How to manage difficult asthma

When I was growing up with hardluck asthma my parents and grandparents and teachers inadvertently placed me in situations that made my asthma worse. They did not do this on purpose. In fact, they probably didn't even know they did it.

I remember my parents taking me to grandma and grandpa's house, and grandpa would chain smoke. That, coupled with smoke raging from the fireplace itself, resulted in me feeling pretty crummy. That's just one example I wrote about a while ago.

But, as the old saying goes, "You do the best you can with the knowledge you have, and when you learn better you do better." And now with new asthma wisdom, we know better. So, through experience and by educating myself with the latest Asthma Wisdom, I have learned (the hard way) some tips for managing Hardluck Asthma.

Thus is the premise of my most recent post at MyAsthmaCentral.com.

10 Tips For Managing Even The Toughest Asthma
by Rick Frea Wednesday, August 26, 2009 @ MyAsthmaCentral.com

So, you (or your asthmatic child) are on all the right asthma medicines, see all the best doctors, are compliant with your medicine regime, and yet you still seem to have trouble managing your asthma. You are, by my definition, a hardluck asthmatic. Now you're wondering: what else can I do to get my asthma under control?

Understanding that there is no cure for asthma, I do however have some basic tips based on my own experience I think might help you out. While many of these are straightforward, they sometimes go overlooked even by the most gallant asthmatic (or the most gallant asthmatic parents).

Here are some tips that might help you better control your asthma:

1. Do not smoke. What more needs to be said. Not only does this damage your lungs and lead to worse asthma, it can trigger an attack. Cigarette smoke is one of the main causes of severe persistent asthma.

2. Avoid exposure to second hand smoke: Every study I've ever seen on this topic shows that second hand smoke can do as much damage to your lungs as first hand smoke. It's not just kids, second hand smoke is harmful to everyone exposed to it.

3. Avoid third hand smoke: You may be thinking I just made that up, but it's real. According to our own Dr. James Thompson, 3rd hand smoke is considered breathing in "the small particulate residue of the burnt tobacco left behind from smoking that occurred minutes, hours or days ago." Like 1st and 2nd hand smoke, this too can trigger asthma. This is one of the main reasons the hospital I work for has gone completely smoke free, and anyone who even shows up smelling like smoke is politely asked to leave. Likewise, you should do whatever possible to create a smoke-free environment, which includes never allowing anyone to smoke in your home or car even when you are not present.

4. Learn your asthma triggers: This may be a good time to review the list of possible asthma triggers I wrote about in this post.

5. Avoid obvious asthma triggers: Some triggers are obvious, like when I was a hardluck asthmatic I'd have an asthma attack every time I visited certain homes, like my friend Todd's parent's house, or my brother Bob's, or my dad's cabin. Sure avoiding these places may not be fun, but it might be the best way to control your asthma.

6. Avoid hidden asthma triggers: You've lived in your current residence for how long? Don't think your house, or something outside it, is innocent of causing your asthma. There may be mold or dustmites lingering in places you never expected. I had a friend once who had terrible asthma. Upon inspection, he found that there was mold on one wall in the basement. After he took care of that, his asthma symptoms disappeared.

7. Learn about hidden triggers: So you inspected your home and found no obvious asthma triggers. Well, think again, because there may still be hidden dust mites, molds or pet dander triggering your asthma. Perhaps, then, it's time you have the air quality in your home tested. When I was a kid my parents had this done by expensive professionals at the request of my doctors at National Jewish Health, and it was found that my mom's plants had mold in them that I was allergic to, and there was pet dander all over the home. Now NJH has a Family Air Care kit so you can do this testing on your own as the Asthma Mom writes about in this post.

8. Learn what triggers are outside: However annoying it may be, pollen in the air outside your home can be avoided by using some tips I write about in this post. There may be other triggers outside you may have overlooked, such as dust that spews up from that gravel driveway or road every time a car goes by, or harmful particulates that might be expectorated from the factory across the street. If you cannot remove these triggers, you may have to relocate.

9. You may need to renovate: Once you learned about your hidden asthma triggers, you may choose to renovate your home in an attempt to remove such triggers. You can paint that moldy wall, rebuild that musty basement bathroom, or replace shaggy carpets with hardwood flooring that is easier to clean.

10. Don't be afraid to relocate: Perhaps you're attached to your home, but if it or something around it is triggering you to have hardluck asthma and you cannot remove the source, then it may be necessary to move to a new, more asthma-friendly home.

Perhaps by reviewing this list you have found something that you overlooked before. Don't worry, it's easy to do. While change may be challenging, it's often the key to regaining control of your hardluck asthma.

RT profession allows for lots of time with family

I would have to say that overall a job as a respiratory therapist -- the profession of respiratory therapy -- is overall a good career. The greatest part is that the variable shifts allow me to spend quality time with my #1 priority: my family.

I know of at least three families in my neighborhood where both the husband and wife work, and they send their kids off to daycare. Even while my wife works regular hours, I am proud to say that my two youngest kids have never see the light of day at a daycare center. Yet, while I'm certain neither has a clue what one is, my rebellious 6-year-old was recently quoted as saying, "I wish I could go to day care."

My oldest son experienced the day care setting for his first 2 years. However, he was the social type early, and loved day care. While the other children cried when dropped off, my son was happy. While the other kids were happy when picked up, my son cried.

Now my son is 11. Most moments he seems more like a chum than a son, as he takes up an interest in many of my hobbies, like baseball. And then at times he acts his age. Anyone with kids knows what I mean.

This summer he made known his individuality and decided he wanted to play football instead of soccer. Tomorrow he gets to wear pads and hit for the first time. I won't miss that moment.

My baby is 10 months old and just learned how to crawl backwards by sliding across the tile in the kitchen. My 6-year-old begs constantly to spend time with her friends, and she's gone most of the day. Yet when I go to work she gets upset, and has to call me so I can tuck her in each night over the phone.

Yesterday we went to a wedding. Our neighbor, the mother of the bride, worked hard to suck in her tears: her baby was all grown up. My wife leaned to me and whispered, "Just think, in the blink of an eye that will be us."

When you're a kid it seems time goes by slow. I remember my mom saying once the older you get the faster time goes by. Now, as adults, we all know what she meant by that. But I don't think it's age that makes time go faster: it's work. The more we work, the faster time appears to go.

That's why when I'm not working I try to absorb the moments, spend as much time with the kids as I can -- each individually and as a group.

I remember being a kid and feeling glad I was a kid, because my parents were old, and my grandparents were older. I remember thinking they were kids once, and now they are closer to the end. Now my grandparents are all gone, and my parents are the grandparents, and my wife and I are the parents. It's the cycle of life.

Thankfully the job of RT is not one I have to take home with me, so without work to do from my home time goes a little slower. Yet, as I return to work and work my 8 day cycle of days on and off, time is flying. When I start my six day off stretch,
I note a whole week has gone by in the snap of a finger. After several of these cycles, a year has gone by and my children. Several years, and life has gone by.

We all experience the same thing. While other jobs may be better paying than the RT profession, it does allow for the clock to tick a little slower. Although I'm sure there are some among us who find work wherever they go. Yet, as we now know, sometimes -- as the old poem goes (who coined that phrase I can't remember)-- sometimes it's nice to stop and smell the roses, lest we find ourselves near death and having experienced none of the great smells of life.

What will happen to us RTs???

My coworkers and I were having a discussion a few days ago, and the topic was: What will happen to respiratory therapists if Obama's Healthcare plan is eventually signed into law by the president. The general consensus was that many of us may need to look for new jobs.

First of all, the first thing Obama would order to diminish healthcare costs is for a complete and thorough investigation into procedures ordered and whether or not they are really needed. Hence, once this investigation gets to the RT Cave of any hospitals, a stunning revalation will be made: 80% of bronchodilator breathing treatments ordered are not indicated.

Right now the RT Bosses of the RT Cave count the "un-needed" bronchodilator orders as procedures, and the more predicted procedures the more staff positions are justified. If this procedure load is lapsing, then there is no way to justify, say, having two RTs on during the day.

After such an investigation, doctors would be instructed to attend "bronchodilator instruction classes," where they will be informed on the correct times where it is appropriate to order bronchodilators.

The end result here is doctors won't want to think that hard, so they will piss and moan enough for Obama to mandate (make an executive order) that all hospitals within the U.S. incorporate RT Driven Protocols that make sure that the RT decides who gets breathing treatments.

The good news is obvious: we'd have the protocols we've yearned for for years.

The bad news is obvious too: fewer RTs will be needed. We RTs on the low end of the totum poll will be out of luck, as will many to be RTs just finishing RT School.

Of course, when it comes to the government making decisions such as this, you never know what to expect. The alternate course will be that government bureaucrats will think along the lines of the RT Bosses, who would rather pay for un-needed therapies as opposed to forcing thousands of RTs out of a job.

Those who run the government, as you know from recent stimulus bills filled with pork projects, sometimes prefer to spend money where it isn't needed to stimulate demand and create jobs. If this is the route bureaucrats decide to take with RTs, then we are safe -- although we ardent supporters of bronchodilator reform will continue to cry foul.

It's possible our position may be absorbed by nursing to the detriment of the patients, and all us RTs will be out of a job. No disrespect to nursing here, but we are the one's with all the RT Wisdom. The major decider here: money!

And, what happens to us RTs will not be made by thousands of independent hospital administrators where we work, but by one bureaucrat sitting in a chair in Washington. He will decide, because he knows what's best for everyone.

So, if you're not a gambler, perhaps you best call your local U.S. Representative and U.S. Senator and make clear your opposition. On the other hand, if you're a gambler, stay put and hope for the best.

Note: This is an editorial and does not necessarily represent the views of the publication.

KUDOS TO THE ADMINS

I have to give kudos where kudos are due. I have to give kudos to the ER boss and the nurses of the ER for listening to and incorporating the advice of this and other RTs.

As I have written on this blog before, it was getting to the point that EKGs were ordered for such frivolous orders, or the patient wasn't available when the RT dropped what he was doing and rushed to ER, that many of us RTs stopped rushing to do EKGs in the ER.

It got to the point our EKG response time was really bad, like 20 minutes. That's not good, especially when you have a patient who is having life threatening chest pain -- or an MI (a heart attack). In these situations, an EKG should be done within 10 minutes from the time the patient entered the door.

ACLS also recommends such EKGs be done within 10 minutes. Yet, still, there were so many stupid EKG orders that we RTs stopped rushing down. I suppose they desensitized us to the word STAT.

Now, I recommended to my RT Boss that ER should call us stat for ACLS EKGs, and ASAP for all others. That way we can prioritize, and if we can't get down right away we can call and the ER staff can do the EKG. My boss said, "There is no reason you should ever not get down to ER right away to do an EKG."

That ended the discussion. A while later I talked to the ER Boss, and she liked my idea. But, five years later, nothing ever changed.

Now, however, my idea is implemented and going well. The door to EKG time has improved from 20 minutes three months ago to 8 minutes. That's great.

In fact, yesterday one of the nurses pointed me to a sign on the window that notified us of this great improvement, and the nurse said, "Kudos to you."

I said, "No! Kudos to you and your boss."

I meant that. Now that the ER staf page us RTs STAT for procedures that should be done STAT, we know that when we get paged STAT it means STAT.

Of course it took money for the change to finally be implemented. Six months ago the head RN boss noticed that insurance companies will pay for any EKG on patients over 29 complaining of atraumatic chest pain. She also noticed that they weren't paying for most of our EKGs because the door to EKG times were way too often greater than 10 minutes.

So, she got one member from each department together at a meeting to determine what could be done to speed up the time from door to EKGs.

I was picked by the RT boss to represent the RT Cave. My suggestion was simple: "Call us STAT only for ACLC EKGs. In other words, call us STAT for Atraumatic Chest Pains."

The idea was implemented. And, no surprise, it works. We RTs are happy because we know exactly when we need to rush, the nurses are happy because they no longer have to complain we took too long, and the RT Bosses are happy because they get paid."

So, kudo's to the bosses at Shoreline Medical Center. You've earned it.

An editorial about soft floors in hospitals?

Yesterday when I arrived at the hospital I heard a code blue overhead, and arrived in a room of a patient who had fallen and banged his head. A CT determined the patient had a head bleed due to the fall, and the patient was helecoptered to a larger trauma center.

Since then I've been thinking a lot about patient's falling. It seems that there are a lot of frail, old and sick people in hospitals. Like little children, they are prone to falls. Yet, when young people fall they are a lot more flexible and less prone to break hips, smash heads, and end up with life threatening pneumonia or a swollen brain as a result.

If you travel to any playground you will find some kind of soft padding to protect kids in case of falls. This is a good thing. Yet, when we get into hosptitals, the floors are made of rock, hard tiles. Hard head on on tile makes for a high risk for intracranial injury, and maybe even death. Falls also equal broken wrists, legs and hips. Broken hips in old people increase the risk of developing pneumonia, which so happens to be the number one killer of the elderly.

So, after discussing this with my co-workers, I have decided that a worthy investment for hospitals would be to have padded flooring in patient rooms. Why not? If we are going to flip the bill to pad floors where our beloved children play, why can't we flip the bill for padded floors in the hospitals where falls are most likely to happen.

It's a hoax folks: Hoaxanex

I had to share this with you guys. The following was an email sent to me by a fellow RRT. 
In the meantime, feast your eyes on his latest revelation of truth:

My term for Xopenex is “Hoaxanex”.

The only plausible reason to give/advocate Xopenex is that one believes that the inert isomer isn’t really inert---but is instead pro-inflammatory. A Trojan Horse of Inflammation if you will.

Could it be that in the past every Bronkosol/Alupent/Terbutaline/Abuterol tx we gave to a newly diagnosed asthmatic kid was, while temporarily relieving the bronchospasm, only instilling more and deeper inflammation?And so many RT dept.’s tout how they have reduced their Q4 tx load down to TID and prn. But, as we know, HHN over-ordering is so over the top and beyond the therapeutic range. Along comes TID Magic Beans and desperate RT’s grasp at it. They played our profession.

Meanwhile asthmatics in a study breathed HHN tx’s with ONLY the inert (pro-inflammatory) isomer version of Albuterol. If the inert isomer was so pro-inflammatory as to allow HHN reduction from Q4 all the way down to TID….one would then expect that having asthmatics breath only that vile isomer would send them into outright bronchospasm, some needing on-the-spot intubation, etc.

But NOTHING HAPPENED!
Hoaxanex.
I showed this to this to my coworker, the infamous Jane Sage, and she sent the following email:

I knew this drug was a hoax all along, I just wanted the free pizza and breadsticks that the drug reps brought in! How was I to know that the 8 and 10 year educated physicians would buy into such a clearly manufactured glot of research and propaganda that the drug company flooded the offices and er's with. And to think that I trust my gallbladder and aches and pains to these doc's. Yours, Jane

Of course it's also a hoax that it is stronger than Ventolin and has fewer side effects, but that bit of falsified information was needed to brainwash all us folks -- that and the free food and drinks.
I'm going to file this under humor, although it's really not.
I've added this to my Ventolyn types. Please check it out by clicking here or the tab above.

Weekly asthma q&a: will expired meds still work? What is extrathoracic obstruction?

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: Will the medication work even though the expiration date has already been reached

My humble answer:

Great question. You will find the answer by clicking here. I write about theophyllin in this post, but the same rings true for all asthma medicines. While most asthma meds lose potency after so much time on the shelf, they are not harmful if used. However, if you do use expired meds, you should know that they may be less potent.

On rare occasion I've found expired Ventoiln inhalers stuffed inside the couch cushions or under the bed, and I have still used these even though I knew they were expired. However, Ventolin has a nasty taste too it when it's expired, kind of like rotten mints.

Bottom line, you are better off tossing expired meds in the trash and getting new ones.

Question: can a 14 month old baby be given Salbutamol via spacer.has a very bad cold and a lot of congestion... wheezing...has a very strong family history of asthma. just wondering how many puffs and is it allowed can it be any harm, for a 14 month old. her siblings have it...just can't remember, at what age was first given to them.

My humble Answer: It sounds like you have plenty of experience with asthma, and your hands full with a sick 14 month old. Still, I'm sure most asthma experts would agree with me that you should never give any medicine to a baby with out first consulting your physician. If he (or she) has already prescribed it for the child, great. But if not, you had better call.

That said, according to the package insert for albuterol, "Safety and effectiveness in children below the age of 12 years have not been established."

Regardless of that little warning, Salbutamol (otherwise known as Albuterol) is prescribed often for children under 12 for use in the hospital and for home use. In fact, I have given this medicine to my own asthmatic child when she was less than a year. So, to answer your question, yes Salbutamol is safe for a 14 month old baby.

The dose is usually the same as it is for adults, which would be 0.5cc of the solution if you give a breathing treatment, and 2 puffs for the inhaler. You can read about the medicine at HealthSquare.com.

Side effects are rare, however from my own personal experience giving this medicine to children I notice they have a tendency to become hyperactive following it. I usually joke that if the child is running around the room shortly after being given this medicine you know it worked.

The ideal way to give the medicine to get the optimal dose to your child (according to studies) is with the inhaler using an aerochamber with mask. You can read about this device and how to use it over at nationaljewishhealth.org.

Question: what does it mean to have extrathoracic airway obstruction?

My humble answer: That is a great question. This refers to an obstruction of the trachea, either above or below the vocal cords. It usually occurs in children because they have narrower airways. The most common type of extrathoracic obstruction we see in the emergency room I work in is croup, which causes swelling around the vocal cords and causes the child to have a barky cough that sounds like a seal, or a constant noise on inspiration called stridor. It can also be caused by an object like a hotdog getting stuck in the trachea, cancer around the trachea, tonsillitis, or other process. According to our site, "Stridor may indicate an emergency and should always be evaluated immediately by a health care provider"

(To read more about extrathoracic airway obstruction you can check out this link.)

If you have any further questions you can

"Coming out of the asthma closet"

I was over at Kerri's blog, "Hold Your Breath to breath," and read a neat article by a guest writer who notes being embarrassed by her asthma, and therefore had a tendency to keep it a secret from everyone around her.


Kerri aptly named the post, "Coming out of the Asthma Closet."

The quest asthmatic, Elisheva from Israel, writes:

" Teachers and other students complaining that my coughing was disrupting the class. A hard time in gym. People thinking I was cutting school cuz I’d miss a week and a half of school for a cold. My friends freaking out and asking if I was ok. I hated using my inhaler in public (still do) and I’d always wait until my friends were begging me to use it already because I was breathing so pathetically they were worried. And then I’d only take it locked in the bathroom when I thought no one was near by. It also didn’t help that I refused to take any preventative inhalers for about 2-3 years because they tasted gross and I refused to allow myself to believe I was actually that sick. I’d end up at the dr every month or so listening to lectures about permanent lung damage and responsible asthma management. By the time I started actually taking the stuff I was prescribed, it turned out it wasn’t strong enough for me anymore. Does anyone else think asthma drugs of the 90’s sucked?"

I find it interesting any asthmatic "comes out of the asthma closet" per se. I suppose all of asthmatics have to have a "coming out" moment at some point. However, now with the Internet, I think it is a lot easier, and people can come out a lot quicker.

When I was a child I was picked on quite a bit. When I was 19 and working at a local A&W Restaurant, I ended up working with one of the girls who used to bully me (yes, girls bullied me too).

We became good friends, and one day she said, "For a kid who got picked on so much, you turned out to be pretty cool."

Later she found out I had asthma. When she learned this, she said, "Now I feel bad for picking on you. I had no idea you were sick."

"Why was it that you picked on me," I asked.

"Because you were always making weird noises, sniffing, sneezing, and you always seemed to have red eyes and were always wiping your nose. So you were an easy target."

She apologized. If she had known I had asthma she never would have picked on me. Yet, feeling as thought I were all alone with the feelings I had regarding my asthma, wanting to hide my inhaler, feeling guilty for missing so much school, it were easier to feel ashamed and to hide.

It wasn't until I met a fellow hardluck asthmatic in RT School that I realized I was not the only one. Now, thanks to the Internet and websites like Kerri's, we asthamtics can share our stories and get the word out that the thoughts you are having are not unique. And you are not a freak.

So don't be ashamed you have asthma. In fact, there's no better time than the present to "come out of the asthma closet."

My success came through effort, not IQ

I've been looking for years to determine what a good IQ score is, and haven't been able to determine it. I even have a book about IQ scores, and no mention of abnormal, normal, above average scores. This morning, however, as I clicked on the computer there it was on Yahoo News.

Here is the chart on an actual IQ test:

• 75 poor
• 80 mediocre
• 90 below average
• 100 average
• 110 above average
• 120 very good
• 130 excellent
• 140 exceptional
• 150 gifted
• 160 genius

As I wrote in a previous post, a higher IQ can lead a person to having a more satisfying life, but IQ does not lead to success. What leads to success is effort and determination.

When I was a kid at the asthma hospital in 1985 I had to see a psychologist. She did an IQ test on me. Actually, she did two IQ tests on me, and my results were inconsistent. I scored a 95 and a 105. So that makes me about average.

You have to consider, though, that I was extremely nervous while taking this test. Likewise (and in my defense), according to Flaurence Litnaur in her book "Personality Plus," I am a Peaceful Phlegmatic Personality.

This means I have a very laid back and indecisive personality. The best way to determine if a person is this type is when giving the test they show signs of being every personality type. The reason is they can never decide on the answers to each question. That was me when I took the personality test. I actually had to have my wife sit down with me to determine my "true" personality type.

I think that IQ test I took so long ago was the same. Plus you have to consider I was 15 at the time, and even according to that psychologist, "He's a very immature asthmatic from Michigan."

That was then, though. A lot of things have changed since I was an "immature" 15-year-old. In fact, back then I was too "antsy" to sit and read a book. Now that's all I do is read.

I think my teacher at National Jewish wrote on my report card once that "Rick would be a much better student if only he would apply himself." Ironically, on my 5th grade report card (I have it right here by my side) Mr. Kaap wrote, "Rick is a very intelligent young man. If he would give a modicum of effort he would be able to get much better grades."

I can't remember my high school GPA, but I think it was very average: like 2.5 or something like that. That might even be high. My first two years of college my GPA was about the same. It's not that I wasn't smart, it was more that I never applied myself. Some tests in high school and college I never studied for and managed to get a "C" grade or better.

Then around my third year of college something clicked, and I stopped dinking around with my life. I started reading books galore (I never read one book in high school. I fudged all my book reports. Lazy?). I studied emphatically and hard. My grades shot up. Yet I still graduated with a below 3.0 GPA because I already blew it my 1st 2 years of college.

Now, so I earned a bachelor's degree, but what good did it do me at that time. I never got a job, perhaps because I never applied myself. My effort was lacking. I chose a degree in journalism and advertising that didn't suit me (however, even right now I'm using those skills).

By the time I was 25 years old my effort caught up with my intelligence. I suppose if I were to see that psychologist again she would note that I "matured late." Many women would probably say, "typical guy."

Well, for whatever reason, I quit taking for granted that I would succeed, and I studied my ass off during the RT program. I studied with my low IQ. There was one girl named Vika in our class I competed for top grade. She never studied. I bet her IQ was 150 or above. Yet, she did not succeed. She did not succeed, I would guess, due to lack of effort.

My friends continued telling me I was smart. I knew that I was not naturally smart like Vika, that I became smart through hard work and effort. I literally studied my butt off.

I graduated tops of my RT class. There were many times while progressing through the program people would ask me, "How do you do it? How do you get such good grades?" I would always say, "I study every chance I get. I never take for granted I'm going to pass a test, even when I know I probably know it all."

Even to this day I'm constantly reading and trying to improve my knowledge base. I think that is a skill my grandma tried to instill in my when I was a kid, yet I didn't apply the effort. I was interested in learning, always have been, but effort was lacking.

So now I'm an RT, and I have to take a class to be an neonatal resuscitation class, and the person teaching me how to do this says to me, "Your boss tells me you are very intelligent." I smiled. My ego went up a notch. I hear this a lot from my co-workers. Sometimes people read my writings here and acknowledge to me how smart they think I am.

Yet, now you know the rest of the story: I am not smart at all. I am no smarter than the average Joe on the street. The only difference between me and any of them is that I apply myself. I go the extra step, and take the extra effort. I go out of my way and read even the most boring text to improve my knowledge base.

Now, here's a thought I've been pondering. Perhaps I'll have to wait another 19 years to get the answer to this, but I am wondering: Does IQ grow as you age. I understand that people get smarter, but can you actually improve upon your IQ score. I've been told the answer is no, that whatever you are born with you have to live with. But I'm just curious.

I think the answer is no: that IQ stays the same forever. That the reason some of us do better as we age is more so because we mature and learn to apply ourselves better. Those who don't mature (including those with high IQs) are left holding down the less satisfying jobs.

I don't consider myself successful by any means. I think I have a decent job. I think I have an easy job. It's challenging at times, although it's not completely satisfying because doctors don't give me the autonomy to really use my skills and knowledge. Sometimes I think I keep studying for no reason.

Then again, on occasion, a dire situation falls before me when my wisdom comes in handy. Yet this doesn't happen often enough in my line of work (or at least where I work). I think my RT satisfaction would be greater if I worked for a larger hospital with a trauma center and RT protocols. Yet, as I talk to RTs who work at these hospitals, they aren't completely satisfied either.

So, in this regard, I suppose my effort is lacking. If I really, really wanted to be satisfied, to succeed on a grand scale, to reach my full potential, I would be more competitive and would move to a bigger city, go back to school, and get a degree in something where I could use my brain a little more --- perhaps as a teacher.

But, then again, I already have 7 years of school in. I have kids, and -- as my wife says, "You are not going back to school." And that brings me full circle and to my point. That is why I started blogging. I wanted to share what wisdom I acquire through my readings and experience I feel I'm never able to use while working.

It's a shame that doctors and nurses don't come to us RTs more often to ask for our opinions, because we are all intelligent people with loads of wisdom to share. In the ideal world, we would have the protocols we want, and the opportunity to find the success and happiness we yearn for the day we enter the doors of that first college class.

Yet unlike we surmise as we start college, success does not come down to how smart you are, it comes down to how much effort you put forth.

We'll consider this RT Cave Rule #37: If you want to succeed in life you have to supply the effort, which may involve going out of your way or doing things you don't necessarily want to do. Thus, success is not determined by IQ, but through effort.

Thoughts.

Related posts: IQ doesn't equal success: focus on your EQ

The Amazing: Telebiokinetosphere

As usual I cannot reveal my sources. The following is a letter from Dr. Al Buterol, the inventor of the Amazing Wheezoscope, the Grumposcope, and the Telekinoscope.

---

From: Dr. Al Buterol
Sent: Thursday, July 30, 2005 4:55 p.m.
To: Shoreline Medical physicians
Subject: The new telebiokineticosphere

Doctors: Further research is going on regarding the telebiokinetosphere I mentioned to you at our annual meeting last month. As I mentioned to you then, this product will eliminate all but perhaps the need for surgeons to ever have to enter a hospital or doctor's office. In the hands of a skilled nurse practitioner, the telekinetoscope can be passed over the patient from head to toe, and the sphere will record anything going on inside the body. The NP will then take the telebiokinetosphere to a specially equipped computer, hook up the telebiokinetosphere by special adaptors, and have the patient assessment transferred over the Internet to the doctors home computer. Then, with a couple easy keystrokes, and without leaving the comfort of his or her own home, the physician can simply type in the orders.

Along with hospitals and physician's offices, we are hoping to have the telebiokinetosphere in every ambulance and medical helecopter in the U.S. At the time being, the product is scheduled to be trialed by Medivac teams in 2011. If any of you are interested in participating in future trials, please feel free to contact me.

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Three ways to deal with stupid policy, orders

In no institution -- hospitals included -- are things run perfectly. So, when management -- or RT bosses -- implement policies that are stupid, or refuse to implement requested changes, or doctors write stupid orders, there are three ways to deal with this:

1. Complain
2. Accept
3. Change

I can't think of any other options. I suppose, here at the RT Cave, we do a little of each. I suppose, in a sense, with my RT humor, I tend to complain in my own way here on this blog.

However, by keeping my mouth shut, I suppose, in a way, I'm accepting the status quo. I guess it's easier that way. Come in, do whatever work is required of you, and go home. Do it that way and there's no controversy, no confrontation.

I guess you can say, in this way, being an RT is no different than working in a factory. Only, instead of soldering two wires together, we are taking care of patient. And, instead of standing still, we are running around like chickens with our heads chopped off doing trivial therapies that suck more money from unaware businesses and government services.

And, then, on occasion we find the energy to implement change. Yet, the effort to do that, the setbacks, the rejections, the changes to the protocols you want, lead acceptance the easiest route.

Now I'm just making this up, but it makes sense to me. What do you think?

Perhaps pulmonary toilet is a dirty word

This is a blog about wisdom, and I recently had a comment left on my blog that provided me with some great wisdom about the pulmonary toilet. I don't usually do this, but I have decided this comment was wisdom enough to make the front page.

So, without further adieu, from my "FAQ about the Pulmonary Toilet," here is a comment worthy of it's own post:

"Hi there- I Googled "pulmonary toilet" because I've had it up to here (picture my hand being held above my head in a chopping laterally motion...) with that term. When are we going to start calling this something a little bit more nice?

When I was an RT student 8 yrs ago, 1 of my instructors was on a kick to change the industry standard and have us students use the term "pulmonary hygiene." I must say that I really prefer that better. Am I alone here, people?

Despite my annoyance with the term "pulmonary toilet" I must give you a big thanks for giving a thorough definition of what it is. I work at a hospital with very few RT protocols (sad, I know) so very often docs will write "pulmonary toilet Q4" without stating what they want.

If they ever answer their pager to clarify the order I then have to pretty much go down the list of items which you described in your blog.

Despite your descriptions I found one error which Glenna sort of corrected. The device that you describe as PEP actually sounds more like the flutter valve, also a very good airway clearance device. PEP is positive expiratory pressure device which has the ability to make the expiratory pressure easier or harder to blow against.

Of note, where I currently work we use an airway clearance modality called EZ-PAP which is often over-ordered at this hospital but in some cases it has literally saved needing to re-intubate someone. I am a huge believer in this modality.

For those folks who can't use an incentive spirometer, EZ-PAP is quite wonderful.I will come back to this blog. Thanks a lot for caring about sharing your RT info!

Believe it or not, pulmonary toilet where I work is under ordered. How's that for an admission. We don't use PEP, EZ-PAP, or flutter valves where I work because the admins here are adamant that insurances will not refund for it -- and they are expensive they say.

So, despite we RTs begging for these for years due to studies verifying there efficacy over typical CPT, we may never get those devices here.

Yet pulmonary toilet is a dirty term. Well, it's a fun term, but Pulmonary Hygiene would be more appropriate, and perhaps more "politically correct" -- not that this blog is necessarily politically correct.

However, we RTs tend to have dry sense's of humor, and therefore it the probably reason for such an inappropriate term as "pulmonary toilet."

Ventilator Delerium should not be overlooked

I don't think this matters so much on day shift, but I think on the night shift we RTs and RNs and doctors when writing orders ought to have more consideration for the amount of sleep our patients get, especially patients in the critical care on a ventilator.

There's this thing called Ventilator Narcosis (Delirium) that I think is way underdiagnosed. In fact, I bet it hardly ever gets diagnosed.

According to the August, 2007, issue of Chest, Ventilator Delirium effects 85% of patients receiving mechanical ventilation, resulting in , "and has been linked to prolonged length of stay, reintubation, higher mortality, and higher costs of care."

Delirium, or cognitive decline, often effects elderly patients who are on narcotics or benzodiazepines and left in a state of coma (or "suspended animation") for lengthy periods of time, thus resulting in a poor quality of sleep.

Or, poor lighting coupled with the above and continued patient agitation resulting in lack of adequate sleep often causes a patient (particularly the elderly) to enter into a state of cognitive decline. This happens even in elderly patients who are in otherwise good physical condition.

Likewise, "recommendations by professional societies have established the importance of delirium monitoring and recommended it as standard practice in ICUs all over the world."

Roger Striker at RTMagazine.com provides a more cons ice definition:

"Delirium, as defined by the DSM-IV, requires an acute disturbance of consciousness with reduced clarity or awareness of the environment (eg, an inability to focus or to sustain or shift attention) and either (1) a new cognitive change (eg, deficits in memory or orientation, or a language disturbance) or (2) a new perceptual disturbance (eg, hallucinations or misinterpretations).2 Delirium frequently develops over hours or days, and fluctuates over time.

One of the major contributing factors is believed to be poorly dosed, or too much, narcotics for the age of the patient. Many experts who study ventilator delirium note that most doctors dose narcotics the same for most patients, when the dose should be adjusted for age and size -- particularly in the elderly.

Along with too much, or poorly dosed narcotics, we hospital staffers add to this problem by constantly irritating the patient.

Think about it though. You would go nuts too if the lights were on in your bedroom all night long, and every two hours someone came in to brush your teeth, and every hour between that someone came in to roll you over, or wipe your bottom, or break the circuit of the vent to give you a breathing treatment or squirt in an MDI, or dump water out of the circuit, or insert a new IV.

There have been studies done on this, and the result to every one I've read the experts conclude that the lights need to be out for at least 8 consecutive hours a night, and interfering with the patient needs to be kept to a complete minimum in order for that patient to get a good nights sleep to prevent Ventilator Narcosis.

However, at Shoreline Medical, we have a protocol that calls for 2 puffs of Ventolin every 6 hours, and a good mouth cleaning every 2 hours, and shifting the patient from side to side every hour. The result here is that the patient never gets more than one hour of consecutive sleep.

Since the average sleep cycle lasts 1.5 hours, one can assume that ventilated patient rarely if ever gets through a cycle. And, the result of lack of enough REM sleep is psychosis.

What has me most concerned is brushing the teeth every 2 hours. I understand that a good mouth cleaning is a great way to prevent ventilator acquired pneumonia, but I think there comes a time you use an amount of common sense and just let the patient miss a few of these mouth cleanings so he can get some sleep.

Some RNs I've talked to agree with me, and they ignore the protocol at night. Some, however (those who do everything by the book), never miss a mouth cleaning. To these individuals, the reasoning "I have to do it because it's protocol," or "I have to do it because the doctor ordered it," supersedes common sense.

I understand that rotating the patient often is a great way to prevent blood clots from forming, although I don't see why a little night time common sense can't prevail to allow the patient to sleep.

I understand why the overhead light needs to be on most of the day to so we can see the patient from the nurses station, but putting on the nightlight for six hours during the night shift is a great way to allow the patient to fall asleep and get some REM.

Thankfully most patients don't remember being on a ventilator anyway, even if they appear to be awake and appropriate at the moment. I have asked many patients a day or two after extubation if they remember anything, and a majority of them say, "No. I remember nothing."

Riker notes, "Most trauma patients have no recall of their ICU stay, but slightly more than one third do remember these events; 88 percent of the time, they have fantasies or hallucinations about being in prison and trying to escape."

So, the next time you are taking care of a patient on mechanical ventilation, ventilator psychosis or delirium or cognitive decline should be something for you to consider discussing with the attending physician.

Improving aerosol drug delivery in children

The following are the latest recommendations for what aerosol delivery device to use for pediatrics and neonates, and at what age that device should be administered:

(Note: SVN = small volume nebulizer, and MDI = Metered Dose Inhaler, DPI = Dry-powdered Inhaler):

• SVN with mask recommended for children under three years of age
• SVN with mouthpiece for children greater than three years of age
• MDI with holding chamber/spacer and mask for children less than four years of age
• MDI with holding chamber/ spacer for children greater than 4 years of age
• DPI for children greater than 4 years of age and older
• MDI for children five and older
• Breath actuated MDI for children greater than five years of age
• Breath actuated nebulizers for children five and older

This information is from an article by ARzu Ari (PhD, PT, RRT, CPFT) in the August, 2009, issue of AARC Times, "Optimal Delivery of Aerosol Drugs in the Pediatric/Neonatal Patient Population."

Likewise, she reiterates that a child should not be crying during a breathing treatment:

"Inhaled drugs should be given to infants only when they are settled and breathing quietly. Crying children receive virtually no aerosol drug to their lungs, with most of the inhaled dose depositing in the upper airways or pharynx, which is essential for clinicians to develop approaches that minimize distress before administering aerosol drugs. These approaches may include, but are not limited to, playing games, comforting babies, and providing other effective forms of distraction."

She also notes that it is fine to give a breathing treatment while a child is asleep because, as studies show, a child gets a higher dose of the medicine during the easy, laminar flow while sleeping.

However, "An in-vivo study showed that 69% of the children woke up during aerosol administration and 75% were distressed."

Which is exactly the reason I give blowby to all my sleeping children. A blow-by breathing treatment, as most of my fellow RTs are well aware, is where you blow the treatment by the patient's face instead of using a mouthpiece or mask.

But Arzu, as expected, frowns on the practice of giving blowby's. She writes, "Although blow-by is a technique commonly used for crying babies or uncooperative children, it has been documented that it decreases aerosol drug deposition significantly as the distance from the device to the child's face is increased. Evidence has discouraged the use of blow-bys."

In the report, Arzu also notes that: "Studies suggest that the mouthpiece provides the greater lung dose than a standard pediatric aerosol mask. Consequently, the use of a mouthpiece should be encouraged, but a mask that is consistently used is better than a mouthpiece that is consistently unused."

No real surprise there.

However, while using a mask, she notes that it is important to have a good seal, whereas "a leak as small as 0.5cm around the face mask decrease the amount of drug inhaled by children and infants by more than 50%."

I'm certain there are more than a few of us RTs who use the less preferred technique that results in poor drug administration in irritated, frustrated, and crying infants and children who are not inclined to tolerate a blowby, let alone a mask or a mouthpiece.

That said, I think all us RTs can do a better job of improving our technique with children to assure that they are getting optimal deposition of the breathing treatment.

Is exercise making America fatter?

I think I wrote about this before on this blog, that you can't lose weight just by exercising alone. I tried it last winter, and I actually ended up gaining weight.

You see ads galore trying to get you to buy one gadget or another to lose weight. They show you a picture of the gadget, and a picture of some guy with six pack abs and say, "This could be you if you buy this product."

The truth is, that person never loses weight using that product. If fact, he probably had that six pack long before the product was ever even invented.

Truth is, it doesn't matter what product you buy, you will not lose weight by exercising alone. You have to diet. Losing weight is a matter of ins and outs. If you take in less than what goes out of your body, you will naturally lose weight.

Yes, there are advantages to exercising. I've written about them too on this blog and my asthma blog. Exercising strengthens your heart and lungs, improves your immune system and makes you feel better overall.

Yet exercise alone will not result in weight loss.

I've always believed this, yet trying to find proof in a world dominated by marketers, and a media, that is content to have you believe that exercise is the key to weight loss.

However, I found an article at time.com called, " Why Exercise Won't Make You Thin," by John Cloud (Thursday, Aug. 06, 2009) that explains quite simply why exercise alone won't make you thin.

Cloud notes that if exercise alone made people thin, the fact that the percentage of people exercising increased from 47% to 57% from 1980 to 2000 would result in a thinner society. Yet, the opposite is true, as America is fatter than ever before.

He writes, "The basic problem is that while it's true that exercise burns calories and that you must burn calories to lose weight, exercise has another effect: it can stimulate hunger. That causes us to eat more, which in turn can negate the weight-loss benefits we just accrued. Exercise, in other words, isn't necessarily helping us lose weight. It may even be making it harder."

He also notes a study where 464 women were asked to maintain their normal diet. Most were told to exercise, while one group was told not to exercise.

The results: "The findings were surprising. On average, the women in all the groups, even the control group, lost weight, but the women who exercised — sweating it out with a trainer several days a week for six months — did not lose significantly more weight than the control subjects did....Some of the women in each of the four groups actually gained weight, some more than 10 lb. each."

He writes that a paper written by a group of psychologists explains why this happens:

"Many people assume that weight is mostly a matter of willpower — that we can learn both to exercise and to avoid muffins and Gatorade. A few of us can, but evolution did not build us to do this for very long. In 2000 the journal Psychological Bulletin published a paper by psychologists Mark Muraven and Roy Baumeister in which they observed that self-control is like a muscle: it weakens each day after you use it. If you force yourself to jog for an hour, your self-regulatory capacity is proportionately enfeebled. Rather than lunching on a salad, you'll be more likely to opt for pizza."

It is possible, Cloud concludes, that the recent trend to get people to exercise more has caused America to get fatter?

Reason for stupid orders: stupid people

I'm telling you folks, you can't make this stuff up. I gave a breathing treatment in the ER an hour ago on a patient I had to wake up to give the treatment to, and auscultation revealed crackles in the bases but otherwise good air movement and no obvious signs of bronchospasm.

While the treatment was going I said to the RN, "Why did the doctor order this treatment?"

"I don't know. You'll have to ask her."

When the treatment is finished I chart, "No difference with bronchodilator."

So, because the doctor ordered Q1 hour breathing treatments on this patient for whatever reason, I travel back down to give the second one. The RN I talked with earlier pulls me aside and says to me:

"As soon as you left after that last treatment you gave he coughed up a big loogie. That's why Dr. Q1 orders these treatments. If you ask her, that's what she'll tell you. She's pretty smart I say."

I concentrated hard not to roll my eyes. But I did manage to say, "That was just a coincidence."

"I don't think so," she said. "Those treatments really work."

I'm telling you folks, you can't make this stuff up.

Ventolin now indicated for low pressure

The patient presented to the emergency room with an spo2 of 80% on room air. He was taking rapid deep breaths as though he were starving for air. Upon placing an NRB on the patient and supplying him with approximately 75% Fio2, his spo2 improved to 95% and his air hunger resided, although he remained slightly dyspneic at rest.

Upon auscultation the RT observed good air movement with rhonchi or rhales in both posterior bases. Good air movement is a tell-tale sign the patient is not having bronchospasm, the RT observed.

However, a Duoneb treatment was ordered by the attending physician, given, and the RT observed (and the patient notes) no improvement following the therapy. The RT leaves the room surprised the physician hadn't yet ordered her infamous Q1 Duoneb.

An hour later the patient's blood pressure dropped significantly to 64/20. The patient was placed in supine position, and a fluid challenge was started and medications provided to improve the patient's blood pressure. The patient remains awake, alert and orientated.

To further resolve the situation, the physician decided the most appropriate action at this time would be to order Duoneb Q1 hour times two. The RT receives the page and is not surprised.

Upon entering the room the RT observes the patient is sleeping comfortably in a flat or supine position(a tell-tale sign he is not short-of-breath). However, since the Duoneb was ordered, he awakens the patient and gives him the breathing treatment.

Upon auscultation the lung sounds are exactly the same as listed before. After the therapy lung sounds are still the same, and the RT resists the urge to write "still the same" in the posterior comment box. He also resisted the temptation to ask the doctor why he ordered the therapy, but he decided better.

In about an hour he will go back down to do the second treatment for no reason.

Although, while this second treatment was running, the RT thought up another Ventolin Type, and perhaps the real reason for the physician's order. He whacks himself on the head and says, "Duh! I should have figured this out earlier. The physician figured out a new use for Ventolin."

This time we have Lopressorolin. It's indicated specifically for any patient diagnosed with low BP or Sepsis. Suddenly the humor strikes him (low pressure = lopressorolin). He snickers to himself. Thankfully no one notices.

Anyway, our Ventolin Types list above has been updated.

Introducing: The Amazing telekinoscope

So, how is it doctors and nurses can get away with making the clear and indecisive decision that a patient must have a bronchodilator when they don't even remove the stethoscope from their shoulders.

Please note that the links referred to in the ad are no longer valid, as the ad was featured in RN and DR. magazines between Oct. 29, 2000 and April 1, 2006, and on Internet websites during this same period. While the product is still available, more surreptitious methods of distributing it are also available (like Secret physician websites that require a password and don't allow pesky RTs who need to stay in the dark about wonderful products like this).

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.

The Amazing -- NO HANDS NEEDED -- Telekinoscope

ARE YOU TIRED OF WASTING YOUR ENERGY LIFTING THAT HEAVY STETHOSCOPE?

ARE YOU TIRED OF RISKING YOUR HEALTH COMING IN CONTACT WITH INFECTED AND GROSS PATIENTS?

ARE YOU TIRED OF GETTING OUT OF BED AT 2 IN THE MORNING?

NOW, THANKS TO THE NEWLY PATENTED TELEKINOSCOPE YOU CAN JUST STAY PUT, AND USE NO MORE ENERGY THAN IT TAKES TO GIVE THE ORDER, "I WANT RT TO GIVE A VENTOLIN TREATMENT."

YOU MIGHT BE ASKING: "CAN IT REALLY BE THAT EASY?"

"YES IT CAN!" SAID DR. AL BUTEROL, THE INVENTOR OF THE TELEKINOSCOPE. "LIKE YOU, I QUICKLY GREW TIRED OF WASTING MY TIME AND ENERGY TOUCHING PATIENTS. NOW, WITH MY AMAZING TELEKINSCOPE, ALL I HAVE TO DO IS JUST STAND BY THE DOOR, LOOK COOL, AND GIVE ORDERS. RTS SAY I'M LAZY, BUT WHO THE HELL CARE'S WHAT THEY THINK. "

THAT'S RIGHT, DOCS! THIS PRODUCT HAS BEEN TESTED, AND IT'S GUARANTEED TO WARD OFF EFFORT AND WORK.

NO MORE WILL YOU NEED TO EXCRETE ENERGY TO ASSESS LUNGS.

NO MORE WILL YOU HAVE TO TOUCH GROSS, INFECTED PATIENTS

NO MORE WILL YOU HAVE TO GET OUT OF BED.

ALL YOU HAVE TO DO IS PLACE DR. BUTEROL'S STETHESCOPE INNOCULOUSLY OVER YOUR SHOULDERS AND YOU WILL PICK UP RADIO VIBRATIONS THAT LET YOU KNOW WHAT'S GOING ON IN THE PATIENT'S LUNGS.

THEN, WHETHER IT'S CHF, PNEUMONIA, PNEUMO, PLEURAL EFFUSION, CROUP, OR SOME DISEASE YOU JUST MAKE UP, ALL YOU HAVE TO DO IS STAND BY THE DOOR, LOOK COOL, AND SHOUT AN ORDER FOR THE BRONCHODILATOR OF YOUR CHOICE.

ORDER ON-LINE AT WWW.TELEKINOSCOPE.ORG AND FOLLOW THE EASY STEPS TO NOT LISTENING TO LUNG SOUNDS.

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 stethescope. If you aren't vigilant, or privy to such sureptitious wisdom as we now are, you may never be able to tell the difference.

My Answer to your respiratory questions

Each week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. I provide this spot each week to make sure no query goes unanswered.Today's focus is on random questions.

1. cigarettes good for asthma? Absolutely not. In fact, despite old fallacies, cigarette smoke can make asthma worse.

2. can a treatment of albuterol solution help chest congestion due to pneumonia? If the pneumonia breaks up causing bronchospasm, pneumonia might help open up the airways. Otherwise, Albuterol will not do anything for pneumonia. Pneumonia is a disease of inflammation of the alveoli, and Ventolin particles do not get down that far into the lungs. Likewise, Ventolin is a bronchodilator that does nothing for inflammation.

3. is humidity bad for lungs : Humidity is not a trigger for any respiratory disease. However, humid air is thicker/ heavier air that can make breathing more difficult for those with already compromised lungs. Actually, humid air can make breathing more difficult for a person with normal lungs. This is also a reason why those with lung diseases should not use humidifiers or sit treat their acute short of breath symptoms with a hot steamy shower.

4. smartest doctors: The smartest doctors are not necessarily those with the highest IQ, rather those who have the most common sense, are the hardest workers, keep up on their medical wisdom, and work with their patients to the benefit of the patient.

5. things respiratory therapist complain about most: Ordered therapies that are not indicated. Doing a therapy because it's part of a protocol, not because the patient needs it. Doing a therapy to meed criteria so the hospital can get reimbursed, and not because the patient needs it. Doing a therapy because a doctor ordered it, and not because the patient needs it.

6. why do we see our breath on cold days?: According to Ask a scientist: "Your breath has moisture (water vapor) in it. When you exhale into very cold outdoor air, the moisture-laden atmosphere from your lungs becomes chilled to the point where the water condenses into a fog... Warm air (your breath) can hold more water vapor than cold air. When you breath out, your breath cools and the water vapor must leave their. It condenses and you see it as a cloud."

7. breath smells like smoke but do not smoke: You probably better talk to your doctor about this. Or, better yet, your dentist.

8. bipap/excrete co2 how: The IPAP setting on the BiPAP can control the patients depth of inspiration. The greater the inspiration (the higher the tidal volume), the more air the patient takes in, and the more CO2 that can leave the lungs with each breath. Thus, the higher the IPAP setting, the higher the tidal volume, the more CO2 the patient will blow off.

10. scratchy neck: This can be a tell tale sign of an impending asthma attack for many asthmatics. I used to get this sign when my theophylin level was low when I forgot to take it. However, since I've been weaned off theophylin, I've never had this symptom. I think the reason the neck becomes scratchy no one really knows.

11. are respiratory therapist programs hard?: Yes. It is an intense two year program mainly due to the fact that the AARC wants to improve respect for this profession by making us as knowledgeable as doctors when it comes to the respiratory system. This is a good thing. But, you better study your butt off. This is also a way to weed out the chumps, the lazy RTs, and the people who just want to work without thinking.

12. what order should patients be seen: By order of severity. A person not breathing or in cardiac arrest should be #1, a patient with CP or difficulty breathing #2, and down the line, a person who generally does not look good #3, and all those people who come to the ER for things they could go to the doctor's office for last on the priority list.

13. http://www.google.com/search?hl=en&q=why

I'll never forget Mrs. Flowers and her quilt

Way back in October of 2008 Karen over at COPDnewsoftheday.com asked me to write a post for her blog about the relationship between RTs and COPD patients in honor of RT Care week. I was honored by her request, and thought instantly of Mrs. Flowers.

The following was first published October 2008 at COPDNewsoftheday.com:

Mrs. Flower
by Rick Frea: October 21, 2008 @ COPDNewsoftheday.com

I was told in report that Mrs. Flower in room 202 was diagnosed with COPD and was having a very difficult go of it. She was only 60. The person who gave me report was concerned that she might be ventilator bait.

So I wasn’t surprised when I was paged STAT to Mrs. Flower’s room early in my shift.
Upon entering her room I immediately observed she was in agonizing respiratory distress. She was gasping like a fish out of water as she sat on the edge of the bed leaning on the table to breathe. Next to her on the bed was an Afghan she had apparently been working on.

“I feel so miserable,” she said, “I… can’t breathe.”

“I know what you’re going through,” I said as I mixed up a breathing treatment.

“NO YOU DON’T!” the patient said.

“Oh yes he does,” someone said from behind me. I turned and saw that it was Tes, a nurse who took care of me back when I was having bad asthma several years earlier. “He has asthma. He KNOWS what you are going through.”

Mrs. Flower looked up at me and managed half a smile, which disappeared in a heartbeat as she concentrated on her breathing. Yet she seemed to mellow at the thought there was a fellow chronic lunger in the room.

With the permission of the doctor, I gave her two breathing treatments. Suddenly, she was breathing normal again — well, normal for her anyway.

Mrs. Flower became one of my favorite all time patients. When she was feeling better — and even when she wasn’t –she’d always be working on an Afghan. When I entered the room she’d stop and take her treatment, and we’d talk.

There were nights I would talk to her for hours not just about COPD and asthma and breathing, but about other things as well. I eventually got to know many of her family members, and she even got to know mine through my descriptions and pictures, as I got to know about her past through her stories and pictures.

Through my 11 years as an RT, there have been many Mrs. Flowers’. Each time I get to know about their entire lives in a few short minutes while I’m helping them breathe better with a bronchodilator breathing treatment.

After she was in the hospital several days, I said, “Well, I’m going to be off the next few days. I’m sure you’ll be home before I get back. So, I hope the next time I see you is in a grocery store.”

She laughed and said, “Absolutely.”

But she came back. At first her return visits were infrequent, maybe once a year. She’d joke and say, “I’m just in for my yearly recharge.”

I think it was about her third visit that I found out she was still smoking, so I discussed with her — as a friend more so than an RT — how much I wanted her to never smoke again.

I explained to her that if she stopped smoking now she won’t be able to undo the damage to her lungs, but it won’t get any worse. She might even improve the quality of her life, and decrease her hospital stays.

She smiled cheek to cheek and promised me she would never smoke again.

Three weeks later she came back for another visit. I didn’t ask her if she was still smoking because I trusted what she told me before. And she went home after a few weeks with our same old good-bye lines.

But eventually she was visiting me more often, and then it got to the point that I said to her, “You might as well move in your dresser you’re here so often.”

She smiled. Even though she was getting sicker, she was still the same pleasant person to talk with, and she continued to work on her afghans.

She went home again. Two days later I finally saw her at a grocery store. Only she was not shopping. She was sitting in her van — smoking.

My heart sank. Of all the things I have seen as an RT, that one moment for me was perhaps among the most disappointing. Here I thought Mrs. Flower was making a gallant effort, and all along she kept right on smoking. No wonder her COPD kept getting worse.

It was kind of a defeatist feeling. I thought I have all this knowledge in my mind that I enjoy sharing, and for a long time after that I couldn’t get myself to share any of it. I thought, “What’s the point.”

Two days after I saw her in the parking lot she was a patient again. This time she was very sick.
She looked defeated. The disease was winning, and she knew it. She was having trouble breathing even while she lay there in her bed. Yet, she still smiled as I entered her room, and stopped whittling long enough to take her treatment and talk.

Out of respect for her, I never said a thing about seeing her smoke. I decided if anything she needs to have her dignity. And I remember when I was a kid trying to stop my grandpa from smoking, and he’d always say, “I’d rather die young doing something I love than to live a long miserable life not doing what I enjoy.”

I thought grandpa died young when he was 70. But he was making a list of things to do when he died, a sign to me that he went out happy.

I thought grandpa’s words rang true here. By smoking, Mrs. Flower was doing something she truly loved to do. I respected that. Yes she was destroying her lungs, but I understood. I didn’t like it, but I respected her.

“You know,” she said one day, “I hope your kids never smoke. It sounds like a cool idea when you are young and think you’re going to live forever, but it catches up to you eventually.”

“When you started smoking,” I reassured her, “The knowledge wasn’t out there. Now-a-days if a kid starts smoking, there is no excuse for it because the education is out there.”

About a year later, after several frequent visits, I learned from reading the paper that she had passed. It was sad, but so is life when you work in the hospital. Yet she no longer had to fight, and she passed the way she wanted: in her own home.

A few days later I was paged to the lobby. “There’s a man here to see you,” the front desk clerk said.

“Who would want to see me?” I thought as I set down the receiver.

In the lobby was Mr. Flower. He held in his hand an Afghan I watched Mrs. Flower make. He said, “This is for you. She finished it just before she passed away, and she wanted you to have it.”
Now I think of Mrs. Flower each and every time I snuggle up in that afghan.

Still, I wonder how many more lives she would have touched with her stories, or how many more afghans she would have made and given away as gifts if she had a few more years to live.

The ongoing drama of crying baby's and blowbys

I'm just curious here, but since most studies show that 90% of the aerosolized medicine is wasted when giving a blowby treatment, and a laminar flow is recommended for maximal impaction of the medicine to receptor sites in the lungs, how much of the medicine do you think a child is getting if he is wailing through the entire blowby treatment?

I bet it's less than 1%, although I'm not sure any studies have ever been done to determine this. Yet commonsense says that most of that medicine I just gave that 3 YO kid impacted outside that boy's body, and the rest never made it beyond is oral cavity.

And, sorry doc, but the treatment was pretty much useless. Although the doctor was convinced that it was my breathing treatment that cured that kid of his congested cough. Well, I've lost patience with doctors and nurses to explain again and again that crying baby's don't get the medicine, and blowby is pretty much useless.

I would give the treatment with a mask or mouthpiece to most kids who are compliant, but the blowby remains the only option for non compliant kids and babies. Now, personally, I don't think the treatment for congestion was indicated anyway, but I don't see any harm in trying. Still, he didn't get the medicine.

The irony of all this is neither the doctor nor the nurse considered any of this science. Nor the fact that my being in the room is merely causing that little boy serious anxiety, and better therapy would be for that kid to be left alone.

Although I'm not a well trained doctor, and I'm prone to be wrong from time to time, science is science, and science says blowbys and crying do not equal good impaction of aerosolized meds in the lungs.

Yet, from behind me, the nurse says, "It's okay that he's crying. He gets more of the medicine that way."

"Ahhhhhhh," I think. I say: nothing. I give up. I've already explained the science a million times. It never yet has sunk.

As soon as I stop the treatment the kid smiles at me, and says, "Thanks." Wow! That's all it took to make him better was for me to stop. Who would have thunk it? Oh, I did!

Yet, it often seems no doctor nor nurse ever seems to consider blowby and crying science as I finish the treatment. They usually simply ask this simple question: "Is he better?"

I say, "We'll have to wait and see, because I can't assess him at the moment because he don't like me much."

More common asthma questions

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: What is a generic replacement for Asmanex. Our medical insurance (Blue Cross/Blue Shield of Arkansas) will no longer cover the Asmanex Inhaler of which my wife uses on a daily basis. Without insurance it will cost about $127 which turns out to be the cheapest. Is there a generic alternative that can be covered by insurance.

My humble answer: That's unfortunate they will no longer cover this medicine, especially if it works well to control your wife's asthma.

Unfortunately for us asthmatics anyway, asmanex is covered under a patent that will not expire until June of 2009, at which time it will be possible for generics to be made.

Thankfully, though, there are other corticosteroid inhalers that are available for asthmatics that are available, such as Flovent. By working with your insurance company and your physician, you should (hopefully) be able to find a corticosteroid they will cover.

Question: Is there a generic for symbicort. Also, I would like to know if there are any side effects when taking foracort 200 inhaler. My 5 year old daughter has been prescribed Foracort for 2 months.

My humble answer: Foracort is the generic form of Symbicort, and therefore has the same side effects as Symbicort. The most common side effects of this medicine are the same as for Symbicort, and include, "Headache, nausea, nervousness, trouble sleeping, cough, hoarseness, or throat irritation."

Also, side effects of this medicine are rare if the medicine is used only as prescribed, and if you have your child rinse his mouth out really well after each use. For more information about this drug, click here.

Question: At what point do I go to the hospital instead of using my inhaler?

My humble answer: It's best to set aside a time where you work together with your doctor to create an asthma action plan to help you decide when to go to the ER. Many doctors (and RTs too) recommend asthmatics use a peak flow meter to help them decide when to use an inhaler and at what point to go to the ER. Likewise, if you find yourself using your rescue inhaler more than recommended, you should probably at least make a call. I explain this in more detail in this post.

Likewise, if your sitting around stressing about what to do, it's probably time to either call your doctor or go to the ER, as I describe in this post, "Having Asthma Symptoms: Here's 5 tips to help you decide what to do."

Question: f ur depressed can it make u have an asthma attack?

My humble answer: Depression cannot cause asthma, but it can trigger an attack. If your friend is having trouble with breathing the best thing for her to do is talk with her doctor. There are medicines available that can treat and prevent acute asthma symptoms.

Kathi MacNaughton, a fellow asthma expert at MyAsthmaCentral.com, provides some excellent tips for dealing with asthma/depression in her post, "Asthma and Mental Illness: Is There a Link?"

It is true that stress can lead to anxiety, stress and depression. Likewise, those illnesses can be asthma triggers as well. If you are having problems with any of these, contact your doctor immediately.

Likewise, know that you are not alone. If you read my asthma story, I've written about (or will) how I was depressed and anxious as a child. While I felt I was alone back then, I recently discovered there is a proven link between asthma and anxiety/depression.

Both asthma and the related anxiety/depression are both treatable.

If you have any further questions you can .

A guide: Which asthma meds are best for you?

Since I didn't have an asthma post published last week at MyAsthmaCentral.com, I thought I'd take this opportunity to share with you a post written by fellow asthma expert Kathi MacNaughton called, "Which Asthma Medication Is Best?"

I think she outlined better than I ever could which asthma medicines work best. I highly recommend any person recently diagnosed with asthma to read this post. It also might be beneficial for any long time asthmatic to read this for a nice refresher course, as perhaps there are better asthma meds available for you that what you are currently on.

The first line of defense, she writes, per the asthma guidelines (and I humbly agree) are inhaled corticosteroids to reduce the chronic underlying inflammation of the air passages in your lungs.

Common corticosteroids are as follows:

• Pulmicort (budesonide)
• Qvar (beclamethasone)
• Asmanex (mometasone)
• Flovent (fluticasone)

She writes: "There are also steroid pills. Being on long-term steroids in pill form can have a number of bothersome or even serious side effects. The good news, though, is that inhaled steroids have very few of the same side effects, because they are mostly limited to acting in your airways, where they are most needed.

"Unfortunately, inhaled steroids are not always successful in controlling asthma for every person. They do work great for most of us, but people with severe asthma may need to try something additional or something different altogether."

Other choices are:

1. Leukotriene modifiers: These medicines (Singulair and Accolate) block leukotrienes that are released when you are exposed to your allergens (asthma triggers) . Since leukotriences can cause bronchospasm, blocking them can help you control your asthma. This works well for some asthmatics.
2. Combination asthma inhalers: These include Advair and Symbicort. These contain both a corticosteroid to help manage underlying inflammation, and long acting bronchodilator to to keep your air passages relaxed. These are used "When Singulair or an inhaled steroid alone don't adequately control asthma symptoms."

Other choices:

1. Inhaled long acting bronchodilators: This would include medicines like Serevent and Foradil. Studies have found if asthmatics need long acting bronchodilators they should also be on an inhaled corticosteroid to control underlying inflammation. Using this medicine alone is no longer recommended by the FDA to control asthma.
2. Oral bronchodilators: This would include theophylline. This was once the cornerstone of asthma therapy, but due to side effects and better medicines (as noted above), this is no longer used except for in cases of severe persistent asthma where front line medicines are lacking in controlling asthma.
3. Oral steroids: These used to be used more often to treat chronic asthma, however due to side effects they are used less often today except for in cases of severe excacerbations, and usually only short term. A common oral steroid is prednisone.
4. Mast Cell Stabilizers: This would include Intal and Tilade. These were very common in the 1980s, and have very few side effects. But due to better asthma medicines listed above, these are less often used today.

So, she writes, which asthma medicine is best for you. "Unfortunately, the only really correct answer to this question is, 'It depends...' Every pharmaceutical company will try to convince you that their drug is best. And if you talk with other asthmatics, chances are they'll tell you whatever they take is best. But the truth is, we are each of us different, with slightly different things going on in our bodies.

"So, how you will react to a specific asthma medication is not entirely predictable. Asthma treatment is very much a case of trial and error. Your doctor will prescribe something for you and wait to see how well it works."

Well stated.

An unorthodox hospital experience for me

Most people, I've observed, hate hospitals. I wasn't one of them. I imagine that's because most of my hospital experiences were positive. Plus I knew when I couldn't breath going to the ER would give me my breath back.

There was one visit to the hospital when I was eleven -- four years before I was shipped to the asthma hospital -- that was not a pleasant experience at all. I had been up the night before overwhelmed by a feeling of tightness, wheezing, and continued worsening of my breathing. And in the morning the malaise hit.

Mom and I entered through the automatic emergency room doors, and the smell of hospital hit me. I inhaled -- half a breath painful breath -- and coughed, and coughed, and coughed. A feeling of sickness overwhelmed me, and I sat in the first chair I could find while mom approached the admitting desk. I could hear the voices of mom and some man talking, although I couldn't make out what they were saying. A chill overwhelmed me, and I crouched in the chair and rubbed my stomach to try to quell the nausea.

"Ohhhhhhhh!" squelched from me, followed by a tap on my back, "Rick!" It was mom. "Time to go." I'm sure the emergency room doctor will be able to fix both my problems! I jumped to my feet and slid my feet alongside mom, although my my now aching head faced the white tiled floor, and my hands cradled my stomach. And, as usual, my shoulders were sky high.

Mom opened a door, and I followed her into the ER waiting room. I sat in a chair to the left of the door and leaned up against the left arm; shoulders high; stomach cradled. I closed my eyes. I could hear mom talking, and then she sat to the left of me. My chest ached; my stomach ached.

"Can we go to the ER room now," I choked out.

"No," mom said. "The lady wants us to wait here. But it won't be long."

"I can't wait!"

"I know. They've never made us wait before." She leaned over me, rubbed my back, and said, "We'll wait a few minutes and have her go get a nurse."

"Oh, come on!" I wanted to say, but held it in. How in the world could I not look bad? Here I felt I was going to die, and that stupid lady won't let me see a doctor. Oh, come on!

I tried to braeth in. The air wouldn't go. I exhaled hard, and tried to force in a breath. It felt like I was inhaling pea soup. I sucked in...and in... and in.. the air came... slowly... about half way. I blew it out, and inhaled again... the pea soup. I shot up unintentionally bumping mom in the face. I sat up high, leaning on the arms of the chair to make more space in my lungs. The air felt thinner now, yet the nausea came back. "Ohhhhh!"

"You okay, honey." Mom's soothing voice.

"No!" A tear rushed down my cheek. I took in a breath... exhaled slowly and purposefully.

Mom hopped out of her chair and approached the window. She said something. The old lady behind the window said something. Mom sat back down. I tried to focus on the other people in the room. There were three in here. Why are they all furry? All furry men. All blurry.

The old lady behind the window -- she was blurry to me -- stood up. I'm coming! I'm coming! I thought. "Sue Smith," the lady called. "Oh, come on," I wailed. I didn't care that she heard me. Not to be rude, but it was my name she was supposed to call. I was the one dying here. That lady, that Sue Smith, she's fine. And she was. She hopped out of her chair, walked through the door oposit me, and then I could hear her laughing and joking behind the counter with one of the ladies back there.

"This is ridiculous!" I heard mom say.

I slouched, rubbed my stomach. The nausea eased. The air got thck as pea soup. Is this what claustrophobia feels like? Air came in slow again, but since my stomach felt better I tolerated it. I could hear the TV. I could hear soft voices in the room. I could feel mom's soft touch on my back.

"Please back off, mom!" I certainly didn't want to slam her in the face again. I sat up. I held my shoulders high using the arms of the chair. I stood. Air came spashing into my lungs like water when you dive into a huge wave in lake Michigan. A cool tingling sensation rushed through my body as it did so. I concentrated. Sucked. Sucked. It was almost all the way in. My lungs were almost full. My shoulders jerked visiously. Finally! Air. All the way in my lungs. Ahhhh!

I exhaled. Inhaled. It was pea soup again. Once the air was half way in, it felt as though there was a wall in my lungs preventing them from expanding further. I sucked in. It came, although very sluggishly... very slowly... slowly. Then it hit a wall again. Exhaled. Inhaled....

A new idea occured to me. The air was not pea soup, but a thick milk shake from McDonalds. Sucking in air was like sucking in the freshly made, thick milkshake through a thin straw. You could suck it up the straw a little bit, but then it would get stuck. That's what it felt like to breath in when a bad asthma attack struck. Like it was doing now. The air was a milkshake, and my air passages were the straw.

"Do you want me to read you a book," mom said. I knew she wanted to do more, yet she was... helpless. I was helpless unless I got into an ER room they wouldn't let me get into, and mom was helpless to do anything about it because of that mean lady behind the window

I nausea seemed to have eased for the moment, so I stayed seated high. I took this opportunity to scope the room. It was a normal waiting room with chairs all the way around except for to my right and behind me where there was the door we came in through, and straight across the room another door that lead to the core of the hospital. Besides me and mom, all the people in the room were three old people that continuously rotated in and out.

There was a TV on the wall across from me, and it was set to CBS and the "Price is Right"
was on, with the familiar voice of Bob Barker a welcome sound. Filling most of the wall between the doors window and a counter where a couple elderly ladies were click-clacking away on their typewriters.

, and occasionally they would call a name of one of the people in waiting room and that person would disappear through the door across from me, have a seat across from one of the old ladies behind the window. The soft ru

"Jane Johnson," the old, rickety female voice from behind the window shouted.

My stomach churned. "Oh come on!" I groaned to mom, not caring if anyone else in the room heard me. "I don't feel good."

"I know," mom said, her voice soothing as usual. "They've never made you wait like this before. This is ridiculous!"

"I have to throw up," I whispered to mom.

Mom got up and rushed to the window. The gray haired lady who kept calling names -- although not mine -- poked her head up. Mom asked for the closest bathroom. The lady said, "He's going to have to wait."

"He can't wait," mom insisted. My stomach churned, my chest ached. I was now wheezing audibly, and I made no effort to stop it. The more I could make myself wheeze, perhaps...

Finally mom left the counter and sat back down next to me.

"Mom! I need to go right now!"

Mom walked back to the counter. I heard a voice, but the lightheartedness had the best of me and I could not make out anything. Your taking forever, I thought to yell, although the voice in the niche mom created in my head was telling me to be nice.

Finally mom grabbed me by the arm and rushed me through the door the nurse kept poking her head through, and I completed that miserable job, followed by five minutes dry heaving.

Back in the waiting room mom pleaded with the clerk to get a nurse, "He needs to get in."

All my life it seemed mom always got what she wanted (at least from dad anyway). And when the lady said, "I'll go talk to the nurse," I felt a modicum of joy.

My stomach continued to toss and turn as I stood, waiting for the nurse to come. She finally came through the door in her familiar white nurses cap and gown: "Joe Schmidt!" she chimed.

Do they not even care about me! "Mom!"

A short, pudgy man with a long gray beard who was seated at the far end of the room stood, and waddled to the nurse in the doorway, who directed the man through the door, which slammed behind her.

Mom was not happy by this event. She once again approached the counter and a discussion ensued. Mom waited as the lady disappeared. I stood because I just knew that finally I would be seen. I listened as the crowd cheered on TV as one of the contestants on the Price is Right checked out her new car, and the program ended. Have I been here that long?

I closed my eyes. The music from "As the World Turns" filled the room, followed by Mr. Whipple's voice as he tried to convince another lady, "Don't squeeze the Charmine!" I hoped I would just pass out, and I just might have if I could get in half a breath.

I heard the aura of soap opera voices fill the room, the click of a door handle, then, "Mr. Thomas Overly!" It was the nurse in the window. An ancient, balding man who sat next to me slumbered out of his chair and approached the window. He answered a few questions and sat back down. I didn't want to sit by him anymore, so I got up and sat on the other side of the room. This turned out to be a bad decision as an elderly lady tumbled through the door next to where I was sitting before and sat in the chair I vacated. And, worse of all, I realized I couldn't see the TV from where I was. NOT that there was anything useful on, but it WAS at least a modicum of entertainment.

The raspy voice from the window chimed in again, "Mr. Green."

Oh, come on! "I can't sit here anymore, mom," I whined.

Another old guy got up, as he slowly... slowly... slowly made his way by me I got a whiff of the musty home he lived in, and my lungs closed up. I tried to inhale... GASP!"

Used to this, I concentrated on my breathing all the more, and withing a few minutes I was back to being able to take half a noisy breath again. The nurses obviously didn't care. I was feeling worse that I ever had before -- both nauseous and not breathing -- and they were making me wait. What awful people.

Mom got up to talk with the lady in the window again, and about 20 minutes later -- or so it seemed, and several trips to the bathroom, the nurse came in and yelled: "Rick Frea!"

Moments later I was sitting on an ER cot. I remember staring at the clock, frogged up on the bed, as I was given a breathing treatment, followed by a shot in the arm, followed by the euphoria of being able to take in a deep breath for the first time in hours, followed by....

"I have to throw up again!" I groaned, and as I sat there dry heaving an emmissis basin was set on my lap. I closed my eyes. Someone said, "Lie down." I did. I closed my eyes. The next thing I remember was staring at the ceiling as I was being wheeled down the hall. The ceiling was blurry. The next thing I remember was waking up in a hospital bed, and I zonked out again.

I remember waking up 3 or 4 times the rest of that day because THEY had to move me to a new room. Each time I remember thinking, "I'm comfortable, just let me be." I would close my eyes hoping it was just talk, but soon I was staring at the blurry ceiling on the way to a new room. Then I'd get to my new bed, crumple up into a ball and fall back to sleep.

The next day I was feeling better and watching the TV dad paid for. Back then you had to pay to watch TV in the hospital. I remember being in the hospital the year before and watching as another kid had a TV wheeled next to his bed while I had to lie there and stare at the ceiling. This time dad didn't hesitate to flip the bill. If I remember right, it was $5 a day, "a lot of money," dad said back then. I appreciated it very much.

I was watching an old western when I heard a thump. I turned and saw a couple nurses trying to stuff a bed through the door. Someone pulled the curtain that blocked my view of the door, and the other bed. I heard several more thumps, and then the curtain was pulled back. In the bed next to me was an old man who stared at the ceiling.

After eating breakfast (I learned if you salt the toast it actually tastes half way decent), I found an old, black and white TV show called "Leave it to Beaver." Then I smelled something that was not awful hospital food. "What in the world is that?"

"Hey, Rick! How's it going. Feeling better today?" It was mom. She was carrying a bag.

"Yeah," I said. "I feel better, but my arm is burning. I told the nurse to take it out, but she refused."

"If she took it out you'd have to get another one." Mom emptied her bag on my bedside stand. "Here's a crossword and a comic book for you." If she could smell that smell she gave no indication.

"I don't care. I'd rather get poked again than have to deal with the pain."

I pushed my call button. A voice quickly sounded over my bed, "Do you need something?"

"Yes," I said, "I need you to come look at my IV. It hurts."

"I already looked at it. It's fine."

"Please, it still hurts. Can you look at it again."

"Be right there." A mechanical ting indicated she was done talking.

A short lady with dark hair and slanted eyes came in, looked at my IV, and said, "It's fine." She left, and mom sat down in a chair next to my bed.

"You can turn on your soap operas if you want," I said. I handed her the nurses call button, which had a TV channel turner on it. Mom flipped through the channels.

The oriental nurse came back in with a wet washcloth. "Here," she said, placing the cold cloth over the site, "perhaps this will help." She left.

Hours past. A respiratory therapist came in to give me a breathing treatment, and mom said she had to get home to pick up my brothers from school and pick up little Tony who she left at grandma's house. "I'll come back tonight. I think I'll bring Tony to see you."

Tony was my little brother. A few years ago I had to quit playing baseball because of my asthma (a story for another day) and instead of playing with the other kids my age I spend most of my time teaching Tony to play ball. Since I couldn't ever play for the Tigers, maybe Tony could.

"I'd like that," I said.

After the treatment I was alone... alone except for that smell... alone except for the burning in my arm...

I pushed the call button several times that day. I flipped through the channels, hoping to find something entertaining, but there was nothing on. I played with the crossword book, but that didn't entertain me for long either. The comic wasn't really a comic at all, but a "Mad" magazine. There was a funny article about "Arnold" on "Different Strokes I read, but then I cast the magazine aside.

The back of my bed was high, and I made the head go down, back up, down, back up, down, back up. Finally the sheets became so taut they crumpled up behind my back.

That stench was overwhelming now. And so was the pain. I cringed on the side of the bed. I pushed my call button. That same oriental nurse came in again, tapped the side (which made the burning worse) and said it was okay. She left without as much as a word.

I looked at my wound. White hospital tape secured the needle in my skin, and the skin around it was red, swollen, and sore to the touch. The clear plastic line of fluid lead up to the IV machine, and it was making a soft mechanical CLIP... CLIP... CLIP... CLIP... CLIP... as the fluid drip, drip, dripped into my veins.

I loosened some of the tape. It was quite the job as it seemed to be melted to my body, but the release of the tension of the tape seemed to feel good. I peeled a little more. The wet, gooey, sticky paste there seemed to be one with my skin. I peeled a little more. Now I could see where the needle pierced my skin. I pulled on it a little. Then a thought occurred to me, "Why don't I pull it out."

I looked at the door. What are the odds that cranky oriental nurse will come back here. What's her name anyway. I don't think she even introduced herself. I cranked my head backward and nearly upside down and looked up at the chalk board above my bed where the nurses write there names. What kind of name is that? "Do..u...nguuuuu.???" I can't even read her name it's so... odd.

What's going to happen if I do it? What's the worse that could happen, she'd have to put in a new one. That's what would happen. She will have to be inconvenienced. She will be irritated. She will be MAD. She will be...?? What? Mad as I am now. Mad because she left this IV thing in all day. Mad because my arm is numb and tingly and sore and...

It was out. I tapped the tip of the needle with my finger tip. It was really a needle in there. Ah, but it felt so good. Now all I had to do was get the tape off. Actually, peeling the tape off hurt more than taking the needle out. The needle going out felt good. The tape tugged on my arm hairs, and that... HURT. "OUCH!" I cried as I did it in one pull.

Now what! Now I had to get rid of the evidence. But why? It's not like she's not going to come in and check my arm? I set the evidence on the bedside stand. The IV started beeping. I pushed the call button and eagerly waited to see the vexation on that miserable nurses face.

"What is this!" she said. "How did this come out?"

"I took it out." Please don't scold me! "I took it out because it burned so bad."

"It was fine. Now I have to put a new one in." I knew it. She's mad because she has to be inconvenienced. She didn't care about me at all.

She grumbled and completed the job. Getting poked again was no big deal: I had been poked a million times already in my short life. I didn't care at all.

Dinner came. It was a stake, and I took a couple bites and cast it aside. Then mom came into the room. "Boy am I happy to see you," I said.

Dad came in. He walked by my bed, looked at the ancient room mate of mine, back at me, and whispered, "Boy, you smell like crap."

"Dad, it's not me. It's him." I pointed.

"I know," dad said, smiling. He left the room.

Mom set down beside my bed in the same chair she sat in earlier.

"Where's Tony?" I said.

"Your grandma volunteered to watch your brothers," she said.

"I thought Tony was coming with you?"

"He wanted to stay at grandmas. How about if I read you a story."

"I like that idea." Mom opened her purse and took out a Reader's Digest. She flipped through the pages until she found something. She started reading. Her words were soothing. I loved hearing mom read. It reminded me of the many doctor's office visits, where she read to me this story about a little dog over and over again each visit to Dr. Gunderson's office in the waiting room. I paid attention to the stories back then, but now I had other things on my mind. Or, to state it another way, my mind was mush.

Dad came back in. He had a smile on. "Guess what, Rick?" he chimed. "You are going to be going to a new room. I told the nurses that they had three choices: either you went to a new room, or that guy went."

"Um, you said three choices."

"Well, the other choice is you get to enjoy that smell for another few days. YUMMY!"

I laughed.