No ideal sollution for allergies, so here's some tips

I'm not sure how I could have possibly have done this, but I forgot to post on here my Asthma Blog Post entry I wrote just for the allergy season. I suppose allergies are still in the air even though we're in the middle of summer, so I will submit it now.

This post was originally published at MyAsthmaCentral.com. You can link to the original post by clicking here.

19 Tips to Avoiding Allergens That Aren't Exactly Fun to Follow
by Rick Frea Wednesday, June 10, 2009 @ HealthCentral.com

Well, the warm weather has finally arrived, and so has the urge to spend as much time outdoors as possible. Yet, while we asthma & allergy sufferers try to be normal, we often find ourselves a-a-achoooo-ing our way through the season.

Like many of you, I've been dealing with dreaded allergies my entire life. Perhaps you can relate to this: I'm on all the awesome new meds such as Singulair and Claritin, yet those dreaded allergens still find a way to wreak havoc. Oh, and yes, I tried allergy shots and they didn't help me.

So, since 70% of asthmatics have allergies, I did some research and came up with 19 tips we asthma and allergy sufferers should follow to ease the effects of seasonal allergies:

• Exercise indoors whenever possible.
• If you can't resist exercising outdoors, at least try to stay away from trees and shrubs and exercise when the pollen counts are lower (sometimes, that's in the afternoon).
• Swallow your pride and have someone else cut the grass.
• If you do decide to cut the grass, wear a mask over your mouth and nose.
• Either way, your grass should be mowed often.
• Keep your gutters clear of leaves and soot. Gunked up gutters are a good place for mold to grow.
• Avoid working in the garden as this will expose you to molds. If you MUST work in the garden, wear a hat, gloves and goggles (which will also protect you from sunburn).
• Avoid raking the leaves as this will expose you to molds. Have someone without allergies do it!
• After doing any outdoor work, take a shower and change clothes when finished or, at least wash your hands to prevent the spread of pollen and molds.
• Ideally you should avoid carpets and rugs (or get rid of them if you have them), however, if you do have them, vaccum oftenwith a HEPA-filter equipped vaccum.
• Use a HEPA filter to purify the air inside your home.
• Keep the windows shut, especially in the morning.
• If you do open windows, do not use a fan as this will blow in more pollen.
• Keep the air conditioning or dehumidifier on to keep the house cool and to filter out allergy triggers.
• Keep dust covers over mattresses and pillows to protect yourself from dust mites
• Avoid clutter in your house (especially bedroom) to limit dust buildup.
• Keep your pets out of the house.
• Wash your pet once a week
• If you allow pets in your home, at least keep them out of your bedroom and most certainly off your bed.
• Avoid other poeple's pets (however cute they are).

Okay, that's enough. Most allergy experts recommend you do everything on that list to prevent or minimize allergies. Still, if there's anyone in the world who does all that, I commend them -- because I don't.

I'm good with the pet part, because I'm a lousy pet owner and don't have any. My daughter loves doggies, so I let her play with the neigbor's dogs. Since I work in a hospital, I'm good with washing my hands. The rest of the stuff on that list I'm not so good with.

I feel guilty (or lazy) having my wife cut the grass, so I do it myself. Same with the garden. Sometimes I wear a mask, but it gets awful hot and sweaty under there. Frequently I shower when finished, but sometimes I'm too exhausted.

I would jog on the treadmill, but I do that all winter and simply love getting out of the house now that the weather is nice. I can't afford air conditioning, and just love a warm breeze, so the windows are always open. Umm, and since I work nights, I often sleep with a fan in the window.

Sorry folks, I'm not Jake Gallant when it comes to avoiding those ubiquitous allergens. I'm simply a normal guy who strives to be the best asthmatic he can be.

Short of a cure, we at least have some tips to lessen the effect of seasonal allergens on our sanity -- if we so choose to accept the challenge.

Shouldn't have been, but t'was one of those nights

Just to give you an idea of how my night went last night I'm going to post here my tweets from this morning.

1. Finally a night with no patients on the floors, but unfortunately Dr. letsordertxsoneverone is working in the ER
2. Since when does croup get treated as asthma. I'll have to do some research on this. She orders Q30 Xopenex for stridor? Huh?
3. now the croupy kid is going home with a nebulizer. Talk about wasted healthcare resources.
4. I don't think Dr. Q1 has a clue what she's doing. This is getting to be a joke. And they want me to take my job seriously.
5. I almost lost my cool when that last order was written. I did if you count rolling eyes at Dr. Q1 as loosing coolness.
6. They have to beg to get Dr.s to come here to this small town. That explains why we have to put up with reject Dr.s who have no clue

Pinheads smoke in front of asthmatic children

I've written more than a few times on this blog how unwise it is to smoke in front of children, let alone anyone; that those who smoke in front of kids are pinheads. If that's not bad enough, smoking around an asthmatic kid should land the smoker in jail for child abuse.

I reiterated this point in my latest asthma blog post:

Smoking around asthmatic children is unwise
by Rick Frea Tuesday, April 14, 2009 @MyAsthmaCentral.com

If common sense were to prevail, no person would ever smoke in front of kids -- especially kids with asthma. Yet we all know it happens.

Just the other day I was paged to do a breathing treatment on a six-year-old boy with asthma. I couldn't help but notice that both parents reeked of cigarette smoke.

As a respiratory therapist, few things frustrate me more than this, perhaps because I was a child asthmatic who, on occasion, had to sit in smoke filled rooms (I wrote about this experience here).

I knew a doctor once who would call the police when he learned a parent was smoking in front of a child with a chronic lung disease. He would say, "This is child abuse."

My job as an RT is to educate these parents not just on the dangers of smoking, but that second-hand smoke can trigger an asthma attack, and make an ongoing attack worse.

Cigarette smoke also further damages not just the smoker's lungs, but the lungs of nonsmokers who are forced to breath in second hand smoke -- like kids.

Some parents heed my advice and stop smoking, at least stop smoking in front of kids. However, a few choose to ignore the wisdom I present. One dad completely denied second-hand smoke was dangerous.

Now, however, thanks to a new study conducted at the University of Alabama (and discussed here), we have proof a link between tobacco smoke and asthma morbidity exists.

The study consisted of 290 children with persistent asthma, 28% of whom were exposed to smoke in the house, and 19% who were exposed to smoke outside the house. All the children were educated on the dangers of second hand smoke, and were educated about avoiding their asthma triggers -- especially second hand smoke. Of the children whose exposure to second hand smoke decreased, "fewer hospitalizations and emergency department visits were reported in the 12 months prior to the second interview compared to the 12 months prior to the first interview. Additionally, these children were 48% less likely to experience an episode of poor asthma control."

While this is a new study, this is not new wisdom. In fatal asthma, a book published in 1998, the authors write:

"Surveys have shown 53-76% of children's homes have one or more smokers, and an estimated 8.7 million children in the U.S. under age 5 are exposed to cigarette smoke at home. Asthmatic children whose parents smoke may have more asthma symptoms and more frequent exacerbation's requiring emergency department management."

I have no problem with people smoking. I think it's fine if a grown adult chooses to put arsenic, acetic acid, acetone, ammonia, benzene, butane, carbon monozide, ethanol, formaldehyde, hydrazine, hexamine, hydrogen cyanide, lead, methane, mathanol, napthalene, nickel, nicotine, phenol, polonium, stearic acid, styrene, tar and toluene and 3,580 other substances into his body (which are the contents of one cigarette). But, a child doesn't get to choose. He is forced to breath whatever air is provided for him.

The importance of the Alabama study is that it acts as a reminder to members of the medical profession the importance of asthma education. It is my job as an educator to inform the asthmatic -- which include my patients and you -- to avoid your asthma triggers, which include cigarette smoke.

If your child has asthma, and you are smoking in front of him, chances are you're making his asthma worse. So, here's my lecture to you: Be a responsible parent and don't smoke in front of your asthmatic child, or any kid for that matter.

If you have asthma and are gutsy enough to smoke yourself, my lecture to scare you into quitting will come soon. So stay tuned.

5 Common myths about performing EKGs

Since I'm the fastest and best EKG technician in the world (yes I'm arrogant. Just call my Ricky Henderson). I thought I'd take this moment to clarify some myths about doing EKGs that slow some of my fellow EKG techs down.

Yes, that's right, if you eliminate the following myths from your EKG routine, you should be able to speed up your time:

Fallacy: I have to set the machine on the left side of the patient.

Truth: The machine does not have to be on the left side of the bed. In fact, I usually set it at the back of the bed so it's out of the way.

Fallacy: The patient has to be flat

Truth: The patient does not need to be flat. You can get the same good EKG whether the patient is supine or sitting on the edge of the bed (although while sitting it's sometimes a challenge keeping the leads from falling off)

Fallacy: No one can be touching the patient when you are performing the test

Truth: I do the EKG test while lab is drawing blood or the nurse is inserting the IV all the time, and this never effects the results. There is no reason you can't share the patient with other technicians while performing this test.

Fallacy: For males, you have to shave the patient.

Truth: I rarely shave patients to do this procedure, and rarely have a poor EKG as a result. So long as you can move enough hair aside to get the stickers to stick, you're good to go.

Fallacy: For females, you have to expose breasts.

Truth: I usually cover the patient with a blanket up to her belly button, and pull up the gown so it's just under the breaths. I rarely ever see breasts. This method works very well for anxious females, and especially young sensitive ones. Some guys who pull the gown down from the top use a towel to cover the breast. Either method will work great, and your patient may appreciate your special care.

Fallacy: You have to prep the skin before doing the test.

Truth: I can honestly say I have never prepped the skin in all my years doing EKGs. The only time I prep skin is when I want the leads to stay on long term, such as when I set up Holter Monitors.

Fallacy: You can't do an EKG when the patients legs are crossed.

Truth: Yes you can.

Myth busted: Influenza does not cause nausea!

So, my daughter has been vomiting any food intake the past couple days. One evening I said -- jokingly -- to my wife, "She's probably got that swine flu thing. You know: H1N1."

My wife, wise as wives are, corrected my fallacious statement. She said: "I think that most people get influenza and gastroenteritis mixed up. Influenza is an infection of the lungs, and the stomach flu is what causes nausea and vomiting.

"In fact," she continued, "I think most people who get the flu shot and complain that they got the flu anyway definitely don't know the difference. Because the flu shot you get every year does not prevent the stomach flu (gastroenteritis), it prevents you from getting influenza."

According to HealthCentral.com:

"Influenza, usually known as the flu, is a respiratory infection caused by the influenza virus. The infection typically is spread by air or by direct contact, from one person to another. Most cases occur during epidemics, which peak during the winter months nearly every year. Influenza virus is very contagious. A particularly widespread and severe epidemic is called a pandemic...

"With many other types of infections - for example, mumps - having the disease once protects against a second infection because the body's immune system 'remembers' the returning virus, attacks it immediately and rapidly eliminates it. With influenza, the virus usually has mutated (changed) somewhat since the first infection, but the change is enough to fool our immune system. Instead of attacking the virus rapidly, as it would a virus that it had seen before, the immune system responds slowly. By the time the immune response is in full gear, millions of the body's cells already have been infected with the virus."

It is because the flu virus mutates that you need to get a flu vaccination each year, rather than just once. Each year the vaccination is adjusted to prevent against the current "mutated" strain.

Symptoms of influenza are as follows:

• Chills
• Moderate to high fever (101° to 103° Fahrenheit)
• Sore throat
• Runny nose
• Muscle aches
• Headaches
• Fatigue
• Cough
• Diarrhea
• Dizziness

As I was perusing the web looking for some information on the stomach flu, I came across a neat article at HealthCentral.com called, "Five Myths about the flu," by David Stanley. He writes that when someone says "I have the flu," and is face to face with him, he knows with relative certainty the person does not have the flu.

He gives the person what he calls the Fast Test, which consists of the following questions:

• Fever - The flu typically produces a high fever that lasts three to four days. Fever with a cold is rare.
• Aches and pains - Headache is a trademark of the flu. Other general aches and pains are common as well.
• Sudden onset - A person can go from feeling perfectly healthy to a full-blown case of the flu in a matter of hours. Cold symptoms tend to develop over days.
• Tiredness- If you have the flu and make it to the store to ask me about it, you are one tough cookie. Most people with a cold can carry on, but if you have the flu, do what your body is telling you to do and stay in bed.

So, basically, if you have the real flu you are not going to be out and about telling people you have the flu. Oh, and speaking of "real flu", Stanley writes that influenza rarely causes stomach irritation, and therefore there really is no such thing as the "stomach flu." Thus, if you are nauseous, what you actually have is gastroenteritis, which is an infection of the intestine caused by a different type of virus.

As per all the people I work with complaining that they won't get the annual flu shot because it caused them to get the flu, Stanley clears up this myth:

"This simply cannot happen. The flu shot uses a dead form of the virus to trigger an immune response, and that dead virus cannot come back to life and infect you. If you think your flu shot gave you the flu, first apply the FAST test to see if you have it or just caught a cold. If you do indeed have the flu, one of two things happened: You became infected during the one to two weeks it takes for the flu shot to begin to provide protection.You became infected with a version of the virus not covered by this year's vaccine.

The author, David Stanley, writes: "This may sound odd, but if you say this to me face-to-face at the store, you probably don't have the flu. While people can easily confuse a bad cold with the flu, I use what I call the FAST test to tell the difference. There are four questions to ask to distinguish the flu from a cold:

So, since my daughter is walking around all day with no fever, and playing with her toys, it's highly unlikely that she has the flu. Likewise, if you are having bouts of nausea and vomiting, you don't have the flu either.

And once again the wife was right.

On vacation & forgot your meds: what can you do? How long do drugs last in the med cabinet?

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Question: I forgot my nebulizer at home i dont have any of my asthma meds what can i do im felling very tight. I normally carry a resuce inhaler with Albuteral and use it in my nebulizer as well but i left everything at home

My humble answer:
First of all, know that you are not the first nor the last asthmatic to do something like this. I've done it, and so do many other asthmatic vacationers I see in the ER.

I have a couple options for you.

1. Most pharmacies allow prescriptions to be transferred. If you go to a Walgreens back home, for example, you can go to the Walgreens wherever you are vacationing and just have them transfer over your scripts. You won't be able to get a new nebulizer this way, but at least they should be able to get you a rescue inhaler. Other pharmacies that will do this are Rite Aid, Walmart, Kmart, etc.

2. In fact, I'm pretty sure any pharmacist would understand your predicament and help you out. I've gone to random pharmacies before and have never had a problem having my prescriptions transferred.

3. Don't be afraid to go to the nearest emergency room. The people that work there will understand your predicament, give you a quick breathing treatment in the ER, and send you home with a rescue inhaler. If you need it, they can also contact the local home health care company and have them supply you with a machine to use until you go home. The doctor there can also write prescriptions for any other medicines you might have forgotten. Since you should never wait too long to treat your asthma symptoms, this might be the best option for you.

4. You might be able to go to whatever home health care company in the area you are vacationing and see if they can hook you up with a nebulizer and vials of meds to last you until you get back home. I'm not positive exactly if they would be able to help you, but you could try.

Good luck!

Question: What is the shelf life of Theodur

My humble answer: Here is a neat article I found concerning the shelf life of medicines.

Basically, most new drugs like Theodur (theophylline) are good for 2-3 years from the date of manufacture. However, once the "original container is opened for use or dispensing, the expiration date on the container no longer applies." When the product is repackaged for you -- the consumer, it is "usually" dated by the pharmacist to expire within one year.

The expiration date of a medicine is the predicted date at which the drug will lose10% of its potency, according to this ABC News post.

The expiration date also assumes you are storing the medicine at the recommended temperature and humidity. According to our own site, theophylline should be "stored between 59-86 degrees F (15-30 degrees C) and away from light and moisture." This means that it should not be stored in the bathroom where it will be exposed to high humidities during and after showers.

While most drugs like Theodur are not hazardous if used after their expiration dates, the efficacy of the medicine after that date can no longer be guaranteed. Thus, if you are using an expired medicine you may not be getting the expected results.

Question: Is breathing-in more difficult for Asthma patient or breathing-out ?

My humble answer: Believe it or not, asthma is a disease of air trapping. What happens is air comes in, the airways constrict and swell, and air gets trapped in the lungs. While it may feel as though you can't get air in, the reality is you can't get air out. In fact, this air trapping is one of the reasons that during an asthma attack it often feels like you can only take in half a breath, or a quarter of a breath.

Those in the medical field may think of this air trapping as intrinsic PEEP. PEEP is air that is left in your lungs after you exhale. Normally PEEP is 2-3 CWP. During an asthma attack, this PEEP increases, thus causing hyperinflation of the lungs (which can be seen on an x-ray). If this intrinsic PEEP gets severe enough, it can lead to a severe asthma attack, and (possible although rare) even death.

This air trapping is also one of the reasons that diaphragmatic breathing is a technique often taught to asthma and COPD patients. The idea is if you give your lungs more time to exhale some more air might escape your clamped down air passages. Of course you probably know your rescue inhaler also works to relax your air passages to, thus letting out this trapped air.

Question: Intal versus Advair for asthma: have problems with asthma (wheezing sometimes) and respiratory allergies. Age 62M. I heard that Advair is a "ramp up" medication for sicker people and has more side effects and causes weight gain. Is Intal less problematic and am I better off with it if it helps or will I create more long term problems by not using Advair right away? Thanks

My humble answer:
You are wise to ask this question. Intal was a popular controller med for asthma in the past, (in fact I was on it in the 1980s) but it is less commonly used today due to much better medicines. It is a anti-inflammatory medicine, but I rarely ever see it used anymore, especially with adults.

The most common asthma controller medicines used today for asthma are inhaled corticosteroids such as Flovent (a ramp up from Intal). Flovent is much more effective for treating inflammation than Intal (at least most asthma experts conclude this).

If you continue to have trouble with your asthma despite inhaled corticosteroid use alone, your doctor might prescribe Advair (or Symbicort). Advair (a ramp up from Flovent) is a combination drug with both Flovent and a long acting bronchodilator called Serevent in it. Advair has been very effective in controlling asthma for many asthmatics, including myself.

There used to be a fear that inhaled corticosteroids had the same side effects as oral corticosteroids (prednisone), but many studies have been done to prove this is not true. If you take your Flovent or Advair properly, and you rinse really well after each use, side effects from these meds should be rare.

In my opinion, if Intal is working for you great. Your doctor may have been wise to have you try it before resorting to inhaled corticosteroids.

If, as you describe, Intal is not working, you might want to talk with your doctor about other options, such as the Advair you mention. Either way, it's always a good idea to keep in touch with you physician as I'm sure you are doing.

Good luck getting your asthma under control.

If you have any further questions you can contact me by clicking the "contact me" icon above.

Do oral or inhaled steroids stunt growth?

Recently someone asked a great question at MyAsthmaCentral.com that got me to thinking, and ultimately lead me to my latest post on my asthma blog.

Question: Severe asthma and on steroids since i was born- do these steroids stunt growth? If a person has severe asthma, and has taken steroids since they were a kid and inhalers, and now advair, do these products stunt your growth or reduce hormone levels? (I almost died of asthma when i was a baby and was pumped with steroids to survive when i was little) Since then i have used inhalers and now advair.

My humble answer: Great questions. There have been many studies that show systemic corticosteroids can cause growth suppression. There have also been studies that show asthma in itself -- especially if not well controlled -- can cause growth suppression.

According to Massoud Mahmoudi in Allergy & Asthma: Practical Diagnosis and Management, "Doses of prednisone as small as 0.1 mg/kg administered daily for as short a period as 3 months have resulted in significant suppression of linear growth."

However, it also should be noted that studies also prove most doses of inhaled corticosteroids (like you receive in meds like Advair) do not cause the same side effects as oral or injected corticosteroids, and therefore should not effect your height.

Honestly, though, when I was 15 back in 1985 I was on oral steroids for over a year and my asthma doctor sent me to a bone specialist who had me undergo a bunch of tests to determine how short I would be when I grew up. He even wanted to take a bone chip out of my hip. I refused that test. To be honest, I didn't really care about how tall I was going to be when I grew up, I just wanted to get my asthma under control. I told my doctors to quit testing my bones, and she duly respected my blunt request. The subject was never brought up again.

However, my doctor did tell me the bone specialist predicted I would grow to be no more than 5'6" tall. It wasn't something I spent much time stressing about, and in the end that turned out to a good thing, because once I was done growing I was 5'8" tall, a pretty normal height. I am the shortest in my family, but that's no big deal.

I think what is important for any asthma doctor and asthmatic combo is to do whatever is necessary to get the asthma under control, because the risk of losing a few inches is a good trade off for being able to live a normal, active life even though you have asthma.

I expounded about my experience in my latest post over at MyAsthmaCentral.com, and whether this is something asthmatics currently taking inhaled (like pulmicort or flovent) or oral steroids need to be worried that their height might be in jeopardy.

To read my latest asthma blog post, please click here and I will morph you there.

A concern for Parents of Asthmatics: Will Corticosteroids stunt my child's growth?
by Rick Frea Wednesday, July 22, 2009: Published at MyAsthmaCentral.com.

So, your son or daughter has been diagnosed with asthma, and his or her doctor has prescribed systemic glucocorticosteroids (GC) like prednisone, and long-term inhaled GCs like Flovent or Pulmicort. Your concern is: Will this stunt my child's growth?

This is a great question. In fact, according to "Allergy & Asthma: Practical Diagnosis And Management" by Massoud Mahmoudi, growth suppression is one of the top concerns of doctors caring for child asthmatics who need GCs.

According to Mahmoudi, "Regular daily therapy, frequent short courses, or high-dose alternate-day (systemic) GC therapy often results in the suppression of linear growth. Doses of prednisone as small as 0.1 mg/kg administered daily for a short a period as 3 months have resulted in significant suppression of linear growth."

Complicating that, Mahmoudi writes, is the fact that asthma itself -- especially poorly controlled asthma -- has been shown by various studies to stunt growth.

Sometimes doctors don't have a choice, and if systemic GC are needed long term, a dose of 20mg or less on alternate days seems to be, according to studies, a safe dose with limited effect on growth.

Now, what about those highly recommended steroid inhalers your child is on? Do these stunt growth too?

When I was a child, hardluck asthmatic growing up in the 1980s my doctors would tell me to stop taking my inhaled GC when I was feeling well for fear of side effects (I wrote about this here).

Later research, however, confirmed that not only are inhaled GCs safe, they are the most effective means of managing asthma. The catch here is this: you have to make sure your child rinses his or her mouth out really well after each use.

That aside, Mahmoudi writes that an extensive study on this subject was performed by the Child Asthma Management Program (CAMP) in 2000 that showed children who took 200 micrograms of Pulmicort twice daily were 1.1 cm shorter than those who took a placebo (1 cm is about the diameter of a AAA batter, do give you a visual reference). Thus, the conclusion of the study was that "GC therapy can result in a modest but transient effect on growth that is unlikely to have any adverse effect on adult-attained height."

Another study followed children who were using 412 micrograms of Pulmicort for 9.2 years, and the "investigators found no difference in the measured versus the expected adult heights in any of the groups studied... Of interest, they too noted a transient suppression of growth... but it did not adversely impact adult-attained height."

I have my own personal story regarding GC induced growth suppression. When I was an asthma patient at National Jewish Health (NJH) back in 1985 my doctor told me all the systemic GC I was on had already effected my height. While I was 15, my bone age was 13.5 years.

In my medical records, my doctor wrote this about me:"Rick's growth and bone development have been affected by his high steroid use. He was evaluated completely in the Pediatric Endocrinology clinic at the children's hospital. Their findings indicate Rick is constitutionally delayed in growth and his severe asthma and requirements for high-dose steroids over the past several years have contributed to this delay. Based on their information, Rick has an estimated adult height of 5 feet 6 inches. Rick also has steroid induced osteoporosis that needs to be dealt with. "

Being the worrying type I was back then, this news caused me much anxiety. Yet my counselor assured me this was nothing to fret about. He said, "Doctor estimations are nothing to worry about. Your main concern right now should be getting your asthma under control and the steroids are helping you with that."

A few months after I was discharged from the asthma hospital, and completely weaned off oral GCs but still on high doses of inhaled ones (4 puffs 4 times a day of Azmacort), my doctor told me I no longer had osteoporosis. But my height continued to vex me. Even as a senior in high school I had the body of a freshman.

Despite those NJH estimations, however, I am now 5 feet 8 inches tall. Sure all four of my brothers are taller than me, but who cares. My current height works just great for me. If the GC shrunk me 1.1 cm, I can't tell and don't really care.

My advice to you is the same as that given to me by my counselor back in 1985: "It's better to let your doctor do what it takes to treat your asthma now than to risk worse asthma -- or even death -- down the road, even if that includes steroids."

New Product: The Grumpometer

As any nurse or respiratory therapist will attest to, sometimes it's simply best to stay away from certain doctors or RT Bosses at certain times, or perhaps, if you must speak up for the benefit of a patient, it's best to be pithy and keep your mouth shut when spoken to in order to avoid controversy.

In other words, some people are hard to work with. That said, wouldn't it be nice to know if someone is approachable or whether they simply look grumpy and are actually in a normal mood. From the makers of the Amazing Wheezoscope we now have the Amazing Grumposcope.

The Wheezoscope, as you may remember, is a stethoscope produced by the Littman company a few years back that is pre-programmed to hear wheezes. The grumposcope is a stethescope made for both RNs and RTs that allows them to know whether other members of the medical field are approachable. And, yes RNs and doctors, it can be added to the wheezoscope because sometimes even RTs are grumpy.

Please note that the links referred to in the ad are no longer valid, as the ad was featured in RN
and doctor magazines between Oct. 19, 1997 and May 6, 2002, and on Internet websites during this same period.

So here, for the first time ever, and approved by the sagacious Jane Sage RRT, I present this ad on an RT web page where RTs can actually see this state-of-the-art product.

GRR....... GRR...... GRUMPOSCOPE

ATTENTION PHYSICIANS, RESPIRATORY THERAPISTS AND NURSES: THE MAKERS OF THE AMAZING WHEEZOSCOPE THAT HAS QUALIFIED SO MANY PATIENTS FOR INHOUSE STAYS (AND HAS HELPED PRODUCE BILLIONS OF DOLLARS FOR DOCTORS AND HOSPITALS ALL OVER THE U.S.) HAVE INVENTED A NEW PRODUCT CALLED THE AMAZING GRUMPOSCOPE.

NO LONGER WILL YOU HAVE TO RISK APPROACHING THE UNAPPROACHABLE, AS THIS AMAZING PRODUCT HAS A CHIP IN IT THAT AUTOMATICALLY ALERTS YOU BY A MYSTERIOUS OSMOSIS METHOD OF ALL GRUMPS. IT KIND OF WORKS THE SAME WAY AS VENTOLIN WHEN IT CROSSES INTO THE BLOOD STREAM AND EASES PATIENT AND NURSE SUFFERING.

SO, YOU DON'T WANT TO SAY SOMETHING THAT MIGHT OFFEND A COWORKER OR DOCTOR. JUST PLUG THE GRUMPOSCOPE INTO YOUR EARS AND YOU WILL INSTANTLY "JUST KNOW" WHO IS GRUMPY.

(IF IT SEEMS NOTHING IS HAPPENING, THIS IS NORMAL.)

GOSH, WOULDN'T IT BE NICE TO KNOW IF THAT DOCTOR STANDING OVER BY THE NURSES STATION IS GRUMPY? NOW YOU CAN KNOW FOR SURE WITH THE AMAZING GRUMPOSCOPE (PATENT PENDING).

ARE YOUR COHORTS GRUMPY OR JUST LOOK GRUMPY? WHEN YOUR PRIDE IS ON THE LINE DON'T TAKE THE CHANCE. DON'T GUESS. KNOW!!!

UTILIZATION REVIEW APPROVED!

ORDER ON-LINE AT WWW.WHEEZOSCOPE.ORG AND FOLLOW THE EASY STEPS TO FINANCIAL SECURITY AND A STRESS FREE WORKDAY FOR YOU AND YOUR FACILITY.

CHECK OUT OUR SATISFIED PROVIDER'S TESTIMONIALS BY CLICKING HERE!

DISCLAIMER: NOT ALL RESULTS ARE TYPICAL AND MAY VARY FROM CAREGIVER TO CAREGIVER!

The neat thing about this product is it looks eerily similar to a normal stethoscope. If you aren't vigilant, you may never be able to tell the difference.

Two well respected doctors discuss health care

After the code in the critical care unit I was standing behind the nurses station listening to the anesthesiologist and the Internist discuss how much they hate President Obama. I did not participate other than to say:

"You better not say that in front of Susan." Susan, of course, is the CCU RN who was in charge of the patient we just coded.

The Anesthesiologist said, "I think he is wrecking the country."

The Internist said, "I voted for him, and I think he is doing a terrible job. He's not doing what he said he would do when elected. He is trying to solve all the world's problems."

"I'd have to agree."

"And now he wants to screw up the health care system. You would agree that we do have the best health care system in the world do you not."

"I do."

"The only problem is not the health care system, but the cost. The government has made some stupid laws in the past that make it too easy to sue doctors. Because of this, we doctors have to order procedures that often are not indicated."

I was shocked they were saying this in front of me. I stood as still as a deer hiding in the woods during rifle season hoping they wouldn't figure I was standing right behind them.

"I mean," the Internist said, "He's trying to solve all the world's problems, to rush all these bills through Congress, when it's not even possible that he nor any one else has even read the bills. This is what you call anarchy. I say this and I voted for him."

The anesthesiologist said, "I don't see why you are surprised, because he's doing exactly what he said. But I completely agree with you he is rushing too much too fast."

Susan arrived at the station, and the discussion stopped on a dime.

RT Cave Rule #36: "Come on! Come on!"

I first met Dr. Stevens in one of the most stressful and inconvenient places for a code to take place: the small cat scan room. On the way I took the time to grab my little black airway box and was a few seconds behind the nursing supervisor in arriving. Before even entering the room I could hear the ominous sound of air rushing through the Ambu-bag.

"Come on! Come on!" the anesthesiologist was saying as he was hovering over the head of the bed of the patient of whom he was bagging. "I need a size 8 ETT already," he said with an irritable expression while holding out his hand and wiggling his fingers impatiently.

I set the black bocks down, ripped off the white lock, and fumbled for the right tube. I found it and set to check the cuff...

"Come on! Come on!"

There's only so fast I can get things done here! I thought to say, but held my tongue, knowing such comments only cause more trouble than it's worth. I took the time grab a syringe, inserted it into the cuff line, and pushed air into it. As usual the cuff was fine.

Come on! Come on!" his fingers wriggling like a little boy waiting for the clown in a parade to toss a lump of candy in his direction. "Come on! Come on!"

I grabbed the surgilube, but cast it aside in favor of handing it to the doc. If you want it lubed you can spit a lug on it, I thought. I pushed my way to the head of the bed and held pressure against the patients crichoid, felt the tube slip through the vocal cords, an made my way to grab the tube to secure it, which is usually my job at this point.

"Secure the tube already! Come on! Come on!" He was holding onto the tube, not willing to let go of it. That's a trait of that only anesthesiologists have. All other docs, as far as I've ever seen, are more than eager for RTs to take over grip of the entdotracheal tube.

I pushed my way through the crowded room where all seven folks now peasant were shoulder to shoulder. I grabbed the airway protector and rushed back to the bed. Due to the crowd, the steaming hot pressure down my spine, sweat now dripping from my forehead, this took about a minute to accomplish, way to long for Dr. prick over there.

"Come on already! We need to get this airway secure!"

I secured the tube. The patient was saved. I took over the airway. I thanked the doctor for all his hard work. He told me rudely I need to be quicker. I smiled told him he did a great job with this patient to boost his ego.

Three years later I stood over the head of the bed bagging a patient in the critical care. The
man with pneumonia in the one cancerous lung he had left was breathing at that rapid, deep rate people starving for air usually do, screaming, "I...," gasp, "need...," gasp, "AIR!"

He had that ominous, distant look in his eyes. I had no choice but to start breathing for him. Knowing Dr. Stevens, or Dr. Come on as I call him behind his back, I had three tubes ready with three syringes connected to the cuff pilot, and a stilet in each freshly lubed tubes ready to slide into the gullet of the patient.

Dr. Come on asked for the size eight and I handed it to him. "Give the succs now!" he ordered to the nurses.

"It's coming," I heard Arny say as he rushed into the room drawing up the medicine as he worked his way to the head of the bed.

"Come on! Come on!" Chanted the doc with the vexed countenance I had gotten to know so well over the years. "Come on! Come on!"

At last it was not just me he became vexed, impatient with. Now it was the nurse that was at the root at his sudden mood change. Or, I now wondered, was he always this way, going home perhaps to be irritated with his wife for not lighting his cigarette fast enough.

Yet, upon leaving the room, I said, "Thanks for coming, Dr. com... Dr. Stevens. You saved us from being worried about this patient the rest of the night."

And this made me think of RT Cave Rule # 36, of which we will also include under Dr. Wisdom in case such a doctor might wish to learn what RTs think of their needless irritability:

RT Cave Rule #36: It is not necessary for doctors to get irritated with RNs and RTs for doing the jobs they are prepared and fully qualified to do during a code. Getting irritated only makes those around you more stressed in a situation that is already stressful."

Most doctors, in my opinion, are very patient and very cordial during a code, especially codes that are in places of the hospital we usually don't have coded (like small rooms), and codes on the young, codes on prominent members of the community, and those we know.

Yet there are those, like Dr. Come on, who are impatient to wait the extra 55 seconds for the RT to check the cuff, and for the RN to draw up the right dose of medicine.

Busy at work! Who cares! I'm on Vacation now!

It's the middle of July. The weather is beautiful up her in Shoreline, Michigan. In fact, I don't think it can get any better -- not too hot, not too cool. And, yet, instead of being out and enjoying it, it seems many individuals are getting sick -- or faking it for attentjion -- and visiting me at the hospital.

It seems to me in that most summers I work business is slow. In fact, in years past I remember telling my friends that I'm never going to take a vacation in the summer again because it's so slow at work in the summer that going to work is like a vacation in itself. I sit there all night and play on the Internet, get caught up on my personal projects -- like this blog and my check book -- and simply enjoy it.

This year, however, it seems the summer vacation at work is not going to happen. Why? Does the economic circumstance lead to depression and hence sickness? I don't know, but that's what I'm beginning to wonder.

We actually got down to 4 patients last Tuesday, but as soon as I stepped in the door Thursday evening (7-p.m. exactly) a Code Blue was called over head. After spending an hour at that, I spent the next two hours in the ER, and it seems every patient I saw was admitted, including Mr. Montague who seems to get pneumonia once every two months. While I was giving him his tx in the ER, his wife says, "He wants to be admitted." It's not very often people come right out and admit that.

Mrs. Cocrain in the critical care has been on a ventilator for the better part of three months. I've written about her on this blog, but I can't seem to find it. She initially had a DNR order the family did not respect. So, now she has to live this way until she dies. Although she hated the vent dependend unit down state, so she gets anxious, a feeling of air hunger befalls her, and she finds herself admitted for the three millionth time. And when she is here, she gets treated as though she were in a VDU: on the vent at night, off during the day.

And then it seems we have at least 12 other patients all admitted for some reason not related to bronchospasm, and yet they all must have breathing treatmtns because???? Your guess is as good as mine. My boss says we should all quit complaining (not that I am), and be happy we have jobs. Well, she has a point, but it would be better to at least enjoy the off season, the usual vacation season that comes with summer.

Normally this time of year it's 90 degrees with 100% humidity this time a year (either that or it's coming soon), and since I don't have air at home I look forward to coming to work where I can enjoy the cool air. Perhaps if it's slow enough I can sit in an empty patient waiting room and watch the Detroit Tigers.

But, none of that seems to be happening this summer. By Monday Morning I'm running around like a chicken with it's head chopped off on my 4th straight day, and, you guessed it, Code Blue! wails overhead. My long weekend ends the same way it began. The code went well, and then just as I'm getting ready to leave I get word my relief forgot she had to work today. No prob.

Either way, I'm happy to be on a real vacation now. My feet are aching and my eyes are weary. It may take a few days into this free time to recoup. So, since I will be on vacation this week, don't expect anything too thought provoking at the RT Cave. In fact, I think I might spend the bulk of it just loafing around and pretending the Internet doesn't exist.

Humidity not fun for COPD and Asthma Patients

On those hot, humid days of summer you cannot breathe. On those extremely dry days of winter you can't breath either. Well, there's a reason for this, and something you can do about it. To learn more, read my latest post at MyAsthmaCentral.com.

High and low humidity not good for asthma
by Rick Frea Wednesday, July 15, 2009 @ HealthCentral.com

It's roasting outside, yet the sun beaming down on Jake Gallant as he rests in his beach chair feels great. The warm breeze wafting over his bare chest feels great too. He closes his eyes and listens to the soporific, relaxing sound of waves.

"This is the kind of weather I'd like to pack into a bottle to open in the dog days of winter," he thinks, "except for one thing: the dog gone humidity make the air heavy to breath."

As anyone with a chronic lung disease will attest to, humidity can make air harder to inhale. Although, as the Asthma Educator's Handbook notes, humidity alone cannot trigger an asthma attack.

That in mind, here is the latest wisdom regarding high humidity and asthma:
An ARIC report notes that areas with a relative humidity lower than 50% had fewer "rates of asthma."

The report also states that "every 10% increase in indoor humidity was associated with a 2.7% increase in the prevalence of asthma."

The American Academy of Allergy Asthma and Immunology (AAAAI) states high humidity levels also have a tendency to be harboring grounds for fungus and molds that might bother asthmatics.

When humidity is greater than 50%, the amount of dust mites in the air is increased.
So now that you know high humidity is not particularly good for asthma, what can you do about it?

According to the American Lung Association, "Air-conditioning can help. It allows windows and doors to stay closed. This keeps some pollen and mold spores outside. It also lowers indoor humidity. Low humidity helps to control mold and dust mites."

Another solution, if you can't afford air conditioning, is to have a dehumidifier in your home. This is a little more work as you have to empty it once or twice a day, but it works to keep the humidity down.

Years ago doctors recommended asthmatics move to warmer, and drier climates like that of Arizona. Today doctors no longer recommend this because of technology like dehumidifiers and airconditioners that allow asthmatics to control the climate in their homes, and modern medicines that allow for better control of asthma.

While we see why high levels of humidity are bed for asthmatics, it's also important to make sure you don't make the air too dry. I say this because new research shows that air that is too dry is not good for asthma either. AAAAI.org reports that if the relative humidity is less than 15%, this may trigger an excessive cough for asthmatics. Low humidity can irritate asthma because it dries out the mucous membranes lining your airway, which are your body's natural defenses against foreign bodies such as viruses and bacteria. Thus, dry mucous membranes make you more susceptible to catching diseases like the common cold virus or influenza. If that's not enough, dry mucous membranes also have the tendency to aggravate allergy symptoms.

In the winter months, the air tends to get very dry, the humidity too low. You can tell when your skin and lips become itchy and chapped and your throat, dry. If the humidity gets too low you can use a humidifier.

Perhaps you're thinking, "How can I win? I can't have humidity too high and I can't have it too low either."

The answer, according to AAAAI.org, is for "asthmatic patients to aim for a 'happy medium' relative humidity in their homes, monitoring their home humidity regularly with a reliable gauge."

The Center for Disease Control and Prevention recommends humidity be set between 35% and 50%.

I'm not endorsing a prouct here, but you can use a humidity monitor like some of the ones at Amazon.com.

The majority of us asthmatics should be able to control our asthma just fine simply by keeping in touch with our doctor and by making sure we take our asthma meds exactly as prescribed. With well controlled asthma, we should all be able to get outside and enjoy the warm, humid, summer weather like Jake Gallant.

Yet, if high humidity continues to pose a problem for your breathing this summer, setting up your home with air conditioning is a great option. You can close all the windows, crank up the air, and enjoy the cool, refreshing, easy-to-breathe air.

Indications for breathing treatments

Since I write so often on these pages reasons nurses call for breathing treatments and doctors order them (my latest version is here), I think it is due time I create a list of the true indications for a bronchodilator breathing treatments.

Keep in mind a bronchodilator only treats bronchospasm. Likewise, rescue inhalers used properly with spacer are proven to be as effective in most cases as a breathing treatments.

That in mind, here we go:

1. Asthma
2. Bronchitis (acute or chronic)
3. Emphysema (actually, this is not a true indication)
4. Cistic Fibrosis
5. Airway swelling due to allergic reaction (actually, bronchodilator doesn't treat swelling)
6. Pt with above diseases who cannot manage an inhaler (Albuterol, Atrovent, Flovent, etc.)
7. Bronchospasm secondary to other disease process such as CHF, pneumonia, pulmonary fibrosis, RSV, lung cancer, sinusitis, bronchiectasis, etc.
8. Bronchospasm secondary to allergic reaction (bee sting)

Note #1: The diseases in #8 do not necessarily cause bronchospasm, but may irritate the sensitive airways of people who have the diseases mentioned above

Note #2: It appears doctors believe treatments are cures for all ailments, and are indicated for all the wheezes and all that causes shortness of breath as you can see for yourself by reading the Real Physician's Creed.

We'll make this RT Cave Rule #25: A wise medical care worker will know the indications for ordering a breathing treatment and not request a treatment (or order one, or give one) unless a patient meets this criteria.

Note #3: Again, I am going to file this under humor, although it is not humor it is serious. Too many doctors fail to understand the true indications for breathing treatments

28 non indications for breathing treatment

For the real indications for bronchodilator therapy, click here.

Just a friendly reminder: the following are not indications for bronchodilator breathing treatments:

1. Dr. ordered it
2. Don't know what else to do
3. Nurse wanted it
4. Pt wanted it
5. Stridor
6. Sinusitis
7. Mesothelioma
8. Lupis
9. M.S.
10. Homeless
11. Depression
12. Pt has home nebs
13. Pt likes tx
14. Pt likes company
15. Bed ridden
16. History of smoking
17. Irritating lung sounds
18. Low SpO2
19. Trach
20. Intubated
21. Post operative
22. Atelectasis
23. Fever
24. Trach
25. CHF
26. Pneumonia
27. Pleural effusion
28. Pneumo
29. Rickits
30. RSV
31. ARDS
32. RDS
33. P.E.
34. Cough
35. Sputum induction
36. All wheezes (all that wheezes is not bronchospasm)
37. All SOB (SOB is not always caused by bronchospasm)
38. Just because the patient is wearing a mask

Note #1: Many doctors are taught the opposite, as you can see by reading the Real Physician's Creed.

I'm going to file this under humor, although this is not humor, it's serious.

So, we'll consider this RT Cave Rule #27:

RT Cave Rule #27: Know the 27 non-indications for bronchodilators and do whatever is in your power to make sure breathing treatments are not ordered for these reasons.

The 100,000 click milestone has been reached

Well, ladies and gentlemen, the RT cave has met yet another milestone. It took all of 21 months, and the RT cave has finally been clicked on 100,000 times. Again I think this is pretty cool since when I initially started this I figured I'd be writing to myself.

It seems things have progressed quite a bit here. At first I'd sit down each day wondering what I would write about, and many times I'd be scrapping just to keep up. Now the list of ideas is so deep I can't even see the bottom. It's like an endless pit.

As other bloggers can attest, we write about whatever is on the tip of our minds, which can vary from day to day. So long as I can keep myself entertained and you interested, perhaps we'll be around for another 100,000 clicks (even if some of them are only for a couple seconds, each is an ego boost for me).

So, I would like to take this moment to once again thank all of my faithful readers and clickerers for finding my blog and finding at least a partial interest in the amalgamate of respiratory minded wit and wisdom of your humble RT.

Thanks.

To call the Dr. or not to call, that is the dilemma

Here's something you will come across from time to time if you work nights. Of course as all RTs may have noticed by now, there often seems to be no rhyme or reason to "some" doctor orders, nor consistency to how a doctor will respond to a request to change the order.

Consider the following example:

The patient is a 75 YO non-COPD post operative patient with a registered SpO2 of 88% at 3-o-clock in the morning. Mind you, I did say three a.m. The patient is in no respiratory distress, and has no respiratory history. Otherwise, his vitals are normal. The order is for 2lpm. What do you do?

1. Call the doctor and wake him up
2. Increase the oxygen to 3lpm and have the RN call the doctor in the morning
3. Ignore the spo2 and pretend you didn't see it as the patients SpO2 probably always drops while he is sleeping
4. Since the SpO2 has an accuracy of plus/minus two, assume actual reading is 90%

Okay, what's your guess?

Day #1: This night the RT decides to use his common decides "b" is the best solution. The patient is stable and no harm done. If the patient's SpO2 was at a critical level, then a call to the doctor would be warranted, but not in this case.

The next day when the RT arrived at work he was lectured by said doctor who said, "Why do I write orders if you're not going to follow them?"

Day #2: Different patient but same information; different doctor, but this doctor is the spouse of the doctor in the scenario above. What does he do now?

Using the same choices above, since the RT now knows option #2 is not good, he decides to go with option #1 and wake up the doctor. The doctor says, "Why the hell are you waking me up at 3 in the morning to tell me this?"

"Um," says the RT, "Because yesterday, same scenario, your husband told me that I have to call before I increase oxygen to get an order."

"Oh," she says, "Well, then increase it to 3lpm and leave it at that."

"Well, then can we..."

Click. The doctor was no longer available.

"...get an order for protocol just in case... oh, what the heck.

So, what is the best thing to do in a scenario like this? Well, based on my experience, you're damned if you do and damned if you don't, so you might as well wake the doctor up and let her lecture you about how idiotic you are.

Thus, RN Cave Rule #72:

If you think you better call the doctor you better call him. If you think the doctor might yell at your and tell you you are an idiot because he doesn't want to be irritated in the middle of the night, call him anyway.

Tons of new meds at the asthma hosital

(Note: This is part VII of my story growing up with hardluck asthma. To view Parts I through VI you can click here and follow the links.).

Perhaps I'm submitting this list of medicine to amaze myself, but these are all the medicines I was on shortly after being admitted to NJH/NAC back in 1985.

• Theodur 400 mg: 6 a.m. and 6 p.m.
• Prednisone 60 mg: 6a.m.
• Nasal irrigations: 6 a.m., 12 noon and 6 p.m.
• Nalalide 2 squirts: 6 a.m., 12 noon and 6 p.m.
• Afrin 2 squirts: 6 a.m., 12 noon and 6 p.m.
• Tinactin Cream: 6 a.m. and 10 p.m.
• Tinactin powder: 6 a.m.
• Cromolyn: 6 a.m. 12 noon 6 p.m. midnight
• Vanceril 4 puffs 6 a.m. 12 noon 6 p.m. midnight
• Theodur 6 a.m., 2 p.m., 10 p.m.
• Blood Pressure 6 a.m, 6 p.m.
• Drixorol 6 a.m., 8 p.m.
• Amoxicillin 6 a.m. 2 p.m. 6 p.m.

Treatments:

• Alupent: 0.5cc at 6 a.m., 12 noon, 6 p.m., and midnight
• Atrovent: 4mg (.63cc) 6 a.m., 12 noon, 6 p.m., and midnight
• Terbutaline 4 mg at 9 a.m., 3 p.m., and 9 p.m.
• Spirometry: 6 a.m., 12 noon, 6 p.m., midnight
• Peak flows: 6 a.m. and 6 p.m.
• Postural drainage: 6 a.m., 3 p.m., 6 p.m., midnight

Initially when I was admitted my asthma was severely uncontrolled, so my doctor basically put me on all the asthma medicines and therapies she knew of at that time. The goal, I believe, was to start me on everything and slowly eliminate.

At that time terbutaline was still a commonly used bronchodilator (it is still available but rarely used in the U.S. I think we still have a vial in our med drawer, although I'm sure it is long since expired) even though it had a tendency to cause some side effects similar to adrenaline (epinepherine, susphrine). And I think it was for this reason I had to have twice daily blood pressure checks.

I think after I was there about 30 days or so (and after I was released from PSC after 3 days)that my doctor told me my asthma was finally stable enough so I could stop taking Terbulatine, and thus Q3 breathing treatments. That was a major day of celebration for me, as it was a major pain leave school every few hours for a treatment and meds.

Postural drainage was initiated on me thinking I was having trouble expectorating, but it was discontinued when Terbutaline was. There were some kids who still got PD, but not me. Although I received some experience performing it on some of the other kids, and them on me. this, in a sense, prepared me for RT school. In fact, all of this prepared me for RT School.

Today PD is no longer recommended for asthma as it is thought that it might loosen up a mucus plug (common with severe asthmatics) and cause even worse asthma.

I think one of the main reasons I wanted to post this list is to show how many medicines asthmatics with allergies had to take to control their asthma. In fact, it should be known that asthmatics with allergies are more likely to develop severe persistent asthma, if not controlled. Likewise, smoking too can speed up the severity of asthma. Thankfully I did not smoke, and only had the allergies to worry about (in case you're wondering, I had allergy testing done three times in my life, once before NJH, once during, and once after. Each time I had a possitive reaction for nearly everything outdoors).

While I was in the asthma hospital I had nothing else to think about, yet when I was discharged to home it became difficult to live a normal life (as they say we should be able to with asthma) and take all our meds as prescribed.

So, for the first three months I was at NJH/NAC I was basically on the meds as listed above. The red were eliminated when the terbutaline was eliminated, and the meds listed in orannge were added. I imagine some of the others were temporary too, but since I didn't cross them out I imagine I was on them a while too.

I have no idea why I was on Tinactin. The Nasal irrigations and nasalide and Drixoral were the only means of treating allergies. While I was in the hospital I wasn't exposed to my asthma triggers anyway, so I don't thing I even needed them while there (the nasal washes were a pain in the arse to do). Yet I imagine my sinus passages were swelled up big time when I was admitted.

I had a major case of sinusitis (common among child asthmatics), so that explains the amoxicillin. The chromolyn was a new medicine available, and it was the first dry powder inhaler (DPI) ever made (I think). You took it with a spinhaler (see picture) which crushed the capsule and you inhaled the powder. It was worse than the new DPIs in that it often caused asthmatics to cough and go into bronchospasm. I had this happen a few times.

The Spirometry was actually fun to do. It let me know how much my asthma was improving not just before and after treatments, but overall. Later on I will publish one of my Spirometry flow sheets. Peak flows were no different back then than today, as every doctor and RT recommended you use one. Although pre-NJH I was not very compliant with mine.

The Vanceril was the common corticosteroid at that time. I think before I left NJH/NAC I was switched to the new Azmacort. Neither were as effective as the newer corticosteroids available today, which is why we had to take so many puffs so often. And yes, it was a pain to remember all the puffs and doses. When I was discharged to home, it was hard to remian compliant with this regime.

Alupent (recently discontinued) was the bronchodilator with the least side effects back then, although it did leave me with a palpable thump-thump-thumping in my chest after each use, but not as bad as the Terbutaline. Atropine was the equivelent to the Atrovent and Spiriva we use now adays, although this line of back door bronchodilators is no longer recommended for the treatment except for when other meds don't work (as in Hardluck asthma).

Asthma Action Plans did exist back then, and before I went home I was given an oxygen tank, a box of epinipherine amps, syringes, and I was instructed how to give myself it. I was told only to go to the ER if the Epi didn't work. I digress though. That's for a later discussion.

There was an incentive to get your pills at the nurses station on time, and to take your treatments on time, and that was a points system. We had to carry a points sheet with us throughout the day and have each of our teachers sign it to prove we attended class. We had to have whomever we had appointments sign for the same reason. Of course if we were bad in class, the teacher (Mr. Rose) would threaten to take away points.

Likewise, every time we left the floor (and returned) we had to sign in and out on a recording sheet. If we forgot, we didn't get those points. The more points we earned in a week the greater likelihood we moved up to the next level. Actually, you moved up levels as you proved you were responsible with your meds and rules. Moving up levels wasn't really too hard on 7-Goodman.

If I remember right, the levels were 1 (poor behavior) 2, 3 and Honors. There was a bulleton board behind the nurses station that monitored our progress.

With each level you get new resonsibility. Such, if you are on level one you cannot leave the floor except for school and appointments. On level 2 you got to participate in anything, but you could not leave the floor without a nurse, a counselor, P.E. instructor, etc. Level 2 is where all new patient's start. Also on level 2 you have to have a nurse supervise when you are mixing your nebs.

On level three you are now able to draw up your own meds unsupervised as you have proven that you are capable and responsible. You can also leave 7-Goodman without an adult escort so long as you are with someone on Honors.

The same is true when we went on excursions to the mall, movies, mountains, etc. If you are on level 2 you can go, but you have to stay with the adult escort the entire trip. If you are on level 3 you can go alone if you have an Honors escort, and if you are on Honors you can do whatever you want so long as you return to the designated meeting area at the designated time. If you prove not to be resonsible enough to hold up the responsibilities provided to you, you had points taken away and risks moving down a level

I guess I'd have to say that my brother David was right in that it was like a camp in a way. They kept us so busy we barely had time to sit around and be bored. However it did happen. And in the initial days it was hard not to feel homesick -- especially the first several weeks.

As far as my treatments were concerned, the nurses initially drew up my meds and watched me take a treatment, but eventually (as I moved up levels) it was my responsibility to draw up my own meds, but I had to find a nurse to watch me. Eventually, though, I earned the right to take my treatments unsupervised (which occured on level 3). On 7-Goodman no patients were allowed to have their own pills in their rooms.

As I wrote before, there were basically 2 air compressors set on a table in the lobby of 7-Goodman and we had to take turns using it, so I usually tried to be the first one considering I was usually tight and wheezing and didn't want to wait for relief (of course I wasn't the only one who was tight, so with only 2 machines one of us had to wait).

Within days after I was admitted I had to attend classes so I could learn about asthma and asthma meds. Back then asthma was basically treated as a disease of airflow obstruction secondary to bronchospasm. In class, we were taught about the acronym ROAD, which stood for Reversible Obstructive Airway Disease. The main treatment for the disease was to control bronchoconstriction.

Today, airway obstruction is considered a component of asthma, but is mainly considered as a marker for airway hyperresponsiveness due to inflammation. If your inflammation is uncontrolled, your airways are more resonsive to your asthma irritants. Thus, asthma today is considered more a disease of chronic inflammation, and the efforts of treatment are mostly aimed at treating this underlying inflammation. Once controlled, your airways become less hyperresponsive, and you'll have acute episodes of acute bronchospasm less often.

Back then, however, we were taught about ROAD. In fact, when I entered RT School I asked about ROAD, and my teachers had never heard of it. So by the time they had become RTs that old acronym had expired in favor of new wisdom. However, to be considered asthma, the bronchospasm component has to have some degree of reversibility, which is why all asthmatics must always have a rescue inhaler handy. (Perhaps ROAD is still in use, as I've found it here and here.)

You have to realize here that the goal was to teach us asthmatics to be gallant asthmatics, and this was the method the asthma hospital used at this time. Since most doctors back then were not privy to the asthma wisdom of NJH back in the 1980s, if you had severe asthma NJH/NAC was the best place for you.

However, the good news is that in the late 1990s several doctors got together and decided something had to be done to improve the way asthma was treated by regional doctors (like mine back home), and the asthma guidelines were created. With the new asthma guidelines, new asthma wisdom, and new medicines, it became easier for local doctors to treat asthma.

In fact, even better for good asthma control, new asthma meds like Adviar and Symbicort allow for puffs to be needed only twice a day. This greatly helps in the comliance department. With greater compliance comes greater asthma control.

In fact, I recently talked with a person in charge of public affairs at National Jewish Health (that's the new name) and she said that 7-Goodman no longer exists because local doctors do such a great job now of managing asthma.

She said one of the reasons it was able to close was because of the asthma guidelines, and another reason is the fact that NJH sends doctors to regional areas to make sure that all doctors are aware of the latest asthma wisdom of how to care for asthmatics. And the Internet I'm sure is also a factor in improved asthma wisdom among both doctors and patients alike.

(I will try to have part VIII of my asthma story up on Sunday, July 19, 2009)

Disclaimer #3

Today I'd like to list the rules of the RT Cave:

1. I have nothing to do with the ads that appear on my blog, so if you see something that offends you keep this in mind.

2. The #1 purpose for this blog is to share RT ideas, facts, opinions and humor so we can all learn in a pithy and/or entertaining manner.

3. This blog is published, edited and written by one lone night shift respiratory therapist who works full time, has three kids, and whose main mission on this planet is not as a writer, but as a husband and a dad.

4. If the author ignored his priorities (as mentioned above in #3), he would be able to delve deeper into a broader array of topics. This would be great for you guys and I'd love to do it, but it would come at the expense of time with my family, and that wouldn't be good, nor wise.

5. Due to #3 above, on occasion an error, typo, or inaccuracy may slip through the cracks. Keep in mind the editor (who's also the author) reads, re-reads, re-reads again, and again most posts. Although due to time factors, this sometimes does not occur.

6. While this isn't ideal, on occasion the publisher (who's also the writer) decides getting an idea out is more important than having an error less publication.

7. The editor has a minor in English, and therefore knows the difference between their and there. Yet, his publisher insists that he not edit while writing. Since the editor often shows up during kid time, he sometimes misses the boat at the expense of #6 above.

8. Due to #2 above, on occasion my political views become as obvious as a neon sign in a small town. While the editor makes a gallant attempt to limit this, on occasion it is necessary to make a point.

9. Besides, this is a blog, which (according to Dictionary.com) is "an online diary; a personal chronological log of thoughts published on a Web page."

10. I invite comments, and this includes criticism, praise, opinions, ideas, praise, ideas, praise, thoughts, praise...

11. The editor is committed to deleting any personal attacks. Thankfully these come seldom.

12. The publisher (who's also the writer and editor) tries to maintain a schedule for what gets posted what day, although he often violates this policy for the sake of sharing ideas that are seeping from the writer's pores and dying to get on this screen.

12. The authors writings often reflect his mood for the day. For example, if he's working he's often inclined to write about work related things. If he is on vacation he's more likely to write about something like asthma or other.

13. The frequency and length of posts often reflects upon how busy the author is. If he is burned out from working, his writings won't be as involved as when he is working and has no patients to take care of.

14. The publisher, writer and author (otherwise known as me, myself and I) try to cater to all his audiences on a regular basis, although sometimes he gets on a roll. A perfect example is last week the writer (me) didn't feel like writing about asthma, and today he doesn't feel like writing the next installment of his asthma story (that should come tomorrow).

15. I imagine these rules are true for most blogger.

I think it's important to remind my readers of this once in a while.

Here's a great con to Nationalized Healthcare

Here is one very good reason I am against a nationalized health care system. I discussed with my boss yesterday about the budget. He said his bosses want him to come up with "everything and anything" ideas for further cutting the budget.

He asked me, "Any ideas."

I said, "Create a treatment protocol so we can get rid of all the breathing treatments that are not needed. That would save us a ton of money." (To learn how much money this would actually save our hospital, click here.)

He said, "Rick, you should be happy just to have a job. We need all the procedures right now we can get."

Here's something to consider. The hospital does not get paid by the government per procedure completed, it gets one flat rate for the patent's stay. So, the fewer procedures done while the patient is admitted the more money the hospital would make.

Thus, if Shoreline Medical Center could come up with a protocol to prevent doctors from giving an asthma/COPD medicine just because a patient is short of breath or sounds bad or looks funny (or to prevent bronchodilator abuse), that would save the hospital hundreds of thousands of dollars a year.

What I understand here is that when it comes to cutting the hospital's budget my boss only thinks in terms of his own wallet, while ignoring the wallet of everyone else. What he fails to understand (what many people seem to misunderstand these days) is the government's wallet is OUR money too.

My boss is afraid if we get a protocol, the number of procedures in our department will go down, and someone will lose his or her job. It seems to me many hospital bosses would prefer the procedure than to prevent government waste.

Yes government reform is needed, but not in the direction the current House, Senate and Executive Branch visions. The change we need is to provide an incentive for hospital admins to spend the government's money as wisely as it spends it's own.

As the old saying goes: people are more likely to spend their own money wisely, yet when it comes to spending someone else's money, they appear to be less wise (or is that a saying I just made up). Anyway, it's true.

Feel free to discuss because, as always, I could be mistaken.

(Other than the links above, for more of my opinion on Nationalized Healthcare, click here.)

He knew no life without her

She was 91 year old mother, grandmother -- wife. Her hair was ruffled to a degree she never in her adult life ever let anyone see, yet I was seeing it. Her skin was pale, no makeup. Her kith and kin may not even recognize her.

She looked up over the BiPAP mask, the machine that was supposed to give her wet lungs time to heal. Her eyes were circled with signs of anxiety and sleeplessness. In her weary eyes I saw all the years of cooking apple pies, hugs and kisses, and love.

On the other side of the bed, holding her frail hand, was the great man she was married to for 75 years; the only man she had ever loved. If ever there was a sign of soul mates, this was it. A feeling of sorrow rushed through my veins as I couldn't help feeling sorry for him.

Although, in a discussion the day before with this man, he said, "Whatever happens it's what God intends. Whatever happens, we had 75 great years together." He smiled then. There was no smile now. He was somber. The decision was made.

I listened to the sigh of the machine as it assisted her with a breath, and the hiss as she inhaled through the mask; the tubing, the machine's exhalation port. The cycle continued again and again. Yet it was my job now to end it. "It's time for her to go home," her husband said.

A vision of yesterday rocked in my head. Dr. Adams walked into the room, shook the old man's hand. I imagine Dr. Adams was thinking the same thing I was thinking now, that for a 93 year old he looks healthy, perhaps not a day over 80.

The husband said to Adams, "I promised her I wouldn't let her suffer, and she hates that thing. I think it's time to take it off. It's time to let her go."

Dr. Adams sighed, said, "With more time we might be able to nip this thing. We can give her body time to heal."

The old man said, "It's time. Let's just do it."

I unleashed the Velcro straps that supported the mask around her head and lifted the mask off her face. She sighed, smiled, looked up at me, took my hand, held it tight, and lipped, "Thank you."

I held her hand what seemed like five minutes, and then I left the room. It was time for her husband to say goodbye -- her best friend. He did not know life without her. What was he going to do. Would he be able to cope? Those thoughts rushed through my somber mind.

Outside the door I turned and looked back: he had his head on her chest, his hand gently caressing her face. They were together as one. Oblivious of the circumstances, they were happy.

I got busy and never saw him again. At around three in the morning I got a page to call critical care. Instead of calling I walked there, and as soon as I looked into her room I knew what the page was for.

The Ideal night at the RT Cave

I came to work today expecting 17 patients and the ventilator I had on Sunday night. Yet, when I was handed the sheet I noticed there were seven patients on treatments, two ventilators, and one patient on a BiPAP who, I was told, might be ventilator bait.

"You're going to have your hands full tonight," Jane said.

"Hey," I said, "This is the kind of work I love. When we're ventilator, BiPAP, and treatment for bronchospasm busy I love it. It's when you have a bunch of people on needless treatment busy I hate. This I love."

"It's funny you say that," Jane said, "'Cause when I got here this morning Paul said, 'Jane, you're gonna be mad at me. You now have three ventilators.' I said to him, 'Paul, this is the kind of work we went to RT school for. I love it.!'"

I said, "You hit the nail on the head. This is what we went to school for: to think."

Do not judge lest ye be judged.

What a busy night for ETOH. We had at least five, but I may have simply lost track. One of the guys apparently crashed his ORV and hit his head. After he was rushed to CT, and he was starting to wake up, he was mumbling things. He said, "I have to go pee."

One of the nurses decided she had to put a catheter in, and nothing was going to stop her. She ripped down his pants, at which time the patient said, "Where are my legs."

"You can't feel your legs." She started poking his legs.

"You took my stuff away," the guy said. Apparently he couldn't find the worked "pants" in his scrambled alcohol saturated brain.

"I'm putting a catheter in you," the nurse said, "You're going to feel something cold."

"You will NOT touch me! I don't want that!"

"If you don't cooperate we'll have to hold you down!"

Now, I understand it was a busy ER that night, and the adrenaline was flowing, but I am a firm believe if a patient is adamant you just leave him alone -- drunk or not.

If there is one thing I've learned working with people the last 12 years, it's that when confronted with an undesirable option, most normal people's initial response is defiance. Then, after given time to think, they reconsider.

I mentioned this to the nurse. She said, "He's drunk. He deserves a catheter."

I stepped back, and got ready to help hold down the patient. I knew I was not going to stop the RN I knew the RN was not going to be stopped, and she wasn't.

I'm not picking on this one nurse, because this seems to be the general philosophy of nurses and doctors & other medical staff with anyone who drinks. They say things like: "Since he's abused his body he needs an incentive not to do this again."

That's also the reason every other invasive procedure the doctor can think of is ordered on these patients -- including ABGs.

Fine. I understand this philosophy. But I also understand that not every person who drinks is a drunk. In fact, most are not. Yet in the ER, all of you who drink are drunks.

But my opinion on this philosophy is that it is a bad philosophy. While many people drink, few are drunks. Likewise, all people, no matter how good, are fully capable of making stupid decisions. And just because someone has one bad night, drinks too much, and ends up in the hospital, is no reason to treat that person like he's a loser.

In fact, the person I wrote about yesterday who came in with a 476 ethonol level was not a loser nor a drunk. In fact, he works in a hospital in another town. He's like you and me, only he made one dumb decision not to cut himself off.

I've seen people come into our ER after doing something stupid, and those people aren't treated like losers. So, just because you don't know someone is no reason to alter this special treatment.

I'm sure every person who is reading this has done something he later regretted, including those who work in the ER who are so perfect they use the power they have to treat those having a bad night like dirt.

Likewise, every time a person walks into the hospital reeking of alcohol that person is immediately deemed a loser by medical staff. The truth be as it is, there are many members of the community who drink responsibly, and for whatever reason sometimes one of these people finds his way to the ER, either as a patient, or as a concerned mom or dad or friend.

Yes, there are those who deserve to be treated as dirt, but not every person who drinks. In fact, I've seen just about every member of that same ER team at bars or partys, or heard stories about their attendance at such places.

So, lest ye be perfect, one should not be so quick to judge. Or, stated another way, do not judge lest ye be judged.

He almost drank himself to death

The page said the ambulance was 5 minutes out, but when I arrived 2 minutes later the patient was being wheeled in. He was a 20 YO non responsive. He reeked of alcohol. The family said he had between 20 and 40 beers at a family outing.

He did not respond to the testicular squeeze the doctor performed -- not good.

He did not respond to the chest rub, nor the foot rub -- not good.

I prepared the ETT and the doctor stuck the blade into his mouth, and the patient gagged. That was a good sign. In fact, the patient gagged enough that the good doc wisely deferred sticking the tube into the young man's airway.

As the blade was extracted from the patient's mouth, the patient started to spew lots of secretions, and for fear he might puke we were all ready to turn the board sideways. The worse news was the direction they were planning to tilt was in my direction.

"Let's get him some Zophran," I heard someone say. I prayed that stuff worked fast, because I hate puke. I especially hate puke when it's coming my way and there's nothing I can do to get out of the way.

The good news is he did not puke. The better news was he was still breathing. So, because he had fallen and hit his head, we rushed him to CT. The results showed no bleed and no spinal injury, which was also good.

The EKG I did upon his return showed ST elevation, though. That was not good. While he escaped head and neck trauma, he may have drank himself into an MI at 20 -- once again, not good.

But he was breathing on his own, that was good. And he was waking up. The first words were of the sorts that cannot be repeated. And his parents came in and said he was a 4.0 student who was just having a good time with his friends and family.

I imagine he won't be drinking for a while. Once I deemed my services would no longer be needed, I left the ER. In the hall I ran into the good doctor. He said, "A person is considered drunk when his ethanol level is 80. This young man's ethanol level was 476."

Hopefully the EKG was just a fluke thing, and all this man will suffer is a major 2-3 day hangover. I can't imagine it will last much less than that. I've been drunk a few times in my day, but there always comes a point when my body says enough is enough.

Social drinking is good to do if you can handle it, and you can do so with a degree of responsibility. Apparently this man couldn't handle it, nor the responsibility. There comes a point when common sense must prevail, 4.0 GPA or not.

Pediatric Specialist Center

(Note: This is part VI of my story growing up with hardluck asthma. To view Parts I through V you can click here and follow the links.)

I never in my life would have imagined asthma was so complicated until I was a patient on 7-Goodman at NJH/NAC in Denver. There were times I was there I felt like a pincushion and a guinea pig.

Yet I found solace learning there were other people just like me, although I barely had time to get to know these other asthmatics kids as I was so busy being a pincushion.

I was at the hospital 14 days by Jan. 23, 1985, on over 14 new meds, and was still wheezing, had Dyspnea and cyanosis with minimal exertion, and was depressed because of it. Actually, I wasn't depressed because I was still wheezing, I was bummed because the nurses wouldn't let me participate in any activities because I was wheezing.

Finally, one day after I came home from school my doctor decided I was too sick to stay on 7-Goodman, and she had me admitted to a ward on the 8th floor of the Goodman building called PSC, or Pediatric Specialist Center.

While I was there I wrote a letter to my grandma:

"Since I've been here in Denver I've been taking a treatment every 3 hours. Drs been trying to spread the hours apart, but I haven't been getting any better. I barely notice a change since my arrival two weeks ago. So last night they put me in PSC, a room of 8 beds where they put patients who need IVs or special attention or treatments.

I'm in a bed right next to the nurse’s station. A mean nurse poked me several times for an IV, and then lab came to poke me again. Finally night came, the curtains were pulled around my bed, the lights dimmed, but I still couldn't sleep. So I played cards with Brian, the night nurse. He was really cool.

The next day the busy nurses worked again, a TV blared, a baby cried, another kid was yapping, voices were loud as nurses rushed around the room, and nobody seemed to pay me any attention.

The next day I got into a neat discussion with the mom of the 4-year-old kid in the bed next to me. She said her son had been in this place for two weeks. There was a public TV in the far corner and I really wanted to watch something I was interested in, but the honorable thing to do was let the 4 YO watch what he wanted.

She kept asking me if I wanted to watch something else, and every time I said, "No, I'm fine." Besides, I really didn't mind watching the mindless entertainment of Bugs Bunny.

Dr. Mitchel said I would be here 2 more days, but things still would be a lot worse if I were home. Maybe by that time (when I get out of PSC), I'll be able to do physical activities."

Unlike 7-Goodman, PSC was basically a hospital, and it really was boring. The only difference between PSC and the hospital I stayed at back in Michigan was I never saw mom. And, other than my counselor Ric visiting me every day, I had no visitors.

I suppose one or two of the kids might have visited me, but at this point in my stay I didn't have a chance to make any friends. I missed most of school due to tests and appointments, wasn't able to participate in gym, wasn't able to go on off campus excursions, and in a way I felt isolated from the world.

While I was sitting in my bed in PSC I kept thinking of my brother David on the day mom asked me if I would be interested in going to an asthma hospital. I kept thinking of David saying, "It would be like going to camp."Well, so far it wasn't like camp at all, it was like an institution. I wasn't happy about that at all. I tried to keep my attitude up, but that task was beginning to be a major challenge. I just wanted to be normal. I wanted to get out of PSC, to stop having tests done on me, to stop having appointments, to stop seeing doctors, to stop wheezing, and to start being able to do things like the other asthmatics.

And, most of all, I wished the dog gone nurses here on day shift in PSC would pay me some attention.