RT cave made a top 50 therapist blog list

It's neat to know there are people in the blogosphere other than chronic lungers and RTs who are interested in the writings of your humble respiratory therapist.

In fact, there have been occasions over the year and a half I've been doing this that I've received emails from random people who write things like this:

"I don't have asthma, nor COPD, nor any respiratory disease ever, and I'm not a respiratory therapist, and I still find your blog extremely interesting."

I think those emails are my favorite. You know if you are writing respiratory stuff for respiratory people and someone not in your target audience is interested you are doing something right -- right?

That's what I'm "Assuming" anyway.

So, the reason I brought this up is because I received an email today letting me know I have been included in a list of top 50 therapists -- on a physical therapy blog. I consider this an honor.

To check out this list and see who else might be on it, click here and I will morph you there.

You know it's time to go home when....

....you just finished hooking up a patient to the EKG machine and, as you go to type in the patient's information, you realize you are in the wrong room with the wrong patient.

Oops. No harm done.

That's about how crazy it's been around here lately.

'Nuf said.

The smartest doctors in the world: part 4

Darn it! I did it again! I busted myself thinking again. When am I gonna learn. They always say old habits die hard.

Let's see. This time I was giving a treatment to a 7 YO asthmatic, and during the treatment he went on a coughing jag. His heart rate was 150 when I started the treatment, but after the jag it shot up to 200.

So I stopped the treatment. I didn't do this because I was thinking, because if I was thinking I would have finished the treatment. I did not think it was the Albuterol that shot the heart rate up. But, I knew who I was working with: a doctor with a 200 IQ.

Less than five minutes after the treatment the heart rate was back down to 145. I also concluded via my assessment -- or simply just watching the patient huff and puff -- that my little patient NEEDED another treatment.

After the treatment I'm standing behind the nurses station, and the doctor asks me for an update on the patient. The nurse interjects, and tells the doctor I had to stop the treatment because the Albuterol made the heart rate go up.

"We better wait awhile before giving another treatment," the doctor said.

I said, "I don't' think it was the Ventolin that caused the heart rate to spike."

The nurse said, "It was definitely the treatment. The heart rate was fine before you started it."

The doctor said, "Yeah. We'll wait a while before giving another treatment."

"I really don't think it was Albuterol," I said, hoping to convince the doctor that another treatment would be safe for the patient. "If it was the Ventolin that caused the Heart Rate to spike, it would still be up. Since it came right back down after the coughing jag, we should conclude the spike was due to exertional dyspnea."

The doctor looked at me dumbfounded. Then he said, "I'll call you when his heart rate goes down and we're ready for another treatment."

"Sounds good," I said.

Yep. I should know better than to ever question the brilliance of a doctor with a 200 IQ. Challenging such a doctor is highly unacceptable and should never be done, as every RT should know that any spike in heart rate during a treatment is definitely caused by the Ventolin. End of discussion.

I have to stop thinking. I have to do it. I need therapy.

Does pollution cause asthma?

There is a lot going around these days that pollution is the cause of asthma. While asthma rates are marginal in 3rd world nations, they are growing in industrialized nations, particularly large cities like New York and Chicago. The question I would like to toss out today is this: is pollution the real culprit?

Now, unlike some people, I have no bias either way. If asthma is caused by pollution it’s caused by pollution. But before I come to any conclusion I like to have all the facts on the table. I don’t like to believe in one theory over another just because one makes me feel better, or is more popular.

Is pollution the cause of asthma? Lets look at the facts.

You can look back at the 1800s when there was horse poop on the streets, coal and wood fires burning in every household, smoke billowing through the air. If you take a deep breath you can smell the smoke, smell the poop. I’m sure all this had a negative impact on any asthmatic in the day.

If you listen you can hear flies buzzing around your head as they swoop down to lay another egg on the horse dung. Whatever diseases they are spreading you can only imagine.

Today, however, we have no such horse poop. We have far fewer coal and wood fires, although they do still exist. However, the horse poop is exchanged for car fumes.

In the 1800s, however, there was no technology available to clean the air. There were no filters. There were no concerns about air pollution. You simply didn’t think about it. But was there less air pollution in 1888 than today. Who knows?

However, we do know that there were still volcanoes that erupted and caused holes in the ozone much larger than any nuclear explosion man has ever made. We know that as a fact. We know that there have always been holes in the ozone. So any bad rays that get through now have always gotten through.

So recent studies that show that asthmatics who are exposed to ozone are more likely to have a decrease in lung function may not necessarily show that this is a new phenomenon.

Based on what I just wrote we have zero evidence that pollution is the cause of asthma, and no evidence that it is not. What we have hear is some groundwork to show that pollution existed long before industrialized nations, and we must not come to a harsh conclusion just because it’s convenient or obvious or popular.

I have been doing a lot of writing lately about asthma. This disease is a major conundrum for scientists in that it has been around longer than most diseases in recorded history and we are just now beginning to understand it.

Considering this long history, there have been a lot of truths, and a lot of false information to go with those truths. In the 1800s, for example, scientists educated doctors that asthma was definitely a psychosomatic disease, "that the disease is all in the head of the asthmatic."

Well, now we know that "theory" was pure poppycock --fiction. Sure stress can act as an asthma trigger, but it cannot cause asthma. Despite this truth, millions of hours and lots of cash was spent in an effort to treat asthma as a mental disorder.

Recently, with the high rates of air pollution, many scientists have been teaching that air pollution may be a cause of asthma. Yet new theories have been created that challenge the pollution theory.

A new theory – called the Hygiene Hypothesis – notes that the cause of asthma may be just the opposite of what the pollution theory postulates: that asthma is caused not because of pollution, but because we are too clean.

It may not be popular to go against the pollution theory, but that's exactly what RT philosophers like myself are not getting paid to do.

Stay tuned, keep your mind open, and I’ll continue to discuss this in the days to come.

The smartest doctors in the world: part 3

I was busted thinking again.

There has been more than once on this blog I've mentioned how I think holter monitors are not an ER procedure. I think that if a patient is so "questionable" that monitoring needs to be done, the patient should be admitted and placed on overnight telemetry.

If the patient is stable, then he can come back during the day time to have a holter hooked up by the people who are hired to do it.

I said to my boss that it's not that I don't want to do holters, nor that I do not like doing them in the ER, it's that I don't have time to do them.

"But the doctor ordered them?" she said to me.

"But..." I grumbled, "Just because a doctor orders something doesn't mean it's indicated."

Needless to say I was put in my place. I was lectured like a 1st grader who said his first swear word.

You see, I was rightfully so put in my place. I was wrong. And I realize that now that I have been informed the IQs of any doctor hired here at Shoreline is 200 (click here for part1 & 2).

Now I know my folly. Now I know never to question the brilliance of these doctors. Now I know that I shouldn't think, but rely on the brilliance of the doctors.

To punish me for thinking, the RT boss purchased nine more holter monitors. She did this so that I could never say again to the ER doc, "I'm sorry, but we are out of holters tonight."

No more excuses. One should learn never to question a doctor. After all, they did go through medical school and you did not.

The smartest doctors in the world: part 2

Going along with what I wrote yesterday about the doctors here at Shoreline Medical being among the smartest in the world. I was written up in February because I placed a patient on 2lpm nasal cannula, and her sat was 94% on that 2lpm.

Now, if you're like me you might be doing a double take as you read over that, and doctors who work for inferior institutions like Butterworth in Grand Rapids or the so-called elite institution up in Ann Arbor might do the same, but the doctors here at Shoreline Medical KNOW better.

Yep, you heard right. While I thought I was doing the right thing by making sure the patient only had as much oxygen as she needed -- which was 2lpm - I was WRONG.

That doctor who was taking care of that patient that night wrote an order for 4lpm -- not 2lpm. She was smart enough to know that that 2lpm was not going to be enough oxygen.

Of course nothing bad happened to that patient in the 8 hours she was on 2lpm during my shift, but that was only because I was lucky. Thankfully that doctor came in right after my shift ended and spotted my medical error and turned that flow up right away.

Man, my heart was just a fluttering as I realized my error. If that patient wouldn't have been turned up to 4lpm when she was, something awful might have happened. So it was only justified that she make the day shift RN write me up for thinking.

On the variance I was forced to write: "I am sorry. I will never think again."

The smartest doctors in the world

I have to tell you guys something about the doctors here at Shoreline Medical Center. It's esoteric information. I'm not supposed to be privy to it, but I am. And, because I am aware of it, I feel it is my duty to share this wisdom.

Look, of course my fellow RTs are familiar with the term "treatment jockey." That's where we go room to room giving breathing treatments to the patients ordered on treatments.

Sounds easy hey? Well, the job opening a vial of medicine and pouring it into a nebulizer is quite simple. Often times socializing with patients is fun too. Yet, when the patient is grumpy or disorientated, it can be interesting to say the least.

Oh, and then you have the occasional labored patient who presents a worry, and forces us to do some critical thinking. Those are the cases that make the job fun.

I guess you can say we RTs here at Shoreline are simple "treatment jockeys." We get grumpy on occasion, or make frivolous whit here at the RT cave, because we get irritated at doing breathing treatments on patients who simply do not need them.

However, I digress. I have learned here that there is a reason that only 3 of the 14 patients on every four hour (q4) breathing treatments have an indication for the treatments. The reason is as follows:

You see. In order for a physician to be accepted to work at Shoreline he or she has to pass an IQ test. He or she must score no less than a 200. That explains why the administration here at Shoreline have trouble attracting doctors here.

There's an old saying: What do you call a doctor who got the lowest score on his medical exam?

The answer:

Doctor.

Well, those doctors are NEVER hired here at Shoreline. We only hire the best of the best; The creme de la creme to say the least.

Those inferior hospitals down state in Grand Rapids and Ann Arbor, Michigan, are just that: inferior. They have trouble recrouting the cream of the crop doctors, and so they have to resort to innovative techniques such as protocols that allow RTs the opportunity to think.

That type of inferiority would never happen at Shoreline Medical. Our "brilliant" doctors never allow us to give a treatment when "WE" think they are indicated, because they KNOW when a patient is going to be SOB and have us give the treatment BEFORE that time.

That's why we often have discussions like this with our patients:

"Are you short of breath?" The RT asked.

"Well," said the patient, "I feel fine, but the doctor said I need a treatment."

Or this:

"Isn't an Albuterol treatment supposed to last four hours? Isn't that how often you should get one?"

The RT said, "Ideally the med should last 4-6 hours. However, every patient is different. For some patients the med lasts only one or two hours when they are sick enough. Most patients, however, get one treatment and then they don't need another one for several hours or even days."

"So why did my doctor order my treatments every four hours?"

"Good question," the RT said, scrapping his brain for a good answer. "I think most doctors order out of habit."

RTs who think this way get frustrated easily. They resort to frivolous humor or sniveling on blogs like the RT Cave.

The truth, however, is our doctors don't have to resort to unwise tactics of having RTs assess a patient because THEY KNOW EXACTLY WHEN A PATIENT IS GONIG TO BE SOB.

It's awesome actually. The doctors here at Shoreline know exactly when a patient is going to be short of breath and they have us give a treatment BEFORE the shortness of breath happens. It's called prophylactic therapy.

Yep, most of what we do is prophylactic therapy. Our doctors -- the smartest in the world -- order Q4 or Q6 treatments on all our respiratory patients because they just know.

It kind of goes like this old saying: lovers think, priests believe, philosophers think: Doctors here at Shoreline Medical Center know.

Hush. Don't tell anyone I told you this.

What are long-term effects of asthma?

"What do you think is the life expectancy of asthmatics?"

This was a question I asked many of my friends and patients I came across as I worked a while back, and the answers ranged from 45-60. It seemed most of my friends had a bleek outlook for us asthmatics.

Last week this question came up at MyAsthmaCentral.com: "What are Long-Term Effects of asthma??"

I wanted to share my answer here at the RT Cave, because I think this would be of interest to any asthmatics who happen to be in my audience, and any one who lives or works with asthmatics.

Here was my answer:

Great question. When I was a teenager with hard luck asthma in the 1980s asked my doctor the same question, and he had no answer for me. The good news for you is I have since found the answer.

Asthma experts now believe that for about 90% of asthmatics the life expectancy is the same as for those who do not have asthma -- 80 years. The key, however, is for your parents and doctors or you to recognize right way that you have asthma and to treat it immediately and aggressively. So long as your acute asthma attacks are treated swiftly, you should have no long term problems.

Likewise, once your asthma is diagnosed you must become a gallant asthmatic (click here and here). You must be educated about your asthma. You must learn what your asthma triggers are. You must avoid your
asthma triggers to the best of your ability.

Likewise, you and your doctor must work together to develop an Asthma Action Plan (AAP) that works best for you. Your asthma AAP will help you decide when to use your rescue inhaler, when to call your doctor, and when to have someone take you to the emergency room (or call an
ambulance).

Another key is that you must be aware that asthma has two components: airway constriction that makes you feel short of breath (this can be treated with your rescue inhaler) and chronic inflammation, which is swelling and redness of your air passages (bronchioles) that's always there.

Both of these components of asthma can be treated with PREVENTATIVE medicines like Advair and Symbicort.

So long as you are always compliant with your preventative (controller) asthma meds you should be able to keep your asthma in check, and thus develop no long term complication.

However, goofus asthmatics (click here and here) who do not take their meds as prescribed, and who do not follow an AAP, can develop lung scarring that can complicate the airways and make asthma more difficult to control (however it is still possible).

Likewise, asthmatics born before this modern wisdom (as myself) may also have developed lung scarring if too many of their asthma attacks went untreated. This shouldn't happen anymore. In fact, according this press release, the number of severe asthmatics is going down.

I hope this is some good information for you. If you have further questions be sure to let me know.

I promise to blog more about this in the future.

Is there a link between air polution and asthma?

Is there a link between air pollution and asthma? That is a question I am going to spend the next seven days investigating, and reporting on here at the RT Cave.

What is the answer to that question? I do not know. Many of us may have an opinion in this area, but are we really right?

It is true that there is a certain level of pollution in the air, and some of it is definitely caused by the burning of coal and oil, and some of it caused by natural things like the sun and ozone.

Setting opinion aside, we have some facts documented.

We know that, according to the AAAAI.org that between 1980 and 1994 the prevalence of asthma increased a whopping 75%. There are many theories for this increase, and one of them is air pollution. But there are other theories too

Likewise, according to the authors of a book called Fatal Asthma, the incidence of asthma related deaths has increased from being "negligible" in 1930 according to asthma experts at that time, to 3,000 per year in 1998 and 5,000 per year as of 2006.

Is pollution the cause of this rise in the prevalence of asthma? Is pollution the cause of the increase in asthma related deaths?

My goal in the next week is to clear my head of any bias I have (and I ask you to do the same), and I aim to investigate this matter and come to a logical conclusion based on the facts.

However, before you clear your head of any bias you might have, take the poll at the top of this blog. Go ahead, do it right now! I'll wait here for you.

Good. Sometime in the next week I will participate in the poll too. Throughout the next week (and time permitting because I do have to work 8 of the next 10 days), I will read, study and report to you facts regarding this matter.

Next Wednesday (April 1, 2009) at midnight the poll will close, and I will announce the results next Thursday. Likewise, at that time I will give you the latest information regarding pollution and asthma, and together we'll come up with a conclusion to our question: Is pollution the reason for the increase in the prevalence of asthma?

Once all the facts are on the table we'll retake the poll and see if the results change.

Oh, and one more thing: If any of my readers has any information regarding pollution, or that shows how pollution is or is not linked to asthma, send it my way and I will share it with my readers.

Go vote! Now! And then, with an open mind, stay tuned to the RT Cave for an open minded discussion on this matter. And don't be afraid to admit you are wrong or gloat if you are right.

c-sections increase risk of asthma by 80%

You heard right. According to a study referred to here, children born by c-section are 80% more likely to develop asthma.

Scientists are unclear of the reason, but there are theories. First off, one must be aware that asthma is an auto-immune disorder that only those who have the asthma gene will have a chance to acquire. In most cases it is caused in infancy when the immune system is forming.

One great theory is the hygeine theory, in which scientists believe we as humans have worked so hard to clean up the way we live to prevent the spread of disease that we have literally cleaned ourselves into some new diseases, and one of them is asthma.

Your immune system ideally is supposed to attack bad parasites and bacteria. It is believed that the immune system has to constantly be stimulated. Absent bad bacteria and bad parasites, the immune systems of some people get bored and start to attack good things, like harmless dust mites, molds, animal dander, cockroach urine and stuff like that (common allergens).

One such theory, according to MedicineNet.com, has scientists thinking, "babies born via C-section have impaired immune cell function because of suppression of regulatory T cells, which regulate the development and function of the immune system."

Basically, children born by c-sections have immature immune systems. The same thing is believed to be true of babies born pre-maturely.

The study, presented at the American Thoracic Society's 2008 Conference in Toronto, "suggests that the stress and process of labor itself or exposure to specific microbes through the birth canal in vaginal rather than C-section delivery may influence neonatal immune responses."

This study significantly impact the decision by many people to have elective c-sections, especially by parents who have a history of allergies and asthma (and probably have the asthma gene).

Stay tuned, because in a future post here at the RT Cave I will explore other possible causes of asthma, or things that might turn the asthma gene to the on position. Stay tuned.

RT Wit & Wisdom

Okay, so it's Sunday. My wife is working and my five year old daughter is working (riding horses with grandma), so that leaves me all alone with my 5 month old. Well, you know what that means, daddy actually has to work today.

She was fine yesterday, but today she's made it quite aware that she's tired of the bottle and wants something I can't offer. She's a happy baby for the most part, has discovered her hands and her voice -- which means she can entertain herself to an extent.

Yet she seems to have learned from her older sister that daddy can be a pushover if you flash your eyes and beg -- or cry. Yep, she's bright that way. She decided today she wants daddy to hold her until "what she wants" gets home -- which isn't for another seven hours.

Right now she's giggling as she plays in her new walker thingy. So, not knowing how long this "happiness" will last, or how long until she remembers she's not being held, I have to be quick here -- sententious so to speak.

Oap, she's crying. Gotta go.

I'm gonna start a new theme here: RT Whit. Oh, it's not whit as I just realized in my header. Whit is not wit, it's wit as in Ben Franklin's Wit and Wisdom. No one seemed to pick up on my error, but since the whole purpose of this blog is RT honesty, I'll confess my error (too bad I can't get the Rt bosses to be as honest like this).

So, today's wit is this:

"You can give the laziest person the hardest job and he will find the easiest solution: he will find someone else to do it."

Let's give an RT spin to this:

"You can give the melancholy, choleric and political orientated boss the simplest job and she will find a way to make it complicated."

Gotta go! She's no longer happy in her walker thingy.

Another type of ventolin

I informed my readers yesterday that soon I would get back to writing useful things. However, soon is not today. That said, warning: you may not want to read on.

However, I have come up with another version of Ventolin common at a hospital near you. You'd be amazed at all the non-bronchodilator uses doctors come up with for ventolin (or Xoponex). It's comical.

Here's the latest version:

Viagronex

Symptom: Shortness of breath, wheezes or diminished lung sounds

Diagnosis: COPD, end stage bronchitis and/ or emphysema

Frequency: Q4

Effect: The idea here is that COPD patients have burned their cilia to the point the cilia are crusty, limp and quite useless at bringing up phlegm. The patient has secretions in his lungs that he cannot expectorate as a result, which can tend to cause infection and chronic cough. The idea with Viagronex is that it titillates the cilia and causes them to stand on end so that they are excited to action.

I warned you I had nothing useful to say today. Have a great and relaxing first weekend of spring 2009.

3 types of lethal arryhthmias

Dear RT Cave readers:

I promise I will write something useful soon. It has been extremely "swamped" where I work each of the past six days. We have one vent right now, but we have had up to two on many of the past several days.

And, if I am not mistaken, I have had at least one BiPAP ongoing all 6 of those days, and have set-up at least one BiPAP each of those nights. And add to this ten regular patients on bronchodilator treatments (perhaps three of which actually need them).

And then you have to add constant calls to the ER. And, of course, you have to note that I am the humble night shift RT here at Shoreline medical, so that means I did this all by myself.

Oh, and you also have to add to that some one in in my department has been a god awful something that rhymes with twitch and starts with a b minus the tw. You can figure that one out. I swear you can have a million more important things to do, and
this person still finds something to nag about.

Whoops, I'm not supposed to complain anymore. Oh, and I forgot that we (I)had an RT student last night too for the first four hours of my shift. And since I love to teach, this kind of added another responsibility to my long list of things to do.

We RTs here at Shoreline like to share our RT humor with our students. Albeit they often aren't sure if we are joking or not. Last night the day shift RT (The sagacious Jane Sage) educated them on the three basic types of lethal arrhythmia's you should be able to recognize on a rhythm strip or EKG.

These Lethal Arrhythmia's are:

1. Too fast

2. Too slow

3. Oh shit

Have a great weekend. And, oh, as soon as my energy level returns to, say, the 50% level, I will write something useful on this blog. So bare with me.

Sincerely:

Rick.

A couple new diseases

Spending so much time with patients we tend to observe new diseases doctors and scientists never picked up on. See if you recognize some of these:

1. Chronic bed syndrome: Here you have your typical chronically sick patients who are unable to get out of the bed. They usually present with some grumpiness and fear not bossing you around without saying thank you. They expect you to cater to their every need; to actually know what they need before they ask. They tend to fit into any or all of the following adjectives: grumpy, demanding, purposeful apathy, melancholy, bossy, condescension.

2. Whoa is me syndrome: Some diseases might be MS, ALS, MSA, trauma, rehabilitation, chronically ill, or any such disease where the patient slowly develops atrophy of muscles and possible paralysis. She needs constant assistance moving and perhaps even drinking. They constantly yearn empathy and can at times fall into the Chronic bed syndrome. Ultimately, they want you to feel sorry for them. Something you might hear from this patient is, "Oh, why did this happen to me."

The future of the RT profession is in our hands

One of the fun things about being a respiratory therapist is that this "profession" is still in the beginning stages. All of us RTs who are in the profession now have an opportunity to shape the profession, and determine the role of RTs in the future.

That is one of the main reasons I love this job. I'm not sure I would like to ever get into administrative work, mainly because the risk of getting canned increase as you get closer to the top (that's a discussion perhaps for tomorrow). But I would like to get more involved in hospital politics. Something I'd have to go to days to do.

During those long, drawn out nights when we had a low census the past couple years I have worked together with one of my co-workers and written several protocols. If nothing else, they are sitting in my locker available if a doctor some day realizes the benefits of RT driven protocols (patient driven protocols).

I have also created several "cheat sheets" so we RTs don't have to "memorize" detail. I think I've spent over 200 hours working on this. Just to give an example, I created a table whereas you can pick the VT range ideal for your patient, instead of just guessing (as many doctors do.)

My VT table has become so popular where I work that our doctors no longer tell me the VT, they ask me what would be best. I have never had a doctor overrule me. And I think this has something to do with the increased respect for us RTs. Respect is something that is "earned."

There are many things at this hospital I would like to see changed. I would like to see more often doctors relying on the wisdom of us RTs (and RNs) who are at the bedside and do the same thing day on out, instead of making up orders extemporaneously. Kind of like the VT table I discussed above.

We have to bide our time, however I think things are getting better for this profession. Nurses who respect us call us every time a patient is in trouble. They ask us for our advice. "What are the I's and O's?... Ah, the patient is wet perhaps?...."

Doctors even sometimes ask to speak with an RT for our advice. "Do you think this patient is bad enough I need to come in?... Do you have any ideas what we can do for this patient?... "

"Definitely!... and YES, I certainly do. I think this patient would benefit from....?"

It's this kind of creative thinking that draws me deeper into this profession. It's the challenge. And, ironically, it's the politics.

You have many RTs who are simply button pushers. They receive their orders and they do them without asking questions. Then you have RTs like me and you who are the question askers and thinkers. We need both. We need all types of personalities to make a profession respectable.

Yet we must not become discouraged and daunted. We must not quit, however tempting that can be at times. The future of this RT profession is in our hands.

Deep Thoughts by Rick Frea

A man came to my house today with a bag. He said there is a million dollars in it. He said, "You can have it if you want." I said "No thanks, I don't know what I'd do with a million dollars."

Quitters are counterproductive

I have been writing lately about things that are wrong with the RT Cave. However, you must remember that I have also written in the past about reason I love my job as an RTs (click here and here).

I say this because some people have emailed me, or left comments on my posts, about how if they worked for a department run as ineptly as the RT Cave they would quit. However, I am going to state here that this is exactly what I will not do. I will not quit. I cannot quit.

Besides, if you click the links above you will see there are too many good things to walk away from.

The management at Shoreline can be tough at times. They like to put people who make mistakes on the spot and make them accountable for their actions. They like to make us aware of our mistakes (however minor) so we become better. And although their methods of doing this may be flawed (are flawed), the cause is noble.

There have been people in the past who did not have the courage to withstand the scrutiny, and they are since long gone. They were the quitters. They were the soft skinned people who would prefer working some place where no one is held accountable.

Or perhaps they quit here and are now working at Sunny Flats. You see, the grass isn't always greener on the other side. But some people don't realize that until after they make a life altering decision. They, as they say, burn bridges.

Likewise, to quit a job one loves because one disagrees with management from time to time would be foolish. It would mean a major life changing experience. Unless you live in a major city, it would mean either driving 2 hours to work every day and being twice as tired. For me it would mean moving the family and taking my kids out of a school they are comfortable with and putting them in a big city school.

I'm sure the kids would be fine by the move, but I'm not willing to make such a rash move. My kids have great friends, live in a great neighborhood, and have a good home life. What kind of dad would I be if I put my occasional irritation about some things that occur at work interfere with this.

Besides, my level of happiness is not determined by other people, it is not determined by my work, it is determined by what happens at home. Work is a nice place to spend my time, but it is not more important that what happens at home. Some people, however, live and die by what happens at work.

Quitting my job would solve nothing. Quitting my job would only make the problem worse. It would be no better than a conservative leaving the United States because he hated President Obama. It would be counterproductive. It would only make the problem worse because the problem would go unresolved until another person with a stronger spine came around.

In fact, if all the people who saw problems in the healthcare system years ago wouldn't have run, perhaps the entire healthcare system wouldn't be in crisis today.

Work is work. Most of RTs do this because we enjoy our jobs. We have fun as best we can. We appreciate that most of our ancestors worked hard and got dirty on the farms and worked un-Godly hours. Yet they had no bosses other than the money they earned to feed their families.

We work three days a week, take care of people as they come in and feel joy in helping them out. Unfortunately, some bosses and some fellow co-workers like to make even the simplest job complicated. They try to make it so that you do everything their way. They don't want you to be a free thinker.

In my opinion, if you tell people they always have to do it your way, you're assuming you are always right. And that is not "always" the case.

No where on this Green earth are we humans ever going to escape the rigors of other personalities, money, or ignorance. Those things will be everywhere we go. Some personalities are stiff and rigid. Money is needed.

Ignorant people are sometimes envied by people like me because they simply go to work, collect a paycheck, and then go home without questioning ignorant decisions made by others. In fact, they don't even see things as ignorant. Yes it's true ignorance is bliss, but you can't say that to the ignorant.

Unless we want to live our lives as miserably as the people pent on dragging us down to their level, we must put our heads up and face the future head on. Perhaps a new protocol is on the horizons, or a positive change. Something that will never happen if we all jump the fence.

When I was a kid I remember going with my dad to his work one day. On the way to work dad
was silent, and I knew it was because nobody was buying his product lately. He was worried. Yet, as soon as dad and I walked into his business, his secretary said, "Hey, Bill, how ya doin today?"

Dad said, "Absolutely wonderful."

The secretary smiled and dad made his point.

Is profit now more important than saving lives??

Most respiratory therapists are pretty good at what they do. We aren't just chums and peons who slap a neb in someone's mouth and leave the room, we assess and we do creative thinking to the benefit of the patient.

But many doctors and nurses and Rt bosses and administrators don't understand that. They see us as ancillary staff, no better than the technician that draws your blood or performs an ordinary x-ray.

Very few times in the 13 years I've been in this profession have I heard of one of my coworkers making a mistake that endangered the life of one of the patients. In fact, I can think of no examples of which this happened. In fact, perhaps it never has.

Yet we have all spent time in the RT Bosses office from time to time defending ourselves because of some write up for some stupid reason, or, most common, because we forgot to chart a treatment.

It's almost to the point now that I spend so much time worrying that I'm charting correctly, and charting all my therapies, that charting has become the priority, with patients taking a distant second place. The number one goal of hospitals is not to save lives and make sick people better, it's to make money.

My coworker told me that she told the boss several years ago if it ever got to the point she was paranoid that she was going to make a mistake for creative thinking that she would quit. Now that's exactly what it's come to here at Shoreline Medical Center. We have all become paranoid.

We're not paranoid because we think we are going to compromise our patients, because they always come first to us. We are paranoid because we are afraid we aren't going to chart perfectly. We are told if we don't chart all our stuff we (meaning the department) won't get paid for a procedure.

Now I certainly want the department to make money, as I want to make a paycheck, but I think it's bull crap now that it's to the point we are all paranoid.

It makes one think this way:

"Which is more important: Doing something to harm a patient or forgetting to chart a treatment?"

I like to think, as do most ethical human beings, that the first goal is to do no harm. Yet now I'm beginning to wonder if the greater priority is making sure we chart so we can make the hospital profitable.

It's a shame I have to write about this, but it's true.

How to create a successful business (RT Cave)

In the past few days I wrote one post on how to make a better Rt Cave as far as morale and productivity (click here), and one post to show the reason why morale is often low in RT caves across the country (click here).

Today I came across another post similar to mine (better actually) over at RespiratoryTherapy101. He wrote about the techniques used by Scott Adams to run a successful business. They are:

1. Have fun. Loosen up.
2. Try something new. Often. Keep whatever works.
3. No penalty for a new idea failing. Trying is the thing.
4. Employees are more important than customers.
5. Stop asking Scott for approval. Just do it.
6. Managers get to see the financials.
7. Being a jerk to coworkers is grounds for termination.
8. Do whatever seems smart and fair to make customers happy.
9. Watch the competition closely and borrow their best ideas.

Like the anonymous RT over at RT 101, I love #4.

One of my coworkers argues with me that the customer is always right. She even puts her patients so far ahead of herself that she often goes nights without eating.

I said to her, "That's stupid. If you don't eat, if you don't sleep good, if you don't take care of yourself, you are eventually not going to be taking good care of your customer. You need to take care of yourself so you can take good care of your customer -- the patient."

Likewise, RT bosses and administration needs to provide good incentives, good benefits, fair wages, respect, and open ears to the people working for them.

As the anonymous RT writes, "...employees need to feel valued and respected to be productive."

I too wish Mr. Adams would come and talk with the bosses and adminstration up here at Shoreline Medical Center. We all would benefit.

Docs and RT Bosses need to quit the bull crap!

Sometimes we RTs simply get tired of the bull crap. All we really want are doctors and Rt bosses to leave us alone so we can do our jobs, take care of our patients, grab our paychecks, and go home to kiss our kids good-night (or good morning in my case).

Sure we do a noble service and enjoy taking care of patients, but the bull crap that goes un-noticed are the things that make us RTs cranky and perhaps even entertaining. We are the watchdogs at the hospital; the overseers; the reality checkers.

This explains why my boss hands my coworker a list of yet another way we are supposed to chart oxygen studies on patients and he pitched it in the trash right in front of her. Now not only do we chart it in our charting, but the doctor notes and another place so the Welfare people have access to it.

This explains why my boss asked me to read and sign some sheets she placed on our desk, and I simply signed it without reading and go on about my work.

This explains why my boss called me into her office to tell me she had a nurse complain to her because she was concerned I was too tired and wasn't "pushing" the patient enough. The patient landed on a ventilator the next day, and somehow that was my fault.

"Consider this a verbal warning. The next time you will be written up."

"Did I not chart I did the treatment and CPT?" I asked while sitting in her office -- the Principal's office.

"Oh you charted excellent," she said, showing me copies of my charting. (That's another irritating fact that the bosses trust us so little they have to double check all our charting and niggle over every i that's not dotted or t that's not crossed).

"So what's the problem?"

"The problem is the patient ended up on the vent the next day."

"The patient ended up on a vent because he was a post op. It had nothing to do with how hard I did CPT anyway. CPT was useless anyway. He had phlegm stuck on the back of his throat because of the NG tube, and CPT wasn't going to help with that anyway. But I did the CPT, so what's the problem?"

"Well, the nurse thought you weren't pushing the patient hard enough," he said.

"Okay, were there other complaints from other nurses?"

"No."

"Any complaints from patients about me?"

"No."

"Any complaints from doctors about me?"

"No. But you were grumpy with me in the morning too because you were too tired."

"So I'm not allowed to be tired?" I smiled. "You're going to write me up for being tired? You'll have to write up the entire night staff."

Well, you get the idea where this is going.

Today another coworker told me he was written up because he put a post OP patient on oxygen who came back from surgery at 2:00 a.m and left a note on the chart for an order instead of waking up the doctor

He was written up for not calling for an order.

A month later the same situation, only instead of leaving a note on the chart this time he called the doctor at 2:00 a.m. "WHY DO YOU CALL ME TO WAKE ME UP FOR AN OXYGEN ORDER!" The doc bellowed.

"Well, because last month you told me I had to."

"WELL, DON'T DO IT AGAIN!"

Last night I turned up a DNR emphysema patients oxygen from 2lpm to 3lpm to bring her spo2 to 92%, which is our protocol minimum. I figured we could just get an order later if need be (remember, I don't believe in the hypoxic drive theory anyway).

After I left work last night the patients code status was changed to full code (for some stupid reason), and she was put on a ventilator. The doctor made sure to tell the nurse to write me up for increasing the oxygen.

Like that's what caused her to need a vent. She was crashing the entire night I worked, her heart rate was in the 170s all night in an SVT rhythm and labored, and the doctor chose to do nothing all that night however many times he was called by me and the RN.

Yet it was the 3lpm that caused her to need a vent.

Boy oh boy, I'm telling you. I love my job, but the RT bosses and Docs need to chill a bit and let us do our jobs. I'd love my job all the more if they'd give us the autonomy we RTs should have so common sense would prevail.

I'm happy either way, yet I'd be happier (and so would all us RTs) if we could knock off the bull crap.

The common sense approach to hard luck asthma

A hard luck asthma patient came to see me in the ER last night. She had asthma so bad she actually spent some time at National Jewish recently (she hated the place). Since I was an asthma patient there in 1985 for six months, we had a nice chat.

That aside, after several breathing treatments I found myself standing behind the nurses station. The doctor (Dr. Q1) was concerned by something the patient said to her, which was this: "I gave myself 25 mg of solumedrol 2 days ago, and today I put myself on 80mg. Obviously it didn't work."

The doctor said to me, "She shouldn't be medicating herself like that without a doctor's order."

"Why not," I said. "I used to do that when my asthma was bad every day."

"You used to abuse your medicine?" Her stare was blank.

"Is it abuse?"

"Well yes it's abuse."

"I used to adjust medicine when I was having trouble breathing. If I didn't do things like that I would have ended up in the ER every week of my life. And since I'm not on welfare, I can't afford that. "

"But that's against the asthma guidelines."

"No it's not. The asthma guidelines are guidelines. They also recommend the doctor and patient work together on developing an asthma action plan individualized for the asthma patient. There are some hard luck asthmatics who can be trusted to treat themselves at home. When the said treatment doesn't work, they come to the ER -- like this patient did."

"I don't like that," the ER doc said.

There are many asthma action plans that allow for asthmatics to have a prescription of oral corticosteroids to keep in the medicine cabinet. When the asthma flares up the patient may self medicate and call the doctor.

If it works the patient avoids another expensive hospital visit. If it doesn't, then the patient has someone drive her to the ER, which is exactly what my patient did last night.

I respect Dr. Q1 in that she does a great job with her patients. But her inflexible methodologies of treating patients means that all patients get treated alike, and the ideal therapy for the patient may be overlooked.

Then again, this is the same doctor who believes only doctors are capable of determining what patients need breathing treatments and how often (usually Q1).

ETT holders work wonders

The worse codes are those that take place in unexpected places -- like CT.

The call was overhead: "Code Blue to CT!"

I rushed to CT to find a patient already intubated. The anesthesiologist was standing at the head of the bed holding an unsecured ETT.

As soon as he saw me he gave me that job, and now I was standing there at an awkward angle with someone breathing down my back in the closed in room holding the ETT in place.

The funny thing I had no idea where this patient came from. Then I realized it was not a patient from ER (of course not, I would have known), it was a surgical patient the doctor decided needed a CT.

The ETT, I noticed, was secured only with tape. Something ACLS does not recommend when you are transporting a patient. Something common sense does not recommend when you are transporting a patient.

Suddenly I hear the following: "On a count of three: one..."

"Wait!" I say

"...two..."

"Wait!"

"...three... heave!"

"Shit!" the patient slid down the table and my feet and my hands stayed firm in the position they were in holding the ETT....

Only now the ETT was no longer in the patient.

The anesthesiologist said nothing. He easily and calmly reintubated. And, at which time, I secured the airway with a good solid and firm bite block or ETT holder or whatever you want to call it.

When I was finished I admired my work. "See doc," I said, tugging on the tube to indicate it was secure, "This is how you secure an ETT!"

He smiled.

The old technique may have worked fine in the day, but now that we have access to better research and better equipment, we might as well use it.

If I were the boss of the RT Cave...

I've been thinking lately how I would run an RT department if I had the opportunity (not that I would want that job.)

The first thing I would do is anything possible to create a mileau where RTs will want to work for this department. Not only will you be challenged, you will be encouraged to participate. You have an idea, come forward! You will not be ignored.

There are many different ways bosses can run their companies, and the one I would choose is the one that involves the worker in every step of the decision process. That way morale stays high because all the workers know they are a part of everthing the department represents.

You see, my goal in life is to be happy. I believe nothing is really complicated, although some people tend to make things complicated. I would not be one of those people.

Surely we'll have rules and guidelines and policies, yet I'd also leave room for individual thought; some leaway; some freedom to move or (for lack of a better word)... to breathe.

You have no excuse not to excercise

One of the things that frustrates us medical care workers the most is that most of our patients are people who never took care of themselves their whole lives, and now they are reaping the punishments of the life choices they made -- or didn't make.

Now that we have research that not only proves a healthy diet can help you live a fuller and longer life, experts actually show us how to do it. Yet few of us listen. The wisdom is not new that exercise has benefits galore.

Working out and do aerobics as little as 15-20 minutes a day result in you not just being healthier but having more energy, more time, more strength, less stress, more ambition, better outlook on life, better able to handle annoying bosses, and (ahem for you lung patients) less winded just walking from the kitchen sink to the bedroom.

And those are only some of the benefits. Yet, when people are reminded to make better choices, they say "okay fine!", and then don't do it.

When I tell people I work out daily, the most common response I get is:

"How do you find time to workout? I want to work out too, but I simply don't have the time."

Honestly, I find this NOT to be a good excuse. Look at it this way: Which is more important...

1. Spending ten minutes making your bed in the morning or going into the basement and riding your bike for ten minutes?
2. Watching TV for an hour before you go to bed or going for an evening walk?
3. Doing the dishes after dinner or walking on the treadmill 20 minutes?
4. Doing that one last load of laundry or doing ten sit-ups or crunches?
5. Lecturing your kids about something or taking them for a bike ride (or sledding if it's winter)?
6. Scrubbing the bathroom for an hour or going for a jog with your best friend?
7. Sitting on your couch drinking a beer or going to the health club?
8. Sleeping in or doing your weight training workout?
9. Stepping outside for 10 minutes to smoke a cigarette, or taking that time to stretch?

I could go on but I think you get the point. I've written before about the importance of exercise. Whether you are 100% healthy or have asthma or COPD. Get off your butt and pace the house! Ride the bike while you are watching Jay Leno or Desperate Housewives.

Don't be a full-time patient in a hospital or nursing home because you ate too many Big Macs or Whoppers, or too many home style breakfasts, or smoked too many cigarettes.

In the past people didn't know any better, BUT YOU DO KNOW BETTER! YOU HAVE NO EXCUSE NOT TO EXERCISES!

I try not to lecture too often, but this is something I feel pretty strongly about, especially considering what I see on a daily basis.

Pharmaceutical companies need to make money

I have written the past 2 days about the high cost of Advair and what an asthmatic might do instead of choosing to not take this medicine at all. One of the ideas that was sent to me was this:
We could make it so pharmaceutical companies no longer make so much money at the expense of people who are sick. It's ridiculous that they make so much money anyway.

Another common question is this:

Why doesn't Obama put a cap on how much prescriptions can cost?

I had a reader email me the following, and I think it will make a fine answer to the above questions:

It is the capitalistic system that developed Advair--and other useful drugs. The drug companies have huge development costs, and huge costs getting through the FDA, and if the drug company can't recoup its expenses, and make a profit for its shareholders, there is no point in the company's ever developing a new drug. We won't ever get any new ones. You don't work for free; me neither. Neither do the shareholders, or the employees, of the companies that develop new drugs.

I agree with this answer completely. What makes America such a great country, and why our economy is the best in the world (despite the recession), is because of capitalism. And the key to making capitalism work is the risk/reward factor.

In the case of Advair, a pharmaceutical company sacrificed millions of dollars and many years of research developing a medicine that they had no idea of whether it would even be approved by the FDA for use.

If it were not for the reward factor (making a profit), there would be less risk taking. And, if there is less risk taking by pharmaceutical companies, that would be fewer new asthma meds, and less hope for even better meds for the future.

8 ideas for those who can't afford Advair

Yesterday I wrote about some ideas I had to help people cope with the high cost of Advair. This may perhaps be the greatest medicine ever invented for asthma patients, and yet it costs so darn much. Those with no health insurance may have to choose between Advair and nothing at all.

But that's not necessarily true. There are options. Here are some of the ideas people have emialed to me.

1. Talk to your doctor about free samples
2. Advair comes in two strengths--for example, if the doctor prescribes the 250, to be used twice a day, and the patient needs only the smaller 100, and uses the 250 once a day, maybe that is better than not using it at all.
3. Perhaps the doctor could prescribe one puff once a day to make the discuss last 2 months instead of one.
4. Talk to your doctor about taking alternative Corticosteroids, like Beclavent, Azmacort, Advair, Vanceril.
5. For those who need the added corticosteroid, they could take Advair in the morning and a substitute corticosteroid in the evening.
6. You could do a combination of the above to make the med last longer
7. Check this website out to find the cheapest asthma meds: http://www.needymeds.org/.
8. Pharmaceutical companies have programs for folks who can't afford drugs- call them!

These are just some ideas from me and some of my readers to help those of you who cannot afford these meds. You can discuss these with your doctor and see if they might work for you. You may have to experiment a little, and get creative.

But, please don't stop taking you preventative asthma meds just because you can't afford them. And please don't stop taking them just because you feel good after not taking them for a week. Asthma can pretend to not be there at times and then can show its ugly head on a dime.

Advair may be too expensive for many asthmatics

Being that we are in a recession and many of us are scrapping for money, some Gallant Asthmatics are finding it quite hard to afford their asthma medicines. This is especially true of Advair, which costs about $120 without health insurance.

Personally, even with health insurance I pay $80 a month for my asthma medicines. Thankfully I have a good job, and (fingers crossed) a recession proof job too. But others aren't as fortunate as me.

That in mind, in this edition of My Answer to Your Rt Queries I tackle the following tough question that was asked over at MyAsthmaCentral.com:

QUESTION:

I can no longer afford Advair. Are there different (and cheaper) meds to take?

ANSWER:

Advair is a medicine that has benefited many asthmatics, unfortunately it is a very expensive medicine. The cost of a medicine usually does not decrease in value until the patent runs out and generic meds are produced. A patent usually lasts about about 25 years.

This is something you should definitely talk to your doctor about, because while Advair may be the best medicine for you because it contains both Flovent and Serevent and is relatively easy to use, there are alternative corticosteroids on the market that are less expensive, such as Vanceril, Beclovent, Azmacort, Aerobid (although Aerobid tastes nasty, like rotten mints), etc.

Even though these may or may not be ideal for you, I think your doctor would rather have you on a med you can afford than to take nothing at all.

As for the Serevent component of Advair, I do not believe there are alternatives to this on the market right now.

I bet another alternative would be to talk to your doctor about getting free samples, but because one discus lasts only a month, this would only be a temporary solution.

I think it is unfortunate that the worlds greatest asthma medicine (in my opinion and my doctors) has to cost so much. But that's the way it is in a capitalistic system.

Does Ventolin benefit sleeping COPD patients?

This post is a special edition to "My Answer to your Rt Queries." This question was asked of me by an anonymous person who did not leave an email for me to resond to. However I think it is a common enough question that I am going to answer it in a public post.

QUESTION:

Hi-I found your site while cruising around the Internet looking for stuff about COPD.. Anyways your post here got me wondering --- I am caring for mom who was released from hospital last week under Hospice care (we are new to hospice). She has end stage COPD and she is soooo weak, barely eats or drinks now. I started giving her her nebulized Txs a couple days ago even though she is asleep all the time (I was waiting for her to be alert and awake and she still is not, so I felt bad and gave her Txs anyways. -Then when I read where you said something to the effect the pt wanted a neb tx even though she wasn't out of breath.. My mom hasn't been out of breath - do you think I should stop doing the neb at this point.. She was previously doing levalbuterol 4x a day.. Just wondering - any thoughts? - thanks! PS- hospice just always answers - "whatever she wants" - well I don't know what she wants because she doesn't wake up!

ANSWER:

Great question. One thing to know about Levalbuterol (Xoponex) and Albuterol (Ventolin, Proventil) is that most doctors agree with me that you cannot overdose on these meds. They are very safe bronchodilators that can very quickly provide relief for COPD and Asthma patients. I would imagine your mother took this medicine every four hours when she was awake because they provided some relief for her, and comfort. Of course now you don't know if your mother is short of breath or not, but it certainly cannot hurt her by continuing to give these treatments, and they may be of benefit. Of course I'm not a doctor, but I would say if the treatments benefited her while she was awake they will continue to benefit her now while she is sleeping, so it cannot hurt to continue them.

Just to make things interesting, I have always believed if a patient is sleeping they are obviously comfortable. I have had some families in this same situation decide to stop the breathing
treatments to no disadvantage to the patient.

So, based on all that I've written here, you can see that you can go either way, and I think that is why Hospice would say, "Whatever she wants." I actually think they are justified in saying that. They also could have said, "Whatever you think she needs for her comfort."

Personally, I'm not there to see what your mother is like, and I don't know how bad her COPD was before her current situation, so it's difficult for me to provide better advice for you. It is never easy making these kinds of decisions. However, I think your mother would be proud of you that you are doing this for her and thinking of her in this way. Whatever you decide is the right thing.

20 facts about asthma

Here are some interesting facts about asthma:

1. The majority of childhood wheezers do not have asthma. They are called "transient wheezers."
2. 95% of children with persistent asthma still have symptoms into adulthood
3. 60% continued to have persistent asthma characterized by acute episodes and interval symptoms
4. The remaining 40% the asthma seemed to be less troublesome in adult life
5. The average life expectancy of mild episodic asthma should be the same as nonasthmatics. Right now this is 80 years.
6. Only 10% of asthmatics develop severe asthma. That comes to less than 1-2% of the population.
7. A near fatal asthma attack consists of a PaCO2 of >50, need to be ventilated, or arrival at the hospital with altered consciousness or unconscious.
8. Nearly all cases of asthma related deaths come as a result of asphyxia and not a cardiac arrest.
9. In most cases, rapid administration of oxygen will prevent asphyxia (which is a severe lack of oxygen).
10. Most fatal asthma attacks do not occur in the hospital. Most patients who reach the hospital with an intact central nervous system survive.
11. Most fatal asthma attacks occur because the patient delayed going to the hospital. A major problem here is denial.
12. Asthmatics with a near fatal episode have an increased likelihood of having a fatal attack in the future. This is why very close contact with your doctor is essential.
13. Most asthmatics who suffer a near fatal attack are severe asthmatics, mild or severe asthmatics who didn't take their medicines as prescribed, delay in seeking treatment, and those who are taking large amounts of beta agonists regularly.
14. Fatal Asthma does not care how old you are, nor what sex, nor what color or race or creed.
15. Mild asthmatics can die of fatal asthma, but mostly due to improper care or delayed treatment.
16. There is no evidence that Albuterol increases the risk of a fatal asthma attack.
17. Use of Albuterol as the sole treatment may possibly contribute to fatal asthma, but probably due to lack of inhaled corticosteroids to manage chronic inflammation.
18. Boys are twice as likely to develop asthma than females, but the exact reason is unknown. Studies show boys are more likely to have a positive allergy test, to show more bronchial hyperresponsiveness and appear to have different patterns of airway function development.
19. Socioeconomic status and asthma fatality are inversely related. Or, poverty and asthma fatalities are linearly related.
20. African Americans have an increased incidence of asthma than whites. Socioeconomic status may be a factor, but recent studies show higher IgE serum levels and prevalence fo bronchial responsivemenss in blacks as compared with whites.

The above facts come from a book called fatal Asthma.

Shoot yourself daily, but Don't Shoot the RT,

The RN was set up alongside the bed with her IV set, and he had just pulled out another failed attempt. As I entered the room the loquacious patient said, "I think we ought to just shoot the RT!"

"Why would you want to do that," I said.

"Because I'm bored," she said. I looked down at her dry, flaky and pale white feet with those long, yellow nails. This lady had every drug related disease in the book I figured, and I wasn't going to get any closer to her than I had to.

"I have three little kids who would be very, very sad if I wasn't around in the morning."

"Well, I suppose you have a point-- ouch! Can you be a little more gentle!" She was glaring down as the RN repositioned her second attempt. "Why don't you poke under here," she pointed to under her arm pit. "You're probably best off poking me where I haven't been already. I can't reach under here."

The expression of the nurse never changed. I could tell she had had it with this body abuser. She said, "You wouldn't want one under there."

The patient said, "It's not like I havent' poked myself everywhere else."

I gave the patient a breathing treatment and when I was done she said she wanted another. I'm sure if she were home that's exactly what she would have done. But she wasn't short of breath, so I put my neb away and left the room.

Here this lady is admitted so we can fix her and the government can pay for it, only for her to go back home and poke herself some more.

Fortunately all I had to do was one treatment and I was done with this patient.

Here's some tips that should help RT patients

Have you ever had an asthmatic patient come to the ER and you just knew they were home the past 24 hours puffing on their inhaler. When you question them they say, "I thought I could handle it on my own."

Or, perhaps you are an asthmatic, COPD or CF patient who was short of breath and stayed home thinking you could take care of it on your own. You puffed on your inhaler instead of following your asthma action plan. Your gut said you should go to the ER, but you second guessed yourself.

I have been on both sides of this aisle. I've been the asthmatic who stayed home when he should have gone to the ER. I've been the asthmatic who "almost" waited too long. And I've been the RT many times whose seen the asthmatic come in too late.

In fact, many times I'm the only one in the ER the bronchodilator abuser can't fool. They can't fool me because I've been there.

In either case, based on my personal and professional experience, I have come up with five tips for any person who is short of breath that will help them decide when it is time to go to the ER.

You RTs can share these tips with your asthma patients. And, you patients can use these. Trust me, I have tried all of these and they work.

So, that in mind, my most recent column over at MyAsthmaCentral.com is titled, "Having asthma symptoms? Here's five tips to help you decide what to do." Please click here and I will morph you on over to my asthma blog.

Having asthma symptoms? Here's five tips to help you decide what to do
by Rick Frea Wednesday, January 28, 2009 @ MyAsthmaCentral.com

One of the most difficult decisions to make as an asthmatic is this: "When should I call my doctor?" Or, "At what point in the progression of asthma symptoms do I decide to go to the ER?"

Obviously if asthma hits hard and fast the answer is easy: "You GO RIGHT TO THE ER NOW!" In fact, you may even be justified calling an ambulance.

However, most asthma attacks progress over a period of time. And many times you are having an attack and can still function. You may not be comfortable, but you are not yet miserable.

Then, over time, you become a little more winded. Now you think you're worse than you've been in a long time. Now you're coughing. Now your chest feels tight. Now you think your respiratory rate has increased. Yet, you still don't really WANT to go to the ER. Right? No one does.

I'll tell you from personal experience that deciding what to do when your asthma is acting up is never easy. In fact, just the other day I was working and there was a microwave fire in the critical care unit. The unit filled with smoke.

The nurse working there had an asthma attack. She came to me hoping I would give her a breathing treatment. I said, "You need more than a breathing treatment. You need to go to the ER."

"But," she said, "I don't think I'm that bad."

"Trust me," I said, "You need to go to the ER."

Ironically, I repeated this same scenario with the other CCU nurse later in the night. While they both knew they had asthma, and were both gallant asthmatics, they still needed assistance deciding what to do.

No asthmatic is an exception to this rule, including myself. Even while I'm a lifelong asthmatic, there have been many times I've had trouble making the decision of what to do for my asthma.

Yes, it sounds like this would be an easy decision. But, trust me, it is not. So, that in mind, I would like to provide you with five tips that should help you know when it's time to go to call your doctor or go to the ER:

1. Ask a friend. I don't care how much of an asthma expert you are, it is never easy to make such a decision on your own. It is far easier to tell someone else what to do than to make the same decision for yourself. I have done this many times, and so have many of my asthmatic RT and RN co-workers.

2. Use your peak flowmeter. Of course you were a gallant asthmatic and determined your personal best, "or highest number you regularly blow," when you were feeling good. Right?

(If you want to learn more about how to use a peak flow meter, click here. If you want to determine your own personal best and how to use it to decide what to do, check out this link to nationaljewishhealth.com.)

According to National Jewish Health, every asthmatic should blow into his pf meter twice a day first thing in the morning before you take any meds, and before bed. After two weeks, you take the highest number that you blew and this is your personal best.

Now, when you blow 80-100% of your personal best, you are good to go. When you blow 60-80% of your personal best, you should use your rescue inhaler, wait 20-30 minutes, and blow in your pf again. If your pf is now above 80%, you are okay for now, but you should use your pf every four hours.

However, if your pf is still below 80%, you should call your doctor.

When you blow in your meter and your pf is less than 60%, you should use your rescue inhaler and then have someone take you to the ER. Or, if you are bad enough, call an ambulance (you should avoid driving yourself to the ER).

3. Inhaler overuse. If your asthma is so bad that you have to use your rescue inhaler more than recommended (click here for proper use of rescue inhalers), it's time to at the very least give your doctor a call.

4. Second guessing. When you start to second guess what you should do, it's time to go to the ER. Likewise, if you are thinking things like the following, go to the ER: "One more puff of my inhaler and I'll be fine." Or, "If I just wait another hour I will turn the corner."

Or, perhaps you have caught yourself saying this a time or two: "If I go to the ER they'll just make me feel stupid. I'm not sick enough to go to the ER."

Look, if you follow your asthma management plan, and it is not working, then you should come in to see us in the ER. At the very least we will give you one Albuterol breathing treatment and send you home and you will have peace of mind knowing you are okay.

5. Downplaying your asthma. "Oh, my asthma is not bad enough to go to the ER." If you find yourself saying things like that, then chances are you are downplaying the severity of you asthma and it's time to go call your doctor or go to the ER.

I think downplaying and second guessing are the two most common reasons asthmatics don't come into the ER when they should. It is true your asthma might get better, but it is also true that your asthma might get worse. It's a gamble. If you wouldn't recommend your friend bet on staying home, don't do it yourself.

Most ER docs, and most RTs and RNs who take care of asthmatics (myself included), would much rather you come in with mild asthma symptoms than to have you come in after waiting three days gasping for breath -- or not breathing at all. It's much easier for the ER staff to fix and send you home if you come in with mild asthma symptoms than if you wait too long.

You should never be afraid to call your doctor and ask for his advice. Likewise, you should never be afraid to come to the ER and seek out our services. We will never make you feel unwelcome no matter how "mild" your asthma attack is.

The questions "When should I call my doctor," and "When should I go to the ER" should be easy to answer. If you are among the many asthmatics who struggle making the decision, the tips provided here should help you.

Here are 12 diseases Albuterol does not benefit

As many of my readers know from reading my past entries Albuterol (and Xoponex> an too) is perhaps one of the most abused medicines in the hospital. While it is a bronchodilator designed to help asthma and COPD patients catch their breath, it is often ordered for diseases that have nothing to do with bronchospasm.

The truth is, Albuterol is a bronchodilator and nothing more.

It's so bad that my Rt coworkers and I often joke that doctors believe in the theory that, "All the wheezes should be treated as bronchospasm (or asthma)," or, "If he's short-of-breath he should get a bronchodilator breathing treatment," or, "If it's a disease in the lungs, a bronchodilator is indicated."

The truth is, all that wheezes is not bronchospasm, and all illnesses that cause shortness-of-breath are not indications for a bronchodilator, and all illnesses of the lungs are not reasons to order Albuterol. Yet that often seems to be the case, as you can see by this post.

What follows are ten common ailments patients are diagnosed with that often cause a doctor to order braething traetments for when a breathing treatment is not indicated and will have no effect on the disease.

1. Pneumonia: Pneumonia is inflammation in the alveolar sacs. Ventolin is 0.5 microns, and the Alveoli are 0.1 to 0.2 microns -- Ventolin can't even deposit into the lungs. And, if by some osmosis process it did make it down that far, it won't do anything anyway because Ventolin does nothing for inflammation, and it will not remove fluid from the lungs. For more information, check out this link here.

2. Cardiac Asthma (CHF, pulmonary edema): I wrote a good article about cardiac asthma a while ago, and I will link to it here. Albuterol does does not heal the heart, and it will not reabsorb fluid from the lungs.

3. Respiratory Syncytial Virus (RSV): This is a virus that causes swelling of the airways and increased secretions in neonates. Studies have been done that prove a bronchodilator is of no use, unless there is an underlying bronchospasm. Likewise, studies show sometimes racemic epinepherine is beneficial to these patients. In most cases, though, studies show simple suctioning of the nares usually clears the lungs before a treatment is even given, making it so a treatment is no longer indicated. I wrote an article about this here and also here.

4. Pneumothorax: This is a restrictive disorder otherwise known as a collapsed lung. It may cause severe shortness of breath, but once a chest tube is in place the patient may breathe just fine. Regardless, because it takes place in the lungs, a bronchodilator is often ordered.

5. Pleural Effusion: Again, fluid buildup around the lungs is a restrictive disease that lessens the ability of the lungs to stretch. Since this process takes place outside the bronchioles, shortness of breath caused by it will not be benefited by a bronchodilator.

6. Lung Cancer: Lung cancer can cause a wheeze because the cancer can put pressure on some bronchioles causing them to become narrowed (squeezing them), and thus they whistle. Since the narrowing of the bronchioles is isolated to one area of the lungs, and the cause is outside the bronchioles (a restrictive ailment), a bronchodilator will be of no use.

7. Fever: I think the theory behind doctors ordering treatments for fever is that they think it's caused by atelectiasis, and that the bronchodilator will somehow reinflate the alveoli. As we now know, Ventolin is too large in size (0.5 microns) to get into the alveoli. And, even if it somehow could get down there, it has no chemical properties that allow it to blow up flat alveoli like a tire pump blows up a flat tire.

8. Atelectasis: See Fever above. Some doctors see atelectasis, or hear it upon auscultation, and assume a breathing treatment will be of some use. Ventolin will not reinflate deflated alveoli.

9. Post operative (prophylactic): One of the surgeons at Shoreline Medical once told me he ordered postoperative breathing treatments because they keep the lungs "clean and open." For this reason one of my co-workers jokes that doctors think Ventolin works the same as Scrubbing Bubbles in that it suds up in the lungs and washes away any crud that might be in the lungs. The truth is, if there is no bronchospasm, a bronchodilator is of no use to the post operative patient.

10. Airway congestion, colds, or influenza: Stuffiness caused by congestion caused by head and chest colds will in no way go away with Ventolin. It will also not clear a stuffy nose. However, it is often ordered for this reason. However, if these ailments may compound asthma and COPD.

11. Meet criteria: This is not necessarily a disease, but it might as well be. Many treatments given in hospitals are not ordered because they are indicated, but because they are needed to meet criteria for reimbursement. Recently I wrote about this over at RT 101. I also wrote a recent post (click here) guestimating how much money is wasted doing non-indicated breathing treatments

12. Pulmonary Embolism: I just about overlooked PE, so here I must add it to the list. A PE is a blood clot that formed in the legs or elsewhere in the body, dislodged, and finds it's way to the pulmonary artery in the lungs and bocomes lodged there. Many times a patients may have two or three PEs at one time. It usually causes symptoms such as crackles, shortness of breath, cough, rapid heart rate, wheezing, leg swelling, anxiety and fever. A PE can usually be discovered via testing, and once the symptoms are figured to be a PE no further breathing treatments should be given. This disease is a good examle of: All that is short of breath is not bronchospasm.