Lungers must be vigilant of Swine Flu

On a yearly basis it is recommended that all people who have a suppressed immune system, a chronic illness like asthma and COPD, the elderly and very young get the annual flu vaccination.

So I think it's safe to bet those individuals are at the greatest risk of developing severe complications if they somehow contact the swine flu. When the flu hits it can hit us folks with already compromised lungs hard.

I witnessed this myself in 1998 when I ended up in the hospital for 10 days because of whatever strand of flu was making its way around that year. It wiped me out and nearly ended me up in critical care. For the longest time it seemed I might never catch my breath again.

I'm not saying anyone should panic, by all means. But this is a call for all of us to educate ourselves about this swine flu thing. What is it? How does it spread? And, most important, how do I prevent myself from getting it? Or, once I get it, what do I do? How is it treated?

Better yet, what do people with Chronic asthma, COPD, or other respiratory illness need to know about the swine flu?

At MyAsthmaCentral.com I answer these questions and more in my post "Here's what Asthmatics need to know about swine flu."

I wrote this on an asthma website, but the information holds true for all chronic lungers.

The important thing to note is to not panic, but be vigilant of the possible threat around us. To learn how, click here.

For the latest updates on swine flu and flu symptoms, click here.

Here's what asthmatics need to know about swine flu by Rick Frea Wednesday, April 29, 2009

By now most of us know about the swine flu, but do we know what it is and how to prevent it? Should we be panicked? As asthmatics, should we purchase a giant bubble and move into it? Are we doomed? Will this be another pandemic like The Great Flu of 1918?

Well, no, we are not doomed. And of course we asthmatics don't need to isolate ourselves into a bubble. Sure diseases can travel over the world in a day now, but medical wisdom has grown exponentially since 1918.

Besides, living in a bubble wouldn't be any fun anyway. Instead of panicking, we should educate ourselves and become vigilant, something us Gallant Asthmatics love to do anyway.

According to the Center for Disease Control (CDC), the swine flu is a typical respiratory virus that usually only effects pigs, but has mutated and now can be contacted by humans, and spread by human to human contact by breathing in air droplets of people you come in contact with, or by touching contaminated surfaces.

The virus then infects cells of the nose, mouth and throat, and usually takes 3-5 days for symptoms to surface.

Government officials have said there is no reason to panic, and I agree. Still, According to a press release from the American Academy of Allergy Asthma & Immunology "Asthma sufferers more at risk of swine flu", asthmatics may be at greater risk.

The article quotes Dr. Thomas B. Casale, executive vice president of the AAAAI:

"As with other influenza viruses, this virus typically attacks the respiratory tract. So if you have a chronic respiratory condition like asthma, it can take a turn for the worse, exacerbating your asthma."

Still, according to the Mayo Clinic, most cases (98%) are generally mild. Yet it's good to be vigilant of the flu symptoms, and contact your physician right away if you have a:

• Fever
• Cough
• Sore Throat
• Body aches
• Headache
• Chills
• Fatigue
• Diarrhea
• Vomiting

Note please that the experts advise you see your family physician and not to panic and rush to already busy emergency rooms. If you are having asthma symptoms, you should follow your Asthma Action Plan, and call your physician or go to the ER as appropriate.

Instead of panicking, or moving into a bubble, or wearing a mask in public like Michael Jackson has for years, what you should do is make sure you are taking your asthma controller medicine and follow these recommendations of the CDC:

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
• Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
• Avoid touching your eyes, nose or mouth. Germs spread this way.
• Try to avoid close contact with sick people.
• If you get sick with influenza, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.
• Try to stay in general health
• Get plenty of sleep
• Be physically active
• Manage your stress
• Drink plenty of fluids
• Eat nutritious food.

While the majority of those in contact with this virus have had mild symptoms (some may not even notice they have it), a few will develop serious complications such as pneumonia and respiratory distress, and about 1-2% will die (which is the average for any year).

Our goal here is to prevent it from becoming serious. This is where vigilance comes in handy again. If you notice any of the following symptoms as recorded by the CDC, you should go to the emergency room right away:

In children emergency warning signs that need urgent medical attention include:

• Fast breathing or trouble breathing
• Bluish skin color
• Not drinking enough fluids
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Flu-like symptoms improve but then return with fever and worse cough
  Fever with a rash

In adults, emergency warning signs that need urgent medical attention include:

• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting

There is no treatment for the influenza virus, but if you call your doctor within the first 48 hours of symptoms he can prescribe Tamiflu or Relenza, antiviral medications. The bird flu has shown sensitivity to this antiviral medicine, which can reduce symptoms and even decrease duration of illness. Tamiflu is also safe for asthmatics.

Other treatment would include treating the symptoms. If you are dehydrated from vomiting a doctor may have you treated with hydration therapy. If you have asthma, your doctor may prescribe additional anti inflammatory medicines such as systemic corticosteroids.

So, according to Dr. Casale asthmatics are at greater risk for developing complications from the swine flu, yet we need not panic. Most of us are gallant asthmatics who take good care of ourselves and effectively manage our asthma all the time anyway, so we are always prepared.

For the latest updates on swine flu and flu symptoms, click here.

Everything you need to know about swine flu

If you suspect you have the swine flu, or if you have recently traveled to Mexico or had contact with someone who has been diagnosed with it, definitely do not panic. Most of the cases of the flu are no different than the common flu contacted on a daily basis.

According to the Mayo Clinic, the swine flu (more commonly referred to as h1n1 influenza virus) is contacted from infected pigs, and infects the cells lining your nose, throat and lungs. The virus enters your body when you inhale contaminated droplets or transfer live virus from a contaminated surface to your eyes, nose or mouth on your hand.

Note the virus is not airborn. It can only be contacted if you breath in actual air droplets from a contaminated person, such as when a contaminated person sneezes.

It is for this reason why a simple mask can protect one from getting the virus when exposed to a contaminated person; that and good hand washing.

The following are the symptoms of the swine flu to watch out for as recorded by the the Mayo Clinic. They usually occur 3-5 days after contact with the virus is made:

1. Fever
2. Cough
3. Sore throat
4. Body aches
5. Headache
6. Chills
7. Fatigue
8. Diarrhea
9. Vomiting

The Mayo Clinic reports that you should:

"See your doctor immediately if you develop flu symptoms, such as fever, cough and body aches, and you have recently traveled to an area where H1N1 swine flu has been reported. Be sure to let your doctor know when and where you traveled. Doctors have rapid tests to identify the flu virus, but there is no rapid test to differentiate swine influenza A H1N1 from other influenza A subtypes."

Click here for more steps to help decrease your chances or your family from contacting the virus.

The key here is to see your doctor. You do not need to panic and inundate already busy emergency rooms. I think that is one of the main concerns of the government is a panic will ensue, and ERs will be inundated and overwhelmed.

So, don't panic. Call your doctor if you think you have the flu and have comfort knowing most cases are generally mild and no more potent than the normal flu people get on a yearly bases.

Technically speaking, there is no treatment for the disease other than to treat the symptoms. For example, if vomiting causes diarrhea, re hydration methods may be indicated. If you have asthma, or other chronic lung disease, your doctor may prescribe additional anti-inflammatory medicines such as oral prednisone.

There two antiviral drugs on the market the swine flu appears to be sensitive to, which may reduce symptoms and duration of the flu. They are called Tamiflu and Relenza. When the government declared a state of emergency yesterday, they basically made back up supplies of these drugs available to all areas in need.

However, most experts contend that if you suspect you have the flu you need to let your doctor know ASAP because Tamiflu and Relenza are most effective if given within the 1st 48 hours.

The key here is not to panic. Even if a pandemic is declared at some point (as of yet is has not), it is important to know that most cases of swine flu are mild and will pass without any long term complications.

The most important thing you can do is know that the swine flu can be obtained from person to person contact, or by touching surfaces containing the virus. So, the Center for Disease Control recommends the following to Prevent yourself from getting the Swine flu:

"First and most important: wash your hands. Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food. Try not touch surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick."

There, that's all you need to know about the swine flu. Don't panic, but be vigilant and wash your hands often, which is something you should do all the time anyway.

For the latest updates on swine flu and flu symptoms, click here.

Swine flu: we must remember 1918, yet not repeat the fiasco of 1976

As you probably well know by now, the White House has declared a state of emergency as 140 plus people have died of the swine flu in Mexico, the disease has been reported now in four countries, and in several states within the United States.

So far, of the 50 plus Americans to get the swine flu in the U.S., all cases have been generally mild and are not expected to be life threatening. Which begs one to wonder if the deaths in Mexico are due to lack of good medical care, or a more virulent strain in Mexico. This lack of knowing is certainly troubling to scientists and politicians, hence the seriousness of the matter.

Officials are wise to add that there needs NOT be a state of panic because of this outbreak, just a state of vigilance because officials are not quite positive how rapidly this virus spreads. The basic reason for the state of emergency is to "allow the federal and state governments easier access to flu tests and medications," according to HealthCentral.com.

I think it was Obama who wrote a memo regarding the seriousness of preparing for a possible flu outbreak when he was a young Senator, and George Bush set aside in his budget monies to prepare for such an outbreak, and to work on finding a cure if such a "mutated" virus were to cause havoc. Currently, drug makers are in a mad dash to create a vaccine.

So I think the Obama administration is making all the right moves at the present time to create awareness, and yet not cause a panic. Which, by the way, reminds me of what happened during the 1976 swine flu scare. One soldier at Fort Dix caught the flu and died, and an estimated 500 other soldiers had the flu while having only mild symptoms.

Yet, with a flu virus spreading so fast, the population -- including those in Washington -- were worried because any virus that spreads that fast could, possibly, cause a pandemic. So, does the government take the wait and see approach, or work to create a vaccine and make everyone take it?

There was a lot of political pressure on Gerald R. Ford. Plus there was the memory of the Great Flu. According to capitalcentury.com, (an article by Paul Mickle) "The Great Plague... rivaled the horrid Black Death of medieval times in its ability to strike suddenly and take lives swiftly. In addition to the half million in America, it killed 20 million people around the world."

The irony of that last quote was the Great Flu more than rivaled the Great plague. The Great flu spread across a nation and killed 20 million people within a short time, and the black plague killed that many people in over a decade of work. The Great Flu, by all means, was an even greater threat as the plague.

And considering the Great flu spread so fast at a time when few people traveled great distances by plane, bus or train, or from one continent to another within a few short hours, it would seem the fear of a disease spreading in 1976 -- or today -- would spread faster and be twice as deadly.

The swine flu comes from poultry and swine, and people who have intense exposure are at most risk of getting it, as the strain can also effect humans. Unfortunately, the strain has the ability to genetically change (mutate), and thus become more resilient and difficult to inoculate against. As what happened in 1976, the current strain of swine flu seems to have mutated.

So Ford, in 1976, amid a highly politicized season where Reagan had just recently beaten Ford in the North Carolina primary, did not want to be seen as doing nothing, especially if a pandemic did spread. And so, he and Washington hastily made a flu vaccine available for mass inoculations, and a $135 million flu inoculation program was swiftly available. It was announced to the public on March 24, a day after the North Carolina primary.

My point is simple: politics had a hand in what happened next, and Obama does not want to make the same mistake. So, while there were the "naysayers" who warned Ford that the swine flu epidemic was limited to one military base, and only one person had died, the plan for inoculating the public was rushed through Congress. The goal was to get all 220 million Americans inoculated.

By October 1 the vaccine was ready and sent to many doctors, health departments and schools across the nation. Jim Florio, a top democratic Senator who supported Jimmy Carter, was the first to take the vaccine. He did this instead of taking a swipe at Ford for his hasty actions. He too was scared of the swine flu.

Soon thereafter two people who had been given the vaccine died of heart attacks. By Dec. 16 40 million poeple (20% of the population) had received the shot, many of whom later reported symptoms of a rare disease called Guillen Barre. Because of the "Epidemic that never was" people were now becoming paralyzed. In total, over 500 people became paralyzed because of the "Epidemic that never was."

Mickle states it best when he writes: "The swine flu case of 1976 forever reduced confidence in public health pronouncements from the government and helped foster cynicism about federal policy makers that continues to this day.Citing the swine flu fiasco, for instance, one scholar recently authored a report suggesting the threat of AIDS has been similarly overblown."

Said another way, because of the "Epidemic that never was" people lost confidence in the government (big surprise there). I can think of several other times where the government has failed the people, and these failures are spread across many presidencys, both republican and democrat.

The fear that "something has to be done" often superseded rational thought. On the other hand, fear that something will be done and it will be the wrong thing -- as was the case with Katrina -- makes governments fear they must do something -- however hastily.

Fear of the inoculations lead people to not want to get the vaccination, and the program was halted by Dec. 16. In total, over 500 people became paralyzed as a result of the vaccine, and 25 of them died. It is also true that only one person died of the actual flu.

So, fear -- especially fear in politics -- is a double edged sword. If you rush to create a vaccine and it works, you are a hero. If you rush and it doesn't work, you are a failure. If you don't do anything and nothing happens, you are fine. But if you do nothing and a pandemic hits, you are again a failure. So, it could turn out that no matter what Obama does, he may merely be a passenger on a roulette table.

So, with all due respect, our politicians must not rush to make judgements, yet they must -- as Obama has done -- educate and prepare, yet not scare, the public. How to do this in the most effective means has yet to be determined, and may prove impossible.

One other thing must be understood about the flu. The current outbreak is said to have effected (at this point) a few thousand individuals, 100 of whom have died in Mexico. One expert, however, was quick to point out that the total number of flu victims is widely inaccurate.

He said that when a flu virus mutates, the death total is usually 1-2% of the total number of cases of the flu. He said, if his calculations are correct, the actual number of people right now with the swine flu is more likely to be in the range of 10,000 to 100,000.

Yet, as government officials have said, we must not panic, yet we must also be prepared.

For the latest updates on swine flu and flu symptoms, click here.

The Wheezoscopes are abonding

I discovered something really neat at work the other day. It's so obvious I'm surprised no RT ever thought of it before: that doctors and RNs have Wheezoscopses -- stethoscopes pre-programmed to hear wheezes.

I have actually come upon a frivolous ad for the darn product. I will share it with you in a few days if it ever slows down here at work. The wheezoscopes have been in full action around these parts.

I hope everyone has a great Sunday. I will be sleeping sound today, letting the blood flow back into my feet -- all thanks to those wheezoscopes.

More new types of Ventolin ('olins)

Here are a couple new types of Ventolin that I'm certain you have seen at a hospital around you. These aren't necessarily conventional uses for a bronchodilator, but -- hey! -- why not!

1. 0.5cc Sinuseuterol:

Symptom: Sinus drainage, mild shortness of breath, stuffiness, sinus headache
Diagnosis: Sinus drainage, sinusitis, stuffy nose
Frequency: Usually 1 dose
Effect: This is a very popular medicine to use, especially in emergency rooms. It's actually been used for years by many doctors but hasn't had an official name other than just Ventolin. The idea here is that 0.0000000005% of the medicine particles waft to the sinus passages to relieve nasal congestion and inflammation. Patients usually says that she doesn't notice a difference after treatment, but that doesn't mean the sinuses won't eventually return to normal.

2. 0.5cc Assessolin:

Symptom: Patient doesn't quite look right. Pt may or may not have annoying lung sounds.
Diagnosis: Generic, but often cardiac or pulmonary history. May have been on vent in past, or and some type of failure in past.
Frequency: No less than Q4 hours. Q4ever may be the best idea here.
Effect: It really has no effect, you see. Even though RT isn't qualified to know when a treatment is indicated, we know they are the best assessors in the hospital. So, when you want to make sure the patient gets a good assessment every so often, there is no better option than to order Assessolin. Hey, there is an old saying: An RT a day kept the code away.

3. 0.5cc Snorebuterol:

Symptom: snoring
Diagnosis: sleep apnea, obesity, other
Frequency: Q4
Effect: Well, the snore sounded like a wheeze when we did our assessment, so better to be safe than sorry. May alternate with any variety of Q4ever treatments.

4.  0.5cc Hypoxolin

Symptom:  hypoxia, high CO2, pulmonary edema

Diagnosis:  Heart failure

Frequency:  Q4-6

Effect:  The patient wearing a 75 percent non rebreather mask to maintain an spo2 of 90% must be given Ventolin because it causes the patient to become hypoxic during the treatment.  Yes, you read that right.  The goal here is  that the 5-10 minutes of hypoxia that occurs during the treatment will increase the patient's respiratory rate in order to blow off excess CO2. Respiratory Therapist grumbling to be expected.  

Note for doctors who barely passed med school:  A breathing treatment from an oxygen source provides approximately 60 percent oxygen.  A nonrebreather does not produce 100 percent oxygen because one flap is always missing due to litigation purposes, and this results in an estimated FiO2 of 75 percent.  

If 75% Fio2 was maintaining a 90% SpO2 you can expect the patient's SpO2 to drop to 85 percent during this highly recommended therapy.  In England this exercise is called hypoxia therapy, yet here in America we don't want to be that obvious, so we just call it an Albuterol breathing treatment.  

For more 'olins, see the growing list at the bottom of this blog. If doctors at your hospital use an 'olin you think would benefit other patients, by God feel free to share it in the comments below.

Matthew Stafford hopes to ignite the roar

I am sure I'm not the only true Lion fan out there. I know I'm not the only dad who won't allow his wife or kids to make plans for Sundays at 1:00 p.m. during football season.

As the Lions new GM said, "It's time to replace Bobby Lane." For those of you who do not know, Lane was the Lions QB during the 50s when the Lions won three NFL Championships.

Lane was injured and did not play for most of the 1958 season and championship game, and the Lions traded him in the off season. He aptly said, "I curse the Lions not to win another championship for 50 years.

Well, 2010 is year #51, which means the curse is O-V-E-R. So, if all goes well, it's MATT STAFFORD time. It's time to restore the ROAR.

Now, you ask, what does this have to do with respiratory. Well, it doesn't. But it makes your humble RT happy when his Lions win. And, since Barry Sander's cowardly retirement in 1999, we haven't had much to cheer about.

Here he is:

Asthmatics can lead a normal life

The following is a question asked by a humble asthmatic at MyAsthmaCentral.com and my humble answers.

Question: Can a person run or exercises or can he lead a normal life if he or she is asthmatic

Answer: Great question. The answer is a definite Y-E-S! Not only can we asthmatics lead a normal life, we also have the same life span as non-asthmatics.

I can start here rattling off the names of famous asthmatics who never let their asthma stop them: Charles Dickens, John F. Kennedy, jerome Bettis, Jackie Joyner-Kersee, Isaiah Thomas, Bob Hope, Billy Joel, Calvin Coolidge, Rev. Jesse Jackson, Peter the Great, Daniel Webster, Dennis Rodman, Art Monk, and a ton more.

If you are having trouble managing your asthma, you should call your doctor and talk to him about it. There are plenty of asthma medicines available today to help not just treat asthma symptoms, but prevent asthma altogether so you can live that normal life. With a good doctor, good asthma management, and a good asthma action plan, you should be able to do just about anything you want, including run in the Olympics like Jackie Joyner-Kersee.

I hope this answers your question. Any further questions please feel free to ask.

RT turned teacher

After you do a job for a while it seems so easy, so second nature. Yet when we have a student we realize how special the skills we have are. We have to slow way down and get right back to the nitty gritty basics.

It's fun in a way, and it's also very educational. It forces you to re-learn some of the elements of the job you forgot and hardly ever use, yet are important in order to develop the skills you now have -- the same skills you hope the student will have one day.

There is another aspect to teaching I think is equally important, and that is making a clone of yourself in the areas you excel, and making sure you do not clone yourself in areas of your weaknesses. That, I must say, is the greatest challenge of teaching.

I suppose this is true of any job, but when you do it a while you develop shortcuts. While shortcuts may be fine for you, they are not fine for teaching. For no other reason than if the student learns the shortcut first, and then later decides to short cut the short cut, the real job is not getting done, and you failed as a teacher.

Likewise, while you are fully competent and confident in your job, and you think anyone could do it with their eyes closed, that is not the case. A new student, even a new RRT who has taken the exam, may see this job as hard and stressful.

For example, when I was in my first conicals, I was nervous as hell. I fumbled with every task to the point my preceptor called my teacher and said she didn't think I'd ever make it as an RT. Well, we all know how things turned out in the end. While honesty with me allowed me to learn the hard way, patients is also a virtue worth having, as everybody grows at a different pace.

I think as I was learning this job about 90% of the people I followed were bad teachers. They just said this is what they wanted me to do and sent me to the wolves. That's fine, but you don't learn that way. You eventually need to be thrown to the wolves, but not when you are first starting out.

I had a non RT job once that taught me the lesson of how important an orientation is, and the importance of a good preceptor/teacher/mentor. Lacking any of these, I failed at my first job as a journalist. I fell flat on my face. In fact, that's why I ended up as an RT, because I failed at that other career.

While I suppose that 90% wouldn't be patient enough to remember the past, I find myself in the 10% -- I think. Perhaps it's easier for me to fall into this percentile because the other thing I wanted to be when I was deciding was a teacher.

Yet, like I wrote before, fate guided me on this path for some reason.

There are certain things that need to be the same way every time. So you teach the student to do it right. Yet, if you teach that everything must be done your way, you put a cork on creativity -- which you don't want to do in any successful business.

So, my point here is that I've decided teaching is a lot harder than one might think. And that's why we must give credit to those who do it every single day of their lives (especially kindergarten teachers).

A virus forced me to take a vacation from RT Cave

While it only takes one day to get burned out, it takes at least five days to get un-burned out. That's where I stand right now, on day #5 of being off. But that, my fellow readers, is not why I haven't posted here at the RT Cave the past four days.

Despite all the spyware on my computer, I caught a virus. It was one of those where every time I logged onto the Internet an anti-virus company had it's ad on my screen saying I had many viruses on my computer, and the only way to get rid of the viruses was to buy the product offered.

It was quite obvious to me that the same company who wanted me to pay to get rid of the virus was the same crooked company that put the virus on my computer. It's fraud plain as day. Yet how do little folks like you and me prove who put that virus on my computer? From what I've learned, it's nearly impossible to prosecute these thugs.

So it took my brother in law five days to read up on and figure out how to remove the virus. And that's where I stand right now. Finally, after a nice vacation from the Internet, I am back on here.

However, I have to say, taking a vacation from the Internet is not so bad. It was actually quite nice to take a vacation not only from work, but from the Internet as well. And three consecutive nights with 12 hours sleep helped as well. The result is that my burnout is gone. I hope it stays that way.

Yet, as all medical workers know, while it may take five days to get un-burned out, it only takes one busy night at the hospital to get all re-burned out again.

The ironic thing about this profession, though, is that if it's not busy at work, work can be a vacation in and of itself. Well, we'll have to wait and see how it is tomorrow when I do return to work.

Great to be back.

Quote of the day -- Imaginary wheezes

I don't know about other hospitals, but where I work a ventilator is an indication for bronchodilator. It matters not if the patient has bronchospasm or not, because just being on a ventilator is indication enough.

So, today, when the third overdose patient in as many hours was put on a ventilator by your humble RT, and this patient too was ordered up on Ventolin Q6 hours, your humble RT approached the nursing supervisor with the quote of the day:

"Hey, Amanda, I was wondering if you'd fetch me -- at your convenience of course-- a Ventolin inhaler for this man's imaginary bronchospasms and imaginary wheezes."

Imaginary wheezes, bronchospasm, asthma, COPD and pneumonia seem to be on the prowl of late, so be on the lookout!!!

A positive note from a fan

I like to contend I have no ego. However, reading comments like the one left on this post are still enjoyable to read:

"I've had asthma since I was four and I'm 29 now. The articles you have written are the best I've ever read on asthma. I was in the ER today and last Sunday with asthma. Thank you thank you thank you for posting. You just don't know how many people you've helped. I'm going to pass this along to my friends and family that are suffering from asthma

This is especially true while experiencing burnout. So ego up a notch from zero to 0.1.

Some burnout brewing

It's been extremely busy around the RT Cave lately. It seems this is the time of year where all the bugs that were brewing around all winter settle in and cause havoc for those with chronic illnesses.

And, since all that wheezes is considered as asthma, doctors are ordering up asthma and COPD drugs that only respiratory therapists can deliver, meaning the workload is skyrocketing, which results in burnout.

What is burnout? According to dictionary.com, burnout is: "fatigue, frustration, or apathy resulting from prolonged stress, overwork, or intense activity."

That's exactly where your humble RT is right now. I would like to add to that definition: "feelings of mush, burning feet, easy irritation."

The busy times will pass, it's just a matter of how long. Since we have no way of predicting the future (other than weathermen), we'll just have to bide our time.

It is for the fact I have no control of how busy it will be here at shoreline that I cannot have regular scheduled posts here at the RT Cave. And why I often promise to write something "tomorrow," and get to it a month later.

For example, I promised you guys I'd write about the link between pollution and asthma. I promised another guy I'd write about Primitine Mist and how it should never be used. I think I also promised once I'd write about PFTs.

This is a perfect example of the challenge of being an RT. You can plan on doing one thing, and the next instant your beeper will be going off and you have to do something else for a long, long time. You just sit down to eat and, WHAM! ER pages you STAT.

Hopefully soon the rush and the burnout will pass and I can get back to writing something useful, like the things I mention two paragraphs up.

COPD: Is Spiriva, Advair or Xopenex right for you?

The following question was emailed to me, and I've decided the answer would be of interest to many of my readers.

Your Question:

Hey - I'm a student therapist right now but I was talking to my manager about her mother and she has emphysema. She's on home oxygen and her doctor prescribed xopenex BID via HHN, advair BID, and spiriva QD. I'm wondering if this is a little excessive considering xopenex and salmeterol are both beta-adrenergic bronchodilators and considering xopenex is a short acting bronchodilator while salmeterol lasts much longer why is the doctor prescribing the xopenex? She doesn't have asthma so I don't believe she has a need for a fast acting bronchodilator. Also since shes taking salmeterol (in advair) twice a day, is the spiriva really needed as well?

My Answer:

Great question. I think your doctor is right on track with the Advair and spiriva. Advair has both a long acting bronchodilator and corticosteroid component to prevent bronchospams and control inflammation. Spiriva, believe it or not, has been proven to improve lung function, something every emphysema patient could benefit from.

Xopenex should definitely be ordered, but only on an as needed (prn) bases to treat acute episodes of shortness of breath due to bronchospasm. In my opinion, there is no added benefit from pre-set frequency of Xopenex unless the patient is often short of breath despite all the other medicines.

Here's an exception to that last statement: some COPD patients have trouble deciding when they need to use their rescue medicine. For these patients, a set frequency may be indicated. For the most part, however, Xopenex should only be used if it is needed.

One of the neat things about Spiriva only being needed once a day, and Advair twice a day, is this improved patient compliance with these meds. With improved compliance, the rescue medicine (Xopenex and Albuterol) should be needed less often.

Note: All asthma and COPD patients should have either a xopenex or Albuterol inhaler handy at all times, and perhaps, if indicated, the capability to take breathing treatments.

No smoking, and no smelling like smoke!!!

I thought it was interesting a few months back when the administrators at Shoreline decided this hospital was going to go smoke free. Not only are employees no longer allowed to smoke on campus, they cannot leave and come back smelling of smoke.

My dad told me when grandpa was on his death bed in a hospital just after I was born in 1970 grandpa wanted a cigarette real bad and no one would give him one. So dad gave him one of his cigarettes. Grandpa would take a puff every few hours, and one smoke would last a long time.

In the 1980s hospitals started to crack down on smoking. And, about the same time nurses were allowed to wear more creative clothing than those prototypical white nursing uniforms and caps, smoking disappeared from hospitals.

When I was hired here in 1997 there was still yellowed tile in the nurses report rooms from when they used to smoke there. The elder nurses here have told me of how they used to sit and smoke at the nurses station while they charted. Patients used to smoke in their rooms.

They have finally disappeared, but we used to have little red magnets that said, "No Smoking" plastered on the file cabinets in the RT Cave. I never once used one, but these were supposed to be stuck onto the doors of rooms where oxygen was in use.

The policy eventually was changes so that if you wanted to smoke you had to go out to your car. However, I remember several nights the nurses would poke their heads out the door and puff. This habit was ended, however, when one summer many patent's had their windows open, and the smoke wafted in. Many patent's complained, and the practice was put to a sudden end.

So up until a few months ago my co-workers who smoked were allowed to do so with restrictions. However, that has come to an end. No person who works here is allowed to smoke on campus. Not only that, no person who works here can smell of smoke. Not following this policy is grounds to be sent home. And, if it is evident someone is not willing to comply, this is grounds for dismissal.

At first I thought this was quite harsh, but after further thinking about it I think this is pretty good, especially since this is a hospital, and many of our patients are Asthma and COPD patients who can have an attack just smelling smoke on someone.

I know this is true because just tonight I had to give a breathing treatment to an asthmatic kid, and both his parents reeked of smoke and filth. When I walked out of that room I had to use my inhaler, and I have controlled and mild asthma.

If it were a factory making a policy like this, I think I'd feel this policy is going too far. I think it's fine for a business to tell someone they can't smoke on campus, but to say they can't come in smelling of smoke is a bit overboard. Yet this is perhaps for the best for a hospital.

MCAT question #36

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

Which of the following is an indication for a Ventolin breathing treatment?

• a. The nurse said so
• b. only bronchospasm
• c. junky lung sounds
• d. irritated doctor
• e. only asthma and COPD
• f. any disease in and around the lungs
• g. only b and e
• f. all of the above except b and e. Only a stupid RT would answer this question b and e.

MCAT question #35

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

You are home taking a cat nap when your phone rings. You pick up the phone when a respiratory therapist identifies herself. She says, "Mrs. Hone in room 232 has been on treatments Q4 hours for two weeks. She has not had trouble breathing in two weeks yet she's still on treatments. Can we change the treatment to as needed?

What would be the most appropriate response?

• a. feign anger
• b. tell the RT you respect her opinion and order the change
• c. Keep the order the same because you know the next treatment might be the one.
• d. Keep the treatment the same because Ventolin prevents an amalgamate of diseases no matter what those pesky RTs think.
• e. Kindly thank the RT for bringing this to your attention, and change the order to Q3 hour IPPB.
• f. All of the above
• G. Any of the above will do except b because RTs are stupid dummies unless there's an emergency

MCAT question #34

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

#34

You are a urologist taking care of a patient who has trouble peeing. Upon inspection you observe his prostrate is enlarged. How often do you give breathing treatments?

• a. q4
• b. q4
• c. q4
• d. q4
• e. RTs are stupid dummies
• f. All of the above.
• g. none of the above

MCAT question #33

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

#33

Pidley and annoying Respiratory Therapists are trained that Albuterol and Xoponex should only be given after an assessment reveals shortness of breath caused by bronchospasm. Yet we doctors know all respiratory illnesses require breathing treatments, and therefore we should always order treatments at which of the following frequencies:

• a. PRN and allow RT to assess and treat as appropriate.
• b. QID because the patient will only be short of breath four times a day.
• c. Q4 because RTs aren't smart enough to assess appropriately.
• d. Q4 because we Drs know exactly when a patient will be SOB.
• e. Q-4ever because this next treatment might just be the one.
• f. Q6 because we Drs know exactly when a patient will be SOB.
• g. b, c, d,
• h. b and f
• i. b, c, d, e and f
• h. All of the above

MCAT question #32

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

#32:

Pidley and annoying Respiratory Therapists are trained that Albuterol and Xoponex are medicines used to treat and relieve the symptoms of Asthma and COPD. That in mind, which of the following diseases are really treated and cured with these bronchodilators:

• a. respiratory failure of any origin
• b. pneumonia
• c. pneumonia
• d. bilateral pneumonia
• e. pneumonia
• f. pneumonia
• g. pneumonia
• h. hernia
• i. fractured leg
• j. Lysis
• k. RSV
• l. pre nop
• m. sepsis
• n. asthma
• o. COPD
• p. rickets
• q. n & o
• r. b, c ,e, f & g
• s. b, c, d, e, f, g & k
• t. b, c, d, e, f & g
• u. a, b, c, d, e, f, & g
• v. h, i, j, l, & m
• w. none of the above
• x. all of the above
• y. all of the above and many more diseases
• z. I don't know. I forgot to do my homework.

Happy Good Friday

Happy Good Friday.

It's obviously not a good Friday to a lot of people, as the patient load here at Shoreline is ridiculously high. Yet, while I have 14 patients on my Asthma/COPD medicine treatment list tonight, none of them have asthma nor COPD. How is that for amazing. I suppose we're providing 14 patients with scrubbin-bubbles, pneumonex, cracklin, preventolatorolin, insanolin, wheresmymamaolin, wedontknowwhatelsetodosoletsgiveventolin-olin, allwheezesarebronchospasmolin, allthatisshortofbreathisbronchospasmolin,
allannoyinglungsoundsarebronchospasmolin, allannoyingpatientsdeserveanrtolin, and you name the 'olin.

That's fine, because we just keep chuggin along biding our time for the day when we RTs at small town hospitals gain the respect of doctors and RT Driven Protocols like they have up in Grand Rapids and Ann Arbor. Perhaps they pray harder than we do up here.

Have a wonderful holiday weekend. I'm celebrating the whole thing right here at the RT Cave.

Cheers!

A vampire, a ghost, or deep brain stimilation

I'd say I'm pretty fast at doing EKGs. I can start and finish an EKG in less than 2 minutes, and provide the Dr. with a quality EKG.

Yet, after I was in the room of Mrs. Leed for over 10 minutes and the machine wasn't picking up any signals, I was getting a bit vexed.

"Are you sure you're not a vampire," I said to the patient with a smile.

"It's possible," she said.

"Sorry, I'll be right back," I said to the patient, and I rushed upstairs to get a new machine. "This one must be broken."

I set up the second machine... nothing. I double checked the leads... nothing. Gosh! This can't be happening. There's no way 2 machines could be broken. Then it occurred to me. Maybe something in her was causing interference. "Do you have a pacer?" I said.

"No!" she said. "But I do have deep brain stimulation." She tapped her chest, and there was a scar covering the device. She said she had it for therapy for MS. She said it helped her with the shaking.

Still, she said the battery has been dead for a year. Just then the nurse came in, and I showed her how I couldn't get an EKG on this patient. She started to say, "Well, we have to have one," but then she looked up at the monitor, where the rhythm strip was flat line.

She checked the leads. They were all fine. "Don't even bother replacing the leads," I said. "She's a vampire."

The patient laughed, and said, "I'm not a vampire, I'm a ghost."

Deep Brain Stimulation was originally approved for depression, but has been approved for other disorders, like OCD. It's a device that requires brain surgery.

According to the Mayo Clinic: "Deep brain stimulation works much like a pacemaker for your brain. With deep brain stimulation, a neurostimulator device is implanted in your chest and electrodes are implanted in your brain. Wires under your skin connect the electrodes to the neurostimulator. The neurostimulator sends electrical signals to your brain, affecting mood centers and possibly improving depression symptoms."

Regardless, one of the disadvantages of the device is it impedes the ability to get a rhythm strip or an EKG. And I learned that the hard way today. I had never heard of deep brain stimulation before.

Now we know.

Now we have e-smoking

We already have e-mail, e-bay and e-magazines. Coming soon to an atmosphere near you may be e-cigarettes. Imagine a future of e-cars filled with people e-smoking.

Anyway, I found this ad while searching for something completely unrelated to this and thought it was a joke at first.

Good ridance to the NBC hit "ER"

I wonder how many of my fellow medical workers watched "ER". I watched it when it began because I thought it would give me a perspective of life inside a hospital. Yet after I started working as an RT I'd find myself watching it with a fine tooth comb.

My friends who'd watch it with me were continuously vexed by my effort to critique everything that wasn't realistic. I never did see a person talking with an ETT stuck down his throat like on the old Emergency show from the 1960s, but there were equal inaccuracies in this show.

The last episode was a perfect example of this. In one scene we see Dr. Carter sitting in a bar with his friends, and in the next scene he has just left the bar and is walking into the ER. His friend says, "Dr. Carter, what are you doing?" He said, "There is work to be done."

So he all of a sudden -- after drinking -- decides he should be working in a hospital he is no longer employed at. If this happened where I worked he'd be fired on the spot.

Oh yeah! He can't be fired because he didn't work there.

In another scene a lady just gave birth and she is bleeding out. As I watched I could see blood pooling onto the floor. The doctor said, "Where the hell is OB?"

Why is it on this show the only time you ever hear about RT or OB the words, "where the hell are," proceed them. In the real world, a lady who was about to give birth to twins would have been RUSHED up to OB, and the babies would have been born there.

Second of all, the doctor in the show kept saying, "Push! Push!" In the real world, if a mom who is at a place she shouldn't be delivering a baby were in labor, the last thing you'd want to to is rush it out. This wouldn't even happen in the OB.

So these are just a few of the inaccuracies I found in the last episode of ER. It amazes me how busy that place seems to appear all the time. Not even the busiest hospitals in the world are that busy.

Likewise, the doctors ran all those codes as though they do everything themselves. When in that show do you ever see a respiratory therapist assisting with an intubation, or intubating, or doing CPR, or doing ABGs, or advising the doctor. Not on this show.

In real life, the doctor gives the order, and the RNs and RTs perform them. Yet, the only time on "ER" the letters R-T is said is when it is yelled by a pissed off doctor after the RTs services are no longer even needed.

I do enjoy watching shows like CSI. As I do, I wonder how many things those forensic scientists
do on that show that they never would do in real life. I bet there is no forensic scientist who works out on the field AND in the lab.

Or how about all the lawyer shows? I bet those aren't very accurate either.

Yet, all the same, they make for good entertainment for the majority of watchers of those programs. But those of us who know better, or are all the wiser, are not fooled by this false entertainment.

ER is done. Good ridance.

The best dose of Xoponex for neonates & infants

The following question was asked at MyAsthmaCentral.com. I thought the answer here would benefit asthmatics worldwide:

WHAT WOULD BE THE NORMAL DOSE OF XOPENEX FOR A NEONATE OR INFANT?

Great question. Most experts agree that the adult dose of 1.25 mg xopenex es equally safe for kids. I think the main reason for this is because the airways of kids is much smaller than the adult airway and so disposition of the medicine into the lungs is greatly diminished.

Likewise, the most common method of delivery of the medicine to neonates is by blowing the med by the patoent's face (blowby treatment), and this results in most of the medicine being wasted to the atmosphere (perhaps even as much as 80% of the medicine wasted).

In fact, according to respiratory therapy experts (read this article) the use of the blowby is not recommended. However, with neonates, we have no real other options. Therefore, the 1.25 mg dose is recommended.

A preferred method to blowby is using a face mask, but still 50% of the medicine is wasted to the atmosphere. The best method is using a mouthpiece, but that's not possible with the neonate population.

However, despite what I have written here, the best dose of xopenex is whatever dose works best for your child with the least side effects, and whatever dose your doctor recommends. Most doctors where I work prescribe the 1.25 mg dose, however, on occasion, they recommend the lower doses.

The same holds true for Albuterol. The best dose for neo and infants is 0.5cc Ventolin.

I hope this helps. Any further questions let us know

2 chronic lungers in Boston Marathon

Imagine having a lung function of 36% and qualifying for the Boston Marathon. That's exactly what Breathin Stephen, creator of breathinstephen.com has accomplished. If all goes well, he will be the first severe asthmatic to run in this most prestigious marathon in the world on April 20, 2009.

Stephen will not be the lone chronic lunger in this race, as Mike McBride, who has oxygen dependent emphysema, will be competing with him for the finish line.

Stephen said he's competed before with Mike, and "it's quite a spectacle to watch him haul a special cart which holds his liquid O2 tanks. He uses liter flows up to 18 lpm during a race, so he has to have people embedded throughout the course the change out his tanks.

"While his body requires supplemental O2," Stephen continued, " he doesn't seem to experience dyspnea, like I do. Even minor exertion makes me breathless. What makes me different than most people however, is that I don't let the breathlessness freak me out. I can tolerate extreme breathing discomfort. ( I don't know if that's good or bad, cuz sometimes I don't perceive when I'm about to crash) Anyway, I hope to beat him to the finish line."

Obviously there is no guarantee their lungs will allow them to participate in this race. And even if they don't, just the fact they have come this far is an inspiration in itself to chronic lungers.

This week in my weekly column at MyAsthmaCentral.com I wrote a nice piece about Breathin Stephen: The Hard Luck Asthmatic who is going to participate in the Boston Marathon. Click here and I will morph you over to this inspirational story.

Meet Breathin' Stephen, the Hard Luck Asthmatic On His Way to the Boston Marathon
by Rick Frea Thursday, April 02, 2009 @MyAsthmaCentral.com

Most asthma experts would say that no matter how bad your asthma is you should exercise. I can think of no better example of this than Stephen Gaudet, aka Breathin' Stephen. Despite being a severe, persistent asthmatic, he has qualified for the Boston Marathon.

He is the perfect example of the Hard Luck Asthmatic, the asthmatic who does everything right, like Jake Gallant, only he and his doctor still have trouble managing his asthma.

Stephen, age 54, said he's been hospitalized 92 times admits, many of those in critical care (his most recent was in Sept. 2008), and 14 times on a ventilator.

"My asthma has gotten progressively worse since the age of 5," he wrote in an email to me. "My first time on a ventilator was at the age of 16. I had a respiratory arrest in the elevator while being taken to radiology for a chest x-ray. I coded, but it's unclear if my heart stopped. I did however suffer 2 fractured ribs which leads me to believe that they did compression for one reason or another.

"The second time occurred at the age of 22," he continued. "I was on the ventilator for over a week. I had really bad [eosinophils], which complicated things. The worst exacerbation I've had in recent years was back in 2004. I ended up on a vent and then developed a bacterial pneumonia on top of the asthma."

Yet, despite his bad lungs, despite these set backs, he understands the importance of exercise and he walks as often as he can. In the "About" section of his blog, BreathinStephen.com, he says:

"Despite being breathless most of the time, I exercise hard and I keep active because it makes me feel good about myself. But mostly I do it... to stay alive! It's a proven fact that physical fitness is beneficial for people with lung disease. I guess in my case, I've taken that advice to the extreme! Daily exercise won't cure you, but it can certainly help you live better and probably longer ...I'm living proof."

As an even greater inspiration to us asthmatics, Stephen walks in marathons. Most recently, on March 20, 2009, he walked in the Rome Marathon (he wrote about his experience here). Up next is the most popular marathon in the world: The Boston Marathon!

There are cash prizes for the quickest to finish the 26-mile ride that takes place the third Monday of April (April 20 this year), but most people run the race for the accomplishment.

"What makes the Boston event so significant," Stephen said, "is that I will be the first person ever with severe lung disease allowed to compete by being granted 'mobility impaired' status."

His pulmonologist, Dr. Joshua Galanter, wrote a letter to the Boston marathon committee during his application process:

"With such severe obstruction, Mr. Gaudet is consistently breathing at his maximal expiratory flow rates and would have significant difficulty increasing his minute ventilation in response to exertion, which places a substantial challenge on his ability to carry out even normal exertion, making his competition in distance events all the more remarkable. I would not have predicted that he would be able to complete a marathon distance competition with his severe pulmonary impairment but for the fact that he has done so on several occasions. This represents a remarkable accomplishment on his part, one that represents a triumph of perseverance over physical limitations, and one that I hope the Boston Marathon would celebrate by allowing him to compete."

Stephen, who lives in San Fransisco, had to qualify for this race just like every other participant -- by having a qualifying finish time from a previous qualifying race. "The only difference," he said, "is that they are waiving the 6-hour time limit for me and a couple other people with disabilities."

However, he remains realistic: "As with every race that I prepare to do, it still remains to be seen if I'll actually be able to pull it off. As you know, the problem with severe asthma is that it has a mind of its own. You can feel great one minute and be sucking on the end of an ET tube the next."

So Breathin' Stephen -- the Hard Luck Asthmatic -- is currently training for the Boston Marathon. He is truly an inspiration to all us asthmatics, who can no longer say, "I have asthma, so I can't do that."

Yes you may have to pace yourself, but with good asthma management you too can be an inspiration. As best you can, keep moving -- or at least keep walking.

Breathin Stephen says it best: "As you know, there hasn't been much written about people with the severe form of this disease. I'm hoping that my taking part in the most prestigious marathon in the world will send a message to other hardcore lungers out there, that anything is possible."

Good luck Stephen. We'll be rooting for you.

The ghost in room b

I promised a report on the relationship between pollution and asthma today, but I am going to have to defer that until Monday. It's been so crazy here at the RT Cave lately all my energy has been sucked out of me like the spirit of a dead man on an ER table after CPR.

I'm sure I mentioned somewhere on this blog about he ghost in critical care here at Shoreline. It's well documented now. There are stories about it that just about anyone who works here knows about. And many of us have seen it.

There have been nights when the door opens and shuts and opens and shuts all by itself, despite no breeze. It's amazing. Sometimes it even stands outside the door and watches over us.

We talk about it nonchalantly, as though it were another member of the staff. So as I was telling a personal story about my experience in that room, no one gave what I said a second thought.

This is the truth. I was standing there giving a treatment to Mrs. C. She had her eyes shut, so she was not witness to it. Or, if she did see it, she had probably seen stranger things in the room as she had perhaps become quite familiar with the spiritual host of the room.

I was looking at the TV, only the TV was no longer there. Instead I noticed another room off in the corner. My mind had been overcome by the moment, so I didn't second guess that the room was there. In my mind, I thought, "Why didn't I notice it before?"

I did a double take, and the room was still there. So I started around the bed to check out what was in this small room, and it was gone now. The TV was back. Everything was back to normal. And the treatment was still going.

I told this story to my co-workers, and they took me seriously. The Ghost in room B had made yet another appearance, albeit in an awkward way.

As I write this I wonder what the ghost was trying to tell me, or show me.

The ghost of critical care, or a patient saying "bye"

The ghost of critical care has been a staple at Shoreline for as long as I've worked here. One of the first days I worked here I was made aware of her. I'm not sure if it is a female, but the vibes I get tend to make me think that way.

I'm not sure if the story I want to relay today has something to do with the ghost or not. But it makes for an interesting story nonetheless.

Mr. Nurse told me on my first day here years ago of his first encounter with her. One of his patients, Mrs. Patient, was in a bed in room A, and she was seriously ill. He was in the room talking to her, and she said, "I think I'm ready to go now."

Back at the nurses station Mr. Nurse listened as the cardiac monitor alarmed. When he looked at it, he saw the following across the screen:

"Byebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebye byebyeByebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebye byebyeByebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebyebye byebye."

He rushed back to her room, and she was no longer in this world.

The funny thing was, Mr. Nurse told me this happened on the old cardiac monitors that did not have the capability to show words.

Cure for asthma discovered

I wrote a while ago I wrote how scientists discovered the asthma gene. Today I would like to be the first to report that scientists at the asthma lab at National Jewish Health believe they have come up with a cure for asthma.

Thankfully I remain good friends with Dr. Dr. Sloof Lirpa, M.D, a pulmonologist at National Jewish Health in Denver Colorado, from my lengthy stay at that hospital when my asthma was really bad back in 1985.

In an email he said a simple blood test will be performed on all newborn babies, and if they test positive for the asthma gene a simple vaccine will be provided to the infant that contains bacteria to stimulate the immune system and, thus, prevent asthma.

"Unfortunately this vaccine will not cure any one who already has asthma," Lirpa said, "But it will prevent newborns from developing asthma, and thus prevent new cases of asthma. By the year 2070 it is possible doctors may no longer be familiar with this now common disease."

In the next few days I will write more about this new cure for asthma, and my discussion with Dr. Lirpa. Until then, I hope you have a great... APRIL FOOLS.