory ailment." There may be exceptions to this rule, but not very many.

This is why it's better to just keep RT mouth shut, however hard that might be to do sometimes, expecially when I'm burned.

For more information check out the list of 'olins at the bottom of this blog page. Even while docotrs order Albuterol, they have these 'olins in mind.