She said it a little too loud

Inside the room, the patient says to me as I'm drawing her ABG because her spo2 is only 78% on a 100% non-rebreather, "I'm really stressed right now."

As I'm walking out of the room to tell the RN the patient might benefit from a Xanax, I hear the RN saying into the phone receiver loud enough for the patient to hear, "Your patient in ICU room D appears to be taking a dump on me."

I look back at the patient and wondered if her heart just flipped as she heard that, and hoped she didn't hear it.

Regardless, we are all guilty of talking too loud at times. And while this RN is perhaps one of the best I've ever worked with, this is proof that even she is human after all.

RT Cave Rule #38: When we are relaying private information about the patient, we must remember to keep our voices down.

Can Albuterol show up on breathalizer? Does Asthma go ever go away?

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: Is there a connection between asthma and anemia?

My humble answer: As far as I know there is no documented link between asthma and anemia.

Question: Can Albuterol show up on a Breathalyzer?

My humble answer: According to materials I have read, Albuterol can register false positives on alcohol Breathalyzer tests. Some of the reasonings behind how this occurs is complicated to understand, but this post here explains it pretty well. If you are using an Albuterol inhaler, and you get pulled over, you should tell the officer you just used an asthma inhaler and tell him that you request a blood alcohol test. To read something a bit more complicated, you can read this court ruling.

Question: Does Asthma go away for both child stage and adult?

My humble answer:
It used to be believed that asthma went away when one became an adult, but we now know this is a fallacy. Even while it may appear your asthma is gone, it is still there in hiding.

There are many theories why asthma may appear to go away with time. One is as an asthmatic grows older his air passages become larger and are better capable of dealing with asthma triggers. Another is he learns to avoid his asthma triggers.

Asthma is a strange disease in that you can go week, months, even years without having asthma symptoms. But you must never forget that you still have asthma, and that you should continue to see your doctor at least once a year to monitor your asthma so he can adjust your medicine accordingly (if you still have to take it at all).

Question: does singulair have steroids in it and could it cause weight gain?

My humble answer: I have never heard of Singulair causing weight gain. For a complete list of possible side effects of this medicine check out this link.

If you have any further questions email me, or Visit MyAsthmaCentral.com's Q&A section.

No excuses, asthmatics! Run!!!!

You'll hear this again and again from people living well with a chronic lung disease, and rightly so: no matter how bad your condition is, you need to stay active. It doesn't matter if it's a simple walk across the room, you have to do it.

In my case, fortunately, I've been able to overcome the Hardluck tag and now I am able to exercise like any other lay person. Sure we chronic lungers have to pace ourselves, but exercise is the best way to maintain a solid mind and body.

Asthma is not a disease that should force anyone to a life of sitting on the couch. I've written about a severe asthmatic and COPDers who participated in the Boston Marathon, and I've read about asthmatics participating in the Olympics.

Asthma -- chronic lungs -- should never be an excuse. If you want to do it, do it.

Personally, I love to run. I love the feeling of torturing myself on the bike path near my home while I complete my 20 minutes of interval training. Best of all, I love the feeling of accomplishment when I'm finished.

I know there are many healthy people who come up with excuses not to do this or not to do that, and it's these same folks who complain when they are all of a sudden 30 pounds overweight. If an asthmatic has this same attitude and lets his body get out of whack, the asthma beast may strike. Out of shape-ness creates a breeding ground for bad asthma.

My 10YO son runs with me, and on occasion a friend runs with me too. I can't keep pace with either one of them. Yet, as my friend told my son one day, "You should just be impressed that your asthmatic dad is even doing this."

I don't really see it that way. As any other person with chronic lungs may attest to, we don't exercise to impress other people, we do it because we have to in order to control our asthma and to live a normal life.

Yes, it is possible to live a normal life with asthma. But, as the Bible says on one of it's pages, "The Lord Helps those who help themselves." So, if you're asthma is as controlled as it gets for you, get up and move. That's my advice for you.

Even We Asthmatics Can Run
by Rick Frea Monday, September 21, 2009

At the beginning of every year we write about how important it is that asthmatics exercise. In the words of a pamphlet I have from my stay at National Jewish Health dated 1982: "Exercise is good for your heart and your lungs. Every asthmatic should exercise regularly, no matter how bad your asthma is."

That was wisdom that still holds true to this day. One of the cheapest and best ways for you to gain control of your asthma, and feel better about yourself in the process, is to exercise. Yet, as most of us know from our New Year's Resolutions, that's easier said than done.

Now, even though I still use my rescue inhaler (better known as a bronchodilator) two to three times each day, my asthma is really under great control. Under most circumstances, I am fully capable of maintining a normal quality of life. I think I need my inhaler more often than your typical asthmatic because I have the infamous airway remodeling, which is referred to as the third component of asthma (after airway constriction and inflammation).

I think this resulted from my asthma being poorly controlled when I was a child (I was a hardluck asthmatic), but it was more likely due to old asthma wisdom back in the 1970s. My asthma is actually so good now that I even run without complications. I imagine I'm able to do this because I'm now a gallant asthmatic who takes all his preventative medicines as prescribed and avoids his asthma triggers.

Nothing is perfect here, but close. I would say my asthma is also better because I'm an adult now and my lungs are bigger, but I don't believe that's true considering I really didn't gain control of my asthma until just a few years ago. So while age may make some asthma cases appear to be in remission, that didn't happen in my case.

That said, my wife and I have been working at losing weight and getting in better shape, and we've been doing the Body-for-Life program. We've done it at least six times now, and it works like a charm, allowing me to lose as much as 30 to 40 pounds in less than 12 weeks each time. Unfortunately, life happens and weight comes back.

Now it's time to get back on the wagon. I've been running (well, actually my son calls it a wog) around a track at the football field, or on the local trails at a city park, or down the streets of town with no complications other than tired feet.

A few weeks ago, however, I decided it was time to move up to the next level. So instead of running for distance, I decided it was time to do interval training. This is where you start out slow to warm up for two minutes, and then you increase your intensity each of the next four until you reach an intensity of 9 out of 10.

Then you rest a minute, and you do the cycle again. All in all, after twenty minutes you are done, but you are at maximum intensity (a ten) and to the point you can do no more.

So I grabbed my son 10-year-old son, and off to the park I "wogged" with him alongside me.
Perhaps I was feeling overconfident (I'm human after all), and as I was completing the final minute of that first cycle I decided to sprint fast as I could. My chest became itchy and started to burn like it used to when I was a hardluck asthmatic and an attack was imminent. I turned to my son and told him my symptoms.

"You better quit," he said. "I'm not going to use this as an excuse," I said. "Good thing I know CPR," he said, smiling. "Nope," I said, "I'm not a quitter." But I'm smart enough to know I needed to rest, I thought. After sprinting for that long miserable minute, it was time to walk slow for a minute. To allow myself time to catch my breath, I allowed myself a two minute walk instead of one. Miraculously, the chest discomfort let up and my breathing was fine the rest of the way (something that never would have happened a few years back).

Since then I've continued to do this interval training. I still have to pace myself of course, but now I find I can do the entire workout without my asthma even showing its ugly face.

This brings us to a good asthma rule. I'll call it asthma rule #1: You see, it's all about pacing yourself. Even us asthmatics can run like the best of them, all we have to do is pace ourselves, and make sure we take our preventative medicines as prescribed, which you and I do.

However, it's also important to know our early warning signs, because that's exactly what that burning, itchy chest feeling was. It was telling me I had to slow down and pace myself. It was telling me if I kept sprinting as hard as I was I would have an even worse asthma attack. So I rested. The attack subsided enough for me to finish the work out. I never sprinted again, but I still did finished the workout. Whenever I accomplish a feat like this I can't help but feel an aura of accomplishment. I'm a gallant asthmatic, and I can run. I can imagine Breathin' Stephen felt something like this as he crossed the finish line at the Boston Marathon.

I confess, as soon as I got home I took two puffs of my rescue inhaler (with a space of course), and then my son grabbed me by the arm and said, "Come on dad, we need to go to the basement to do our sit-ups and push-ups."

I highly recommend all asthmatics, no matter how bad your asthma is, that you exercise. It not only makes you feel better, it makes your lungs and heart stronger. And, as you pace yourself, perhaps some day you can step it up a notch as I just did.

Appreciate!

It's good to take some time off to appreciate life. It's good to take time to squeeze your kids hard and appreciate them regardless of the nonsensical talk, talk, talk. It's good to enjoy the attention grabbing of your kids because sooner than you realize they will be all-growed-up. It's time to enjoy the company of your wife after your children are asleep, either sitting in front of the boob tube or on the front porch with a glass of wine and a beer. And even while you might not think you have the perfect job, it's great to appreciate the fact that you have a job at all. Even while politics at work and on a national basis seem to be quite frustrating, it's important to appreciate we have what we have and we were born where we were born. It's good to take a deep breath, relax, and appreciate what God has given us. It's good to take some time off to appreciate life, to feel the pleasant breeze blowing in from the West, to actually hear the wind rustling through the Oak trees, to watch the sun set, and to observe as the dew sets on the grass in the dusk. It's good to take some time off to appreciate life, even if it's a span of 30 minutes before you go to work.

RT Care Week Coming October 25-31, 2009

The last week of October is Respiratory Care Week. Not that it's a big deal, but there has only been one year since I've been an RT that this event has been celebrated, and that was a year we did it ourselves.

Nursing week is celebrated every year. The nurses have never planned the event, as this is done by the admins. Sometimes the festivities are simple, and sometimes there are games and freebies handed out.

With all due respect, however, sometimes the RN Week celebrities include us RTs.

It's not what is done that matters. It's that something IS done. It's showing respect for the profession. It's giving acknowledgement. It's saying, "We know you work hard. We respect you."

Being on the backseat of patient care, we RTs usually work in the background, we provide advice to RNs, work as part of the patient care team to the benefit of the patient, and usually take no credit. We are fine by this. It's how we work.

Yet when we RTs get a basket of goodies from a patient, or even a simple card, we appreciate it perhaps even more so than other professions who get special attention and appreciation on a regular basis.

RT Care week for 2009 will be October 25-31. Whether or not your hospital will be celebrating this occasion, we will here at the RT Cave.

New Scrubbin-family Black Box Warning

LABEL WARNING ADDED FOR ASTHMA DRUGS:

THE FDA HAS REQUESTED that a psychiatric warning be added to the labels of the cure all medicine Scrubbin-Bubblin and Scrubbin-Bubblinex which was originally created to treat bronchospasm for asthmatics and COPD patients. But, since this medicine is now used to treat all annoying lung sounds and all that wheezes are now considered to be treated with bronchodilator, changes in mood and behavior have been reported in some respiratory therapists giving those drugs, including humor and annoying dry humor, agitation, aggression, anxiety, dream abnormalities (dreaming of choking stupid doctors), hallucinations, depression, insomnia, irritability, restlessness, and tremors. The Scrubblin family line of medicines have receptors that not only dilate bronchial muscles, but have the ability by magic osmosis process to travel to various parts of the body and cure the ailment of choice. It also has the ability to cross the blood brain barrier to ease patient suffering. It also has the ability to emit its soothing effects on those family members and nurses taking care of the patient. The FDA said its recommendation followed a review of neuropsychiatry events that included post-marketing reports and all available clinical trial data.

US Food and Drug Administration. Updated Information on Scrubblin family meds: Scrubbin-Bubblin is marketed with a special scrubbing bubble formula that suds up in the lungs and cleanses the lungs of all ailments. Scrubblin-Bubblinex is the same with twice the sudding action. FDA Web site. http://www.fda.gov/Drugs/drug Safety/PostmarketDrugSafetyInformationforPatients andProvider/DrugSafetyInformationHealthcareProfessionals/usm165489RTHUMOR.

your rt queries: COPD, Asthma & Ventilators

Every week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

do you think respiratory therapists make good money?: Quite frankly, I think the answer to that depends on location. I think the highest paid RTs are in Arizona and Hawaii, but then again the cost of living in those areas are the highest too. In Grand Rapids, MI, the wage for RTs is about $5 more an hour than here in Shoreline, but you must also consider the cost of living is greater there too. So, in general, I think the wage of RTs is acceptable, but -- to be honest -- I really don't make enough money so I can tell my wife she doesn't need to work. The RT wage is okay, but nothing to gloat about. The answer, I would suspect, also depends on what your goals are in life. If you want to live in a condo and have three boats and six cars, then this isn't the career for you. Yet, if your goal is to live a modest life and be happy raising your family, or if you're strapped for money and need a guaranteed job that is recession proof, then the profession of RT is right for you.

ABG neonate values:

flovent strengthens lungs: Yes it does. It makes your lungs stronger, it helps control inflammation, and it creates more beta 2 receptor sites for beta adrenergic medicines like Albuterol to land on and ultimately helps them work better too.

what causes restrictive airway: That's a great question that has many scientists perplexed. I discussed one theory in my post: The Hygiene Hypothesis: Does Cleanliness Cause Asthma?

low hospital census: Is this true or what? Where I work the census is so low half the hospital is closed and layoffs are abounding. We RTs have been safe so far, although many of us have been forced to take many no work days (except for us night shift RTs). I think the reason for the low census here anyway is because few are electing to have elective procedures.

pulmonary toilet chf: Pulmonary toilet is a term to describe all the techniques used to help COPD, Cistic Fibrosis, pneumonia or other patients with thick secretions loosen, bring up, and expectorate those secretions. It is not a procedure that will benefit CHF patients. In fact, I believe it is contraindicated for CHF patients, especially if they are in pulmonary edema.

spiriva and symbicort combination therapy for copd: That's a good combination. The symbicort treats the chronic inflammation and prevents bronchospasm, and the spiriva also prevents bronchospasm but via a different route. Symbicort is proven to improve lung function, and Spiriva is also proven to improve lung function. Both are highly recommended, and they also work well when taken together. Likewise, they are both proven safe so long as you rinse after each use.

too much heat bad for asthma?: Heat does not trigger asthma, but humidity does.

Symbicort versus Advair: They are both the same type of medicine. Both have a long acting bronchodilator and inhaled steroid. Both are highly recommended as great ways to control and prevent asthma. The only real difference is the bronchodilator in Symbicort works a bit faster, and Advair is a dry powdered discus and Symbicort is an inhaler. Which one is best for you is basically a personal preference of yours and your doctors.

what happens when you stop the ventilator?: That's kind of a vague question, because the answer depends on the patient. If a patient who is not breathing is taken off the vent, he will most likely die. However, most patients are placed on a ventilator short term while their lungs (or heart) heal, or during surgery. Once a patient's lungs are healed, or wakes up from surgery and starts to breath on his own, the ventilator can be removed without complications.

what should a respiratory therapist do in a case where a patient tells you she wants you to turn off the ventilator and let her die: Talk to the nurse and the doctor. An RT must never discontinue a ventilator without a doctor's order.

respiratory therapy basics for the layman: Check out the link to the left, or click here.

how do dr.s listen to the lungs: Hopefully they use a stethescope.

can patients with copd and chf expect higher co2 levels when given morphine: Morphine is a medicine used to relax patient's in respiratory distress, and it is also a mild bronchodilator. It can slow the respiratory rate down, but it should not have an effect on CO2 if the dose is appropriate for the patient. It can also help lower blood pressure, especially if it is caused by anxiety due to respiratory distress.

how to give ippb via trach tube: In this case, the IPPB treatments works similar to a ventilator or BiPAP. You use an adaptor to hook up the machine to the patient, and then you adjust the settings and instruct the patient as appropriate. Note: This RT does not endorse the BiPAP. It is a worn out machine that works only to overinflate good alveoli. Cough and deep breathing, incentive spirometry, and PEP or Flutter valves are much more effective ways to recruit alveoli and promote airway clearance.

If you disagree or agree with my opinion feel free to leave a comment below, as we are all entitled to an opinion. If you have further comments or questions, feel free to write it below or email me.

Are capillary blood gases coming back?

When I started working as an RRT I was instructed on the correct method of doing a capillary blood gas (cbg) on a neonate. When I was told I had to cut the foot with a blade and drip blood into a tube I cringed, "I don't' want to do that."

For a couple years thereafter I gulped every time my pager went off that I had to go to OB for a bad baby. Just the thought that I might have to do one of those CBG things made my cringe.

After I had been here five years it occur ed to me the pediatricians who work here had never ordered a CBG. Yippy! I never had to do one of those dreaded things. Then one day I noticed that the CBG kids were gone too. It was clear I would never have to do one.

A few days ago, however, I was talking with a pediatrician from Spectrum Health in Grand Rapids, Michigan, and he said to me, "Do you guys to capillary blood gases where you work?"

"No!" I said, "and thankfully so."

"Do you even have kits anymore?"

"No. The pediatricians must have realized those things are pretty much useless."

"Well," he said, "the reason I asked is because we do CBGs now at Butts. Too many studies show that umbilical lines cause to many infections, so we try to stay away from them wherever possible."

Oh, I thought. So you're not on my side. "Oh! So you're recommending that we do ABGs?"

"Yes. I know most hospitals got rid of them, but now we've pretty much decided that a venous pH, along with a sat monitor, can give you a pretty decent estimate of what is going on with the baby."

Actually that does make sense to me. I've debated with doctors in our ER for years that a venous pH is not much different from an arterial. And we all try to convince doctors that a sat is all that is needed to confirm hypoxia.

"Do you guys have the capacity to do them," he asked, "I mean on your ABG machine?"

"Yes. I think we do."

He said, "The procedure is much better than it used to be. All we do now is prick them they same way you prick someone when you are going to check their sugar. It's not as bad as it used to be."

"Well that shouldn't be so bad then," I said. "And since we send all our bad babies to you guys, all our protocols are based on your protocols anyway. So, if you recommend we do CBGs, I bet we'll probably do CBGs"

"Good deal," he said.

So, will CBG kits find their way back to hospitals? Do you guys do CBGs where you work? Does anyone have any research on the value of CBGS, or studies that show UV lines cause too many infections to make CBGs worthwhile?

Weekly Asthma FAQ

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: My child was diagnosed with adhd and mild autism, is there a link between that and asthma. Likewise, my son gets unruly when I give him breathing treatments, what can be done about this?

My humble answer:

I can think of no link between asthma and adhd or autism. However, as a respiratory therapist, I do give lots of breathing treatments to kids, and I can tell you first hand that it is not uncommon for kids to be unruly during treatments -- in fact, it is quite common. It can sometimes be a challenge to get them to take their treatments.

When your child is on treatments, how often does he take them? I ask this because one side effect of bronchodilators is they can make kids hyper active. I see this quite a bit in the hospital. In fact, I often joke that you know a treatment is working when the kids starts running laps around the bed.

What bronchodilator do you give your son? If your doctor prescribed Albuterol, you might want to discuss your doctor prescribing Xopenex, which some studies show has fewer side effects (although I often question this finding). The only other option I can think of is to limit the # of treatments you give to only when he is short of breath, as opposed to giving them every four hours regardless.

Keep in mind this is my opinion and personal observation. Always, the best person to talk with about your concerns is your child's physician.

Question: What causes me to have asthma?

My humable answer:
No one really knows why people get asthma. However, it appears scientists are getting closer and closer to figuring this out, as I wrote in a recent post, "The Hygiene Hypothesis: Does Cleanliness Cause Asthma?"

Or are you refering to why people get asthma attacks. Usually an asthma attack occurs when an asthmatic is exposed to one of his (or her) asthma triggers. Asthma triggers are things (like dust mites, strong smells, etc.) that don't bother people with normal lungs, but will irritate the asthmatic lung, thus causing your air passages to become inflammed and to close up making it hard to get air out of your lungs.

So, in a way, asthma is your body attacking itself. What makes your body decide to attack itself? Scientists are still to this day working to figure this out, although they seem to be coming closer and closer each day.

To determine what your personal asthma triggers are you will need to be vigilant and communicate with your physician. Your physician may also prescribe asthma medicines to PREVENT asthma attacks from occuring.

Question: Will the weather effect my asthma?

My humble answer: Great question. The answer is yes. Both high and low humidity can effect your asthma as I wrote about in a recent post, "High and low humidity not good for asthma."

Cold air can also be an asthma trigger, as I also wrote about in a recent post, "Gallant Asthmatics Know and Know How To Avoid Their Asthma Triggers."

This issue was also addressed in this post. I also recommend reading this Q&A.

If after checking out these links you continue to have questions, please feel free to

Question: Will I always have to use asthma medicines?

My humble answer: Our own Dr. James Thompson wrote a post on this recently called, "When Can I Stop My Asthma Medication?"

Question: Will my asthma medicines become habit forming?

My humble answer: If you're referring to controller asthma medicine, the answer is "hopefully." You want to make sure you take all the medicine exactly as prescribed, especially if you are feeling good. If it gets to be a habit to take your medicine all the better -- that's a great thing actually.

Or did you mean addicting. Can you become addicted to asthma medicines? I have never heard of anyone becoming addicted to asthma medicines. However, for some people with severe asthma, it may seem they are addicted to their rescue inhaler as they use it more frequently than the average asthmatic. But I don't think you can become addicted to any asthma medicine.

Question: Can stress bring on an asthma attack?

My humble answer: Believe it or not, it used ot be believed that stress and anxiety caused asthma, or that asthma is all in your head (as you can read about in this old book). However, that old theory has since been disproven. However, while scientists now know your asthma is not all in your head, they have proven that anxiety and stress can "trigger" an asthma attack. You can read an excellent post about stress and asthma by clicking here.

If you have any further questions you can.

Is your asthma controlled? Here's how to tell

One of the neat advancements in asthma wisdom is that this is a disease that can easily be controlled -- for most of us -- if we use our smarts and take our prescriptions as prescribed and see our asthma doctors on a regular basis.

That said: what is asthma control? That is the topic I delved into in this weeks post on my asthma blog at MyAsthmaCentral.com.

How To Tell If Your Asthma Is Controlled
by Rick Frea (From MyAsthmaCentral.com, Friday, September 04, 2009)

It's easy to think your asthma is controlled when it's not. We asthmatics like to forget we have asthma and go our merry way with our lives. It often gets to the point when we take our meds by habit, without even thinking about what we're doing. It's normal.

This is a worthy thing to think about from time to time, and to discuss with your physician, especially as newer asthma wisdom is learned, and better and safer medicines are invented that can help you gain better control of your asthma.

Is your asthma controlled? The answer is: It depends. For most asthmatics, needing your bronchodilator inhaler (often called a "rescue inhaler") no more than twice a week is considered controlled. However, some severe asthmatics still need to use their rescue inhalers a few times throughout the course of a day.

However, if you don't pay attention to your asthma, you cannot determine how well controlled it is. Likewise, if you don't admit your asthma is not well controlled, you will not gain control of it, and this may come back to cause you greater asthma problems down the road.

I'll use myself as an example of this. There was one time in my life where I thought my asthma was well controlled and it wasn't. In fact, I had been educated when I was a kid how to maintain good control of my asthma, and yet I somehow let this wisdom slip from my conscious memory -- for a while anyway. I went years without seeing my asthma doctor.

I was winded throughout the course of the day, and used my rescue inhaler at will. A friend approached me and told me I needed to see a doctor, and I refused. I said, "My asthma is well controlled." Like most people in denial, I didn't realize that I was in denial!

It wasn't until I a severe asthma attack landed me in the hospital that I started thinking differently. While there, my friend approached me again and said "Rick, you put yourself in here. You need to take better care of your asthma."

That was the day I decided I was going to become the model patient and work to manage my asthma (just like the Gallant asthmatic personality type!). It took a while, but by 2007 I had worked with my doctor and shed the hardluck asthma tag. Right about this time, I wrote on my RT Cave blog that my asthma is under control,and that I also use my rescue inhaler every day. An anonymous blogger responded to my post:

"Dude... You might want to rethink your answers on using albuterol... It should be as needed in asthmatics and generally if used more than twice a week (excluding EIA) your asthma is out of control and you are put into a bracket that is at a higher risk of death from asthma. Patients should always tell their doctors if [they are] using albuterol more than twice a week on a regular basis and their doctor should step them up on their maintenance medications. It's all in the asthma guidelines."

So, was I wrong? Was my asthma not controlled? Considering my past bad experience of being obstinate to the opinions of others, I decided to read these asthma guidelines. What I learned was that you cannot determine "control" in every asthmatic the same way. That anonymous blogger was unaware that I was a hardluck asthmatic even as recently as a few years ago, and that using my rescue inhaler "a few times a day" was a marked improvement for me.

However, generally speaking, he was right when we speak of a majority of asthmatics. Most of us can say our asthma is controlled if we rarely need our rescue medicine. And, for all of us, using your rescue inhaler more often is a sign of poorly controlled or worsening asthma (and that you need to call your doctor).

So, that said, how do you know if your asthma is controlled?

According to the Asthma Guidelines from the National Heart Lung and Blood Institute, regardless of asthma severity, the following are the most common markers for determining asthma control:

* Decreased symptoms or, better yet, prevented symptoms (such as coughing, breathlessness in daytime, night, or after exertion.)

* Decreased use of bronchodilators (rescue inhalers) for quick relief or, ideally, reduced use to less than two days a week.

* Fewer days or no days or school or work missed

* Ability to engage in normal daily activities or in desired activities

* Improved ability to exercise without having asthma symptoms

* Improvement in FEV1 in a pulmonary function test (PFT), or maintaining a normal pulmonary function.

* Reduction in exacerbation's

* Fewer emergency room visits and hospital stays for asthma

* Fewer nighttime awakenings due to asthma

* Optimal asthma meds with minimal adverse effects

* You're expectations are met or exceeded

* You're satisfied with your asthma care

In fact, the greatest marker for determining asthma control is a positive response to asthma therapy that allows an asthmatic to live a normal, active, satisfying life. After all, the goal of any asthmatic is to be "normal."

So, if after reading this you have decided your asthma is definitely well controlled, congratulations! Keep up the great work. If you suspect your asthma could be better controlled, then perhaps it's time you give your asthma doctor a call.

I Respect Nurses

In response to a recent post I made, Anonymous has left a comment. Anonymous seems to think that my post indicated that I (or RT's in general) have no respect for nurses. I've carefully re-read my post and see nothing disrespectful of nursing. I do see that I have disdain for those who recognize only nursing as a qualified medical profession. Pointing out the error of thinking that any job title with the word nurse in it is synonymous with competent, educated, compassionate patient care does not indicate disrespect and I will not back down on that.

That said, let me tell you how I feel about nurses and nursing as a profession. Nurses are my right hand, they are an integral part of the patient care team. Did everyone pick up on that? TEAM! I start almost every shift here at Shoreline Medical by stopping at the nursing station and asking the charge nurse on the medical floor; "Who are WE concerned about today? Anyone WE need to keep OUR eye on?".

Then on to the surgical floor, "Good morning Charge Nurse, anyone WE are worried about on your floor? What about surgeries, anything that WE are going to need to be expecting trouble from?" Then on to CCU, same thing.

Yes I can and do look at the charts, but I want to hear what the nurses have to say, they are the ones who are with the patient eight, ten, twelve hours each day and "gut" instinct does not transfer well with today's computerized charting. I wish I had a dime for every time a good nurse paged me to help assess a patient that he/she just didn't seem quite right. I love 'em!

And when I'm out doing the work that I am here to do, I communicate, communicate, communicate. I value my nursing staff, my nursing assistant staff, and all other direct and non direct patient care staff that I work with. We are all here to do the same job, give good compassionate competent patient care, and advocate for the patient. I also respect and value the physicians, of which I am not and do not pretend to be. As the old saw goes, "sure I like nurses, some of them are my friends".

And so Anonoymous, I started my nursing program in 1966, when did you start yours?

Before the hew and cry starts, no I am not a nurse. I decided I did not like a couple of things about nursing. I did not like working in one area every shift, and I do not like POOP! Thankyou, Jane

Discharge = Serevent, Admitted = Preventolin

Dr. Marilyn strolled into the RT Cave with a pleasant deportment. She said, "Hey, Rick. How's it going?"

"Wonderful!" I said.

"So how are the kids?"

"Awesome."

As she read her EKGs I told her a funny story about something my daughter did, and she shared a story or two of her own. Then somehow the conversation switched to a patient with COPD (imagine that).

I said, "Yeah, she's doing excellent. Maybe we could take her off treatments."

She said, "Well, I was thinking we ought to keep those treatments going so we can prevent bronchospasm. I thought that would be a good idea."

Doh! I tried.

I suppose this is a perfect example of why we often call Ventolin Preventolin.

I wanted to ask her why she didn't simply order Serevent, which is what the patient will get when she gets home to prevent her from needing Ventolin.

So, I suppose the Real Doctor's Creed must say something about Serevent not working within the walls of a hospital. Hey, why else would one of our better docs believe this BS?

Later on that night I called the physician who gave me a copy of the Real Creed, and he directed me to page 767 of the Real Physician's Creed where it states :

Serevent is a the recommended medicine to prevent bronchospasm. However, if a patient is admitted, Serevent must be discharged, and Preventolin ordered Q4 hours and prn. If questioned by ignorant RTs, the correct response is: Ventolin prevents.

No further explanation was given.

Do you have RT Deja Vu?

As I was performing an EKG on a patient the doctor asked the patient who her family practitioner was, and the patient said, "Dr. Pepperhead."

A minute later I was typing in my information on the EKG machine and I asked, "Who's your family doctor."

"It's Pepperhead," the patient politely said.

The RN said to me, "And she already said it."

"What?" I asked.

"The patient already said who her doctor was.

"Now that I think of it, I did hear you ask. I guess I have selective hearing

Along with selective hearing, I also have:

1. Selective hearing.
2. Lack of attention.
3. Habit of asking questions automatically at that point in the procedure.
4. Burnout
5. Brain infarct
6. Exhaustion
7. Combination of the above
8. Selective hearing

Chances are the reason I ask repeat questions is #7, or simple exhaustion from working nights

It's funny, but many times I find myself asking the patient the same questions, especially late into my shifts.

It's funny, but many times I find myself asking the patient the same question, especially late into my shifts.

"Is there anything I can get for you?" I say.

"No." Says the patient.

I proceed to wrap up the nebulizer and put it away, then say, "Is there anything I can get for you."

"No," says the patient. "I'm fine."

I do the same with EKGs. We need to put reason for visit on the EKG when they are done in ER. I ask, "So, are you having chest pain?" The patient says, "Yes." A moment later, as I'm typing in the information , I ask habitually, "So, are you having chest pain."

"Yes," the patient says.

I ask the question the second time, and then I feel a sense of deja vu.

It's funny patients, nurses, or even doctors don't make fun of me regarding this as often as I make fun of myself. Am I alone in doing this?

Perhaps we can call this situation RT deja vu, and add it to our RT Lexicon.

RT Deja vu: When an RT asks a patient the same question over and over again. When an RT askes a patient the same question over and over again."

Layoff's at Shoreline Medical

Recently at Shoreline Medical there have been about 30 direct patient care positions eliminated, either by attrition or actual lay-offs. Of course the resulting outcry from staff and community is loud and outraged. But I have another view of these events.

Over the years I have observed many area hospitals of all sizes experience large lay-offs, closings and mergers. With the declining re-imbursement of medicaid and medicare and many for-profit insurers who follow that lead, hospitals are struggling.

Here at Shoreline, administration deserves kudo's for their financial stewardship. For the first time in the twenty five years I have worked here, we are experiencing the financial crush that makes these layoffs necessary. We are not closing our doors, we are not (at least at this time) merging or being purchased by a for profit corporation.

It took a major recession coupled with all the huge re-imbursement cuts before we also had to make staffing cuts. This speaks for the commitment and expertise of our hospital administration. With their guidence Shoreline Medical survives to keep on providing the competant caring service that we always have provided to our community.

I remain a proud Shoreline Medical employee. Jane Sage

Is it our duty to question stupid doctor orders?

I'm sure other RTs and even RNs have experienced the same thing, but there are a lot of times doctors order bronchodilator breathing treatments that are not indicated. I like to say that at least 80% or all bronchodilator treatments ordered are not indicated.

I don't like to pick fights. I don't like to complain. I'm not the kind of person to roll my eyes at a unit secretary when she gives me the order for yet another treatment order for a pneumonia, CHF, croupy kid, or whatever have you.

However, my coworker, Jane Sage, said to me tonight, "Have you ever thought to walk up to the doctor and say, 'Just what did you expect to happen when you ordered that 20th Xopenex treatment for croup after the first 19 did not work? Did you think to try race epi? Did you think to try nebulized Decadron?"

"Well," I said, "I think to say something like that every day. But, do you want to know the reason that I don't."

"You don't want to tick off the doctor?"

"Actually, that's not the reason."

"Well," she said.

"I don't because I know I'm not perfect, and there is a 1% chance I could be wrong."

"You could be wrong, but you're still pretty confident you are right."

"Yeah. I'm non confrontational."

"I'm like you," she said, "I don't like to cause controversy. Perhaps it's because most RTs are like us that no progress ever gets made at Shoreline Medical Center."

"True," I said.

"However," the sagacious Jane Sage said as her eyes lit up, the tel tale sign she was going to say something brilliant, "If a doctor were to order 200mg or Morphine, don't you think the nurse would say to the doctor, "Wait!"

"I see what you mean."

"Don't you think, like the nurse of that patient who was ordered to get 400mg of Morphine, that it is our duty as respectable members of society to question it when a bronchodilator is ordered and not needed?"

Anyway, that's something to think about.

EUREKA!

Today here at Shoreline Medical, I was needed, effective and successful. The ER was full of truly difficult breathers, a couple of chest traumas and a man found down. Four nebs, 2 vents and a chest tube later I was flying high on adrenaline! How great it is to practice my skills of patient assessment, decision making and administering effective treatment. This is what I trained for, acute respiratory distress, trauma and ventilators. However, my euphoria was to be short lived,

Strolling down the hall feeling very full of myself, confident, serene and buoyant, I got a page for a now neb treatment in room 46A. Feeling much like superwoman, I rushed off to save to the day, only to find that a nursing assistant had walked Mr. Anonymous Endstage Emphysema, up and down the hallway without his OXYGEN on! Grudgingly, I reconnected the oxygen, monitored the sat and proceeded to give a Do-allolin treatment to a patient who was by now, totally comfortable, breath sounds clear, with a sat of 95% and talking a mile a minute. If only the nurse had called me to assess the patient before she called the physician I would have been so pleased. Even if I had still had to give the Do-allolin, I would have at least felt that I had been involved as part of the professional patient care Team.

A couple of days ago I heard my beloved respiratory department described as an ancillary department. I thought that this ancient thought process had finally died a natural death, what with minimum education requirements and licensure, and today I felt demonstrated that we are no longer an ancillary department. Then came Mr. A and the nursing assistant, oh well that nursing assistant probably knows more that I, afterall, she has the word nursing in her job title. Maybe we should change our name to Respiratory Therapy Nurses. Love you all, Jane Sage

I'm sleep deprived, but not a slacker

A coworker (not in my department) lectured me recently because she thinks my work is being effected by lack of sleep. She came to this conclusion after having a discussion about me with the nursing supervisor on duty a few nigths ago after I was asked to assess a patient.

"The patient was fine when I assessed her, and she was not in need of any respiratory intervention," I said.

My coworker said, "That's what you say, but the supervisor and I decided you weren't at the top of your game because you were overly tired."

"Why did she say that?"

"Because during the next shift the patient coded and died."

"I'm sorry, but when I assessed her she was fine."

And she was. I auscultated her lungs, and noted in my charting no change from previous assessments. The patient was mentally sound, and showed no such mental changes.

"Well, you need to be careful, and you need to get more sleep."

"Yes maam," I said. She proceeded to lecture me another ten minutes or so, and I stood there like a 1st grader in the principal's office after melting a wax crayon on the heater.

The truth is, it doesn't matter how much sleep I get prior to coming to work a night shift, because I suffer from what a lot of night shift workers suffer from: Chronic lack of sleep.

There is another word for it, "Circadium Rythm Sleep Disorder." When you have this problem you either don't get enough sleep (chronically) or you sleep and you don't sleep sound enough for it to make you totally satisfied.

Either that, or you never quite get caught up on your sleep. It's a chronic disease and it is a documented disorder for people who work nights. And I can honestly say it has never effected my work... PERIOD.

In fact, that patient crashed the next day and it was totally unrelated to what happened to her the night in question. Even if I had foresight and could predict when a person would crash, I couldn't have stopped her event from happening six hours after I went home at the end of my shift.

In fact, the patient coded following surgery that day. So, according to the night shift supervisor, I could have prevented this if I had been less tired. Then again, my assessment must not have been too far off, because both the Internist in charge of the patient, and the anesthesiologist, and the surgeon all approved the patient for surgery.

I wonder if those doctors were lectured about being too tired. Yes, I admit to being chronically exausted (which may also have something to do with having three kids, one of whom is nine-months old, at home), but it does not effect my work.

And yes I do "humor" about stupid doctor orders. But when it comes to taking care of my patients, my patients get 100% of my attention and RT experience. And I don't care what that stupid supervisor says.

Yes I'm sleep deprived, but I'm not a slacker. If there was no thing as politics, I probably would have said that to my boss, and sought out that supervisor and said it to her too. But, being the professional, laid-back, polite, humble, person I am: I said nothing. I bit my lip and said nothing.

I have a voice, and that's where my power stops

I was at an administrative meeting as a representative of the RT Cave. There were 11 admins and me. The admins wanted us RTs to do something that I thought was unnecessary.

One of the admins said, "We have to do something. Doing something is certainly better than doing nothing."

Your humble RT said, "I beg to differ. Doing something stupid is far worse than doing nothing."

How's that for some great philosophy.

The thing is, I don't have a problem with adding new procedures to the RT list of things to do. The problem is, they keep adding more things to our list and never even consider taking things off. I understand: it's business. I understand: profit is the bottom line.

They won't do protocols because we live in a small town and we have to please the doctors so they don't up and leave. They won't buy the new equipment we need because they don't have enough money (yet the CEO got a whopping bonus this year).

Yet when it comes to something they want, or something the doctors want, it's done in a heartbeat, regardless of what the people who actually are doing the real work think. And yet, in the end, we have no choice but to be submissive to the request (which really isn't a request so much as an order.

I think it's neat they let a peon like me sit in on their meetings. I think it's neat they allow me a voice. I only wish there was more of an incentive for them to listen to the voice they're hearing.

Wheeze no longer indication for bronchospasm?

I've come to the conclusion that a wheeze should be removed from the list of indications for a bronchodilaotr, and replaced by the word "diminished lung sounds."

The reason I say this is the word "wheeze" is too subjective, and prone to lead to questionable breathing treatments or bronchodilator abuse. Bronchodilator abuse is when bronchodilator breathing treatments are ordered for patients not having bronchospasm.

The following is a list of noises that are not true wheezes:

1. cardiac wheeze
2. upper airway wheeze
3. stridor

Likewise, there are other disease processes that can cause a wheeze, such as a pulmonary embolism, cardiac asthma (CHF) and lung cancer.

Therefore, due to the fact the word "wheeze" is too open to subjective opinion, I hereby petition it be removed from as an indicator for a bronchodilator order.

In place of wheeze I would like to see the word, "diminished lung sounds." I say this because if you listen to a patient and he has good air movement, you can be pretty assured he is not having bronchospasm -- even if you think you hear a wheeze.

Perhaps this might result in true bronchodilator reform.

Do not look at horrendous accident pics

The EMTs sometimes show pictures of accidents in the ER. I used to look at these pictures all the time until one young lady decided to commit suicide by driving head on into a Mack Truck. That picture was so gory I vowed never to look at one of those pictures again. That was eight years ago.

Recently a lady decided to sue because her daughter was in a horrid accident and pictures of it were leaked to the Internet. She's suing because it was the police who leaked the pics.

My wife said, "I thought: how bad could it be and I looked at the pics. Rick, she had no face. All it was was bone, skin and blood. Now that pic's going to haunt me forever."

I'm telling you folks. Do not look at pictures of accidents. Do not.

The first year of RT School

So, aspiring respiratory therapists, what can you expect from your first year of RT school? Instead of relying on my memory (I started RT School in 1995 in the pre-blogosphere world), I found the perfect person for the job: the Trauma Junkie.

Getting ready to start his second year, he wrote a report on the first year. I thought he summed it up quite well:

At the end of the first year of RT school, I remember several things:

Some of these things, very basic, but very important:

-Never withold oxygen from a patient who needs it

-Bronchodilators are intended to treat bronchospasm/bronchoconstriction

-Normal respiratory rate is 12-20bpm, normal heart rate is 60-100, normal B/P is 95-145/50-80

-Always wash your hands

-Central cyanosis, hemo-/hydro-/pneumo- thorax, and pulmonary emboli are very serious and require immediate intervention

Some of these things, slightly humorous, but slightly irritating:

-Patients who tell you they know how to properly use their inhalers and nebulizers (you know, they have been doing them at home for years), in fact prove to you that they cannot demonstrate the proper way to do them

-Almost everyone who is admitted with a respiratory problem, such as pneumonia, will have bronchodilators scheduled, even if they have no indication for this therapy (they aren't "wheezing" and have no history of asthma or reactive airways)

-Doctors, especially residents, don't always know how or when to properly order a neb treatment, including frequency and dosage ("Albuterol 4mg per neb TID and q1h PRN SOB," anyone?)

-Patients do not know why they take their breathing treatments, they don't help, but they just do it and have never asked why

-Some of the therapists you work with in clinicals will tell you all the wrong ways to do things

I think he pretty much sums it up. I think any current RT with a memory will remember how hard that first year was. The Junkie described it this way:

They say that the first year of RT school is the toughest. You learn basic concepts, formulas, laws, and equations that you will carry with you for your entire career as a therapist. The second year just consists of building on these concepts.

I think he pretty much sums it up correctly. However, I will add one comment: Yes, in the 2nd year you build upon the wisdom you learned in year one of RT School. But hold on to your seat, because by the end of round 2 you will feel as Rockey did at the end of his match with Apollo Creed -- exhausted, barely able to stand on two feet.

There! How's that to look forward to?

I love intelligent patients

I love intelligent patients. As I was performing an EKG, he asked, "Does that EKG measure voltage or resistance?"

"You got me," I said, "I know it measures voltage, but I'd guess both."

"It's kind of a complicated machine," he said, "but all such machines are pretty much the same."

"What did you do for a living," I asked, assuming he was retired.

"I was an engineer. I made products for NASA."

"Cool," I said, for lack of a better word. "Impressive."

"Yeah, it was a good career."

"I bet."

"Didn't mean to stump you, I was just curious."

"No. I love to be challenged. About 20 years ago we RTs knew all our equipment inside and out. But now with all the microprocessors inside them, we leave the "inside" part to the engineers like yourself."

"Yeah, it does get pretty challenging."

I said, "My grandpa was a mechanic, and I remember him telling me once that all engines were pretty much the same. By the time he retired, he told me once, all the machines were so different you had to grab a different manual for each car."

He rattled off the parts of an old car that were always the same. "Computers certainly complicate things. But the workings really are pretty much the same as they were 36 years ago."

I wouldn't know, but I'll take his word for it. I love intelligent patients. I love an intelligent discussion.

Ventilator Graphics Cheat Sheet

By popular demand, here is a Ventilator Graphics Cheat Sheet I created a while ago. The only thing to note here is all my graphics were drawn to correlate with the Servo 300a ventilator, so the loops may appear different on other ventilators. The information, however, should be the same for whatever ventilator used at your hospital.

Also, I tried to make everything here as accurate as possible. If you find a flaw, or think something here is inaccurate, please let me know by leaving a message in the comments below.

Likewise, if you have access to ventilator graphics not listed here that readers of the RT cave might benefit from, please feel free to share.

That said, don't be one of those chump RTs who ignores the graphics screen.

For a printable version, click here and then click ventilator graphics part 1 and 2.

Ronald McDonald's Teacher

It was 1977 and I was seven, and there was a blizzard so bad school was cancelled the entire week before, so my hopes were high the streak would continue. Would it work for church too?

“It’s freezing out there, folks. We recommend you don’t go outside unless you absolutely have to,” the voice on the little bedside radio said.

I was sitting on Bobby’s bed, and he was pacing the room, looking at the window each time a gust of wind knocked snow against it. David was standing on his bed leaning against the wall with his arms resting on the windowsill. You could see his breath mark on the glass.

Bobby was nine. He was the oldest and wisest. Or, I suppose, he was the one from whom we learned what worked and what didn’t with mom. Being the eldest, he was the Guinna pig of sorts with mom and dad.

David was a year younger than me, but just barely. Mom and dad were busy in those early years.

“It’s snowing!” shouted Danny as he stomped through the house. Danny would have been two and a half.

Bobby jumped off his bed with an audible thump that was probably louder than Danny’s wail. “No, Dan. You’re gonna wake up mom!”

David and I followed in Bobby’s wake.

“Shh! Quiet!” Bobby was shushing Dan in the dining room when David and I caught up with him.

“Let’s watch TV then,” David said. We trounced into the living room, turned on the TV, and there was nothing but church shows on all 2 of the channels. He flipped the hard to turn dial slowly, waiting a moment between each flip to see if a picture might come in, but each time all we could see was white snow and hear static.

“Hey, look at this,” David said, after several minutes of this process. I saw the picture was very hazy, but could clearly make out the music of Sesame Street.

The four of us sat down in front of the TV. The volume was turned low as possible so we could barely hear it. My stomach grumbled, but knew very well that mom would wake up the moment I set foot in her kitchen. I’d starve.

“Dah! Dah! Dah!” It was Baby Tony.

David and I hopped up and rushed to Tony’s room, which was right off the kitchen next to mom and dad’s.

“We don’t want to wake mom up,” David whispered, patting Tony on the head through the bars of the wood crib.

“Dah! Dah! Dah!”

“Quiet!” I said, poking my face between two bars. Tony bent over and slobbered on my face.

“Yuck!”

“Dah! Dah! Dah!”

I rushed out of the room, wiping saliva off my face, through the kitchen to the dining room and looked out the window at the front yard and watched the snow blowing every which way.

“Dah! Dah! Dah!”

From Tony‘s room I heard David, “We’ve got to be quiet. Dad’s gonna--”

“I’m up.” It was the familiar voice of dad from the dark bedroom next to Tony’s. Now I could hear the sound of curtains opening, and was certain now that mom was up. I watched as the bedroom quickly filled with white light.

“Crap,” I whispered.

“It doesn’t matter,” Bobby whispered. He was now standing beside me. “It’s already 10:30, too late to get ready for church. We’re safe.”

“All right kids,” Dad said, trudging from his bedroom in his underwear. He scratched his butt, opened a drawer, and drew out a clean pair of underwear. “Get dressed kids. It’s time for church.” He walked down the hallway and closed the door to the bathroom.

“You were too loud, David,” I said, no longer whispering.

“It wasn’t me, it was Tony,” David whined.

“If you would have just left him alone mom never would have--”

“We’ve been up a long time,” mom said. She was out of bed now holding Tony, who was making happy baby sounds. “Come on, Ric, let’s pick out what you’re going to wear.” I followed her, slipped into whatever hand-me-downs she picked out for me, and heard the bathroom door open.

“Well, you looking forward to going to church,” Dad said, smiling. “I love going to church.” I watched as he bounded down the hall naked and into his bedroom. I walked toward the kitchen and, not 30 seconds later, dad bounded into the kitchen already dressed.

“David! Bobby! Let’s go!” he said.

“I’m hungry,” David said as he sauntered into the kitchen, his hair askew.

“Me too,” Bobby said from behind David.

“No time to eat. We can do that after church,” Dad said.

"Awe!!" The audible sound of disappointment from three kids.

Dad drove carefully, but we made it to church just fine.

The organ was playing loud, and I looked back to see. I felt a friendly hand on my forehead, and the hand forced me to look at the front of the church. I slouched while standing, and a friendly hand touched my butt, forcing me to stand straight.

I slouched again, and dad whispered in my ear, “Slouching makes you look lazy.”

I stood straight. I slouched again, and he patted me on the side. I concentrated on not slouching, but found myself looking back at the clock under the balcony where the choir sang, and dad made me aware of what I was doing once again.

Near the end of mass I saw an old man resting his butt on the pew while kneeling, so I did the same. Dad was quick to correct me.

I yawned, and thought of grandma as I covered my mouth. I smiled. This day, at least, dad wasn’t going to discipline me for yawning without covering my mouth. I could hear grandma’s voice clearly though, “Nobody wants to see the inside of your mouth.”

Church ended. I have no idea what Monsignor talked about. Dad never said anything about whether I listened. He never said anything to Bobby and David.

Back home mom was lying in her bed with Danny and Tony snuggled up next to her. Tony was sleeping, and Danny was watching Sunday Morning with Charles Kuralt with mom, who smiled as we entered. I heard dad in the kitchen moving pots and pans, and sat at the kitchen bar with David and Bobby and watched as dad cooked pancakes.

Later in the day he cooked French fries. David, Bobby and I got the first batch, and pretended the fries were matches as we lit them by scraping them through the catsup. Dad smiled as he cut up more potatoes. He checked the batch currently sizzling in the grease, and dumped them onto a paper plate covered with a paper towel.

“Here you go boy’s,” he said, smiling. “You want to know something really cool.” He said, as he dumped a new batch into the fryer.

“What?” We all chimed in at once. “These are just as good as McDonald’s Fries. Do you know why?”

“Why?” I said, stuffing my face.

“Because I taught Ronald McDonald how to make fries.”

Bronchodilator Reform: Part II

After I wrote about Bronchodilator Reform as a quest post at Respiratory Therapy 101 last February, I decided this post needed a follow up. And thus is what inspired the following post:

Bronchodilator Reform: Part II
By Rick Frea: February 25, 2009 @RespiratoryTherapy101

So we are in a healthcare crisis caused mainly by skyrocketing healthcare costs. Perhaps one of the culprits of this crisis is something RTs have been vying against for years — bronchodilator abuse. Shockingly, few have listened to our cries for reform. Perhaps, however, money will talk.

While important officials often go to hospitals looking for procedures and therapies that are no longer needed in order to save money, never do they set their beedy eyes on the respiratory therapy department where millions of dollars are wasted every year on frivolous treatments.

While Ventolin breathing treatments may not be the only cause of rising healthcare costs, they are a major contributing factor. In a pithy manner I will explain.

By now you know Ventolin is ordered by many doctors for all annoying lung sounds, and many patients who are short of breath regardless of the cause. That is what they do despite the fact Ventolin is ONLY indicated for shortness of breath due to bronchospasm.

Now you might be asking: what do useless breathing treatments have to do with the healthcare crisis. Well, consider the following.

Where I work treatments cost $84 a pop. I estimate (on the conservative side) that 80% of Ventolin treatments ordered are not indicated and thus are non-beneficial to the patient. You can see, Houston, that we have a problem.

You do the math. Say the average hospital gives 40 breathing treatments during one 12 hour shift. That’s a total daily profit just from Ventolin treatments of $3,360. So you can be certain here we will not have hospital adminstrators on our side in our battle for bronchodilator reform.

But, when you consider who is paying the cost, officials might want to be aware that (80% of $3,360) $2,688 each day is going to this one non-indicated procedure. Multiply that by 365 and you gett $981, 820 wasted on Ventolin Abuse at just one hospital.

Multiply that by all the rest of the hospitals in the U.S. and that’s a lot of wasted money. Plus, mind you, I’m being conservative. The actual amount of money wasted on Ventolin therapies is more likely much higher.

Yet, still, when important officials go to hospitals demanding cuts in un-needed procedures, rarely ever do beedy eyes peer into the RT department.

Bronchodilator Reform: Part I

In February of 2009 I was asked by Anonymous RT to write a guest post for his blog respiratorytherapy101. Right away I decided what his readers and mine have in common is the need for bronchodilator reform, which inspired the following post:

Bronchodilator abuse
By Rick Frea, February 24, 2009 @ RespiratoryTherapy101

Many RTs, along with myself, have been on a crusade for bronchodilator reform. It is our humble goal to end bronchodilator abuse. By this we are not referring to asthma and COPD patients abusing their inhalers, but doctors ordering bronchodilator breathing treatments on patients who don’t need them.

Where I work there are no treatment protocols, so the problem is worse than at hospitals with protocols. Yet my RT friends who work at hospitals with protocols still complain to me about useless breathing treatments. Either it’s in the form of doctors overruling the protocol, or senior RTs who like to play it safe.

So it can be stated here that breathing treatment protocols seem to help, but do not end bronchodilator abuse.

Why is this? Because HMOs and THE government require certain procedures be ordered in order to meet criteria. If criteria is not met the hospital does not get paid.

Pneumonia is a great example. Some unwise person who has no clue what a bronchodilator even is decided that to for them to reimburse for the diagnosis of pneumonia, Q4-6 bronchodilator treatments need to be given.

The idea here is that if the patient isn’t sick enough to need a treatment he’s not sick enough to be in the hospital. Well, we humble RTs know this is ridiculous, but that’s the rule we have to live by. And that’s why our pneumonia protocol calls for Q4-6 Ventolin.

And this is why every single pneumonia patient has to be on Q4-6 Ventolin treatments regardless of whether or not they are having bronchospasm. When we are busy to begin with, this can be quality that could be spent with a person who REALLY needs the services of an RT.

Likewise, since 50% of patients admitted to hospitals are diagnosed with pneumonia, and many of them just because of this reimbursement criteria. That’s the only reason I can explain why so many patients diagnosed with pneumonia have clear lung sounds, a normal x-ray and labs.

The first step in ending bronchodilator abuse is educating folks that Ventolin is a bronchodilator and not a cure all for all annoying lung sounds and diseases. The second step is protocols.

The final step may be going beyond doctors and hospital administrators and finding your way to Washington on a quest to get Senators to pass laws (not that I like laws, but it was the government that caused this problem in the first place) banning Insurance companies and government agencies from setting quotas for reimbursement criteria.

Anyone up to the task?

Report: Jogging may not be bad for joints

My wife and I have been trying to get into better shape, and one of the things I like to do for aerobics is run. Well, I don't actually run, I job. Oh-okay, I don't really jog, I wog. I'm a wogger, all right. I don't have the ability to do all out sprints if you know what I mean.

So, anyway, I've been "wogging" with a friend. He's a lot more athletic than myself, and as we're working our way around the track around the football field he usually laps me once or twice. Sometimes he makes fun of me and walks fast alongside me as I wog, "Why don't you just walk," he says.

"Because I'd rather make myself miserable." Actually, I think it's a great feeling being able to run (or wog), especially when I finish. And if it means that when I turn 40 next winter and I can still run and play catch with my son, then it's worth it.

The friend who's been jogging with me has decided that he no longer wants to run on the track because he believes that running is bad for his joints. So now when I run I have to go by myself.

That in mind, I recently found a report over at womenshealthmag.com that where a study was done that "postulates" that running is not bad for your joints at all. The report notes:

Dedicated road ­runners, listen up: You've probably had to defend your sport a thousand times against this persistent myth, so take note: Running will not wreck your hips and blow out your knees.

According to a research ­review in the Journal of Anatomy, running does not increase your risk of osteoarthritis, the ­decay of cartilage that causes joint pain and inflammation.

In fact, many researchers even propose that the strong muscles you develop putting in all those miles could actually help guard against osteoarthritis.

Exercise will definitely help you avoid one ­important risk factor for the disease in women: obesity.

Of course one report is nothing to get overly excited about, but it makes sense to me. However, now we need to learn if what we are running on effects our joints, because my friend continues to run, only not on the track with me because he believes it's better to run on dirt trails as opposed to the crushed tire surface of the track.

The debate: Are RTs professionals or Ancillary

My boss referred to us RTs as ancillary staff in a recent meeting. I personally have argued against this term for RTs, claiming that we are professionals. Yet the debate continues.

How about if we define these terms before we go on:

Ancillary staff: These are workers who are told what to do, and do them as instructed without asking questions.

Professional staff: These are professionals who are involved in the care of the patient and are a part of the team that "thinks" of solutions to acute and/or chronic problems the patient is confronted with.

By these definitions, the following are ancillary services:

1. doing abgs
2. doing breathing treatments
3. being a treatment jockey
4. performing ekgs
5. doing cpt
6. assisting with a boost

By these definitions, the following are professional services:

1. interpreting abgs
2. understanding what decisions to make based on your interpretation of it
3. educating a patient
4. questioning a physician order
5. knowing what to do as a patient is failing
6. delving into the patient's history to solve an acute problem
7. recommending new therapies to the attending physician
8. researching and coming up with new ideas to help the patient
9. researching and coming up with new ideas to help the RT department or hospital

So, I think the RTs of old may have been ancillary, and I can think of a few who exists in the RT Cave today who would qualify as ancillary RTs. Yet I am convinced most of us work alongside the patient with RNs and doctors for the benefit of the patient, and are thus professionals.

What do you think?

Blog problems? the solution is always "simple"

Blog problems? The solution is always simple -- or so they say. It's not simple, though, until you figure out what the problem is. Then you hit yourself alongside the head and say, "duh!"

If you viewed my blog yesterday, my right sidebar was sitting below my posts. It was an irritating problem that vexed me for nearly 24 hours. Then, as what usually happens, the solution is something simple. Yep -- simple -- that's what "they" said in every blogger help blog I read about "the disappearing sidebar."

I was about ready to pull my hair out. My wife was getting irritated by me for my obstinate desire to fix the problem. "You need to get off that computer and spend some time with your family," she kept wailing at me. "And stop dinking with your html. You keep getting your blog just the way you want it, and then you play around."

And I agreed with her. But I was unable to pull myself from the problem. And no matter what I did I couldn't get it to work. Hell, I even changed templates -- twice, and the problem didn't go away. Even with a new Minima template, no tabs, no third column, that right hand sidebar was sitting down below where I didn't' want it. I could have screamed. Maybe I did scream at one point. When you work nights and you are chronically deprived of sleep, irritation sometimes seems one missing sidebar away.

About a week ago I had a similar problem. While my blog was functioning fine, and my html template was visible, my "page elements" page was gone. No matter what I did I couldn't get it to come back. Then, by some miracle by my guardian angel perhaps, I decided on a whim to delete something I put into my template the day before, and wham! The problem was resolved. Now, with my right sidebar missing, I was hoping for a similar "guardian angel" moment. But it wasn't happening -- until just now.

I woke due to allergies. I decided I had better sit on the couch sniffling and sneezing and blowing until the antihistamine kicked in. Then I noticed my wife never shut the computer off when she went to bed. It was calling me: "Rick, come to me! Rick!" You know the feeling. That Internet was-a-calling. So I clicked the mouse. The computer woke. It said hi! Well, not really.

So I clicked on my blog hoping the problem would be gone. It wasn't. I changed templates on a whim. The dog gone right sidebar was still hanging below the posts. Knowing this wouldn't solve my problem, I googled "Why is my sidebar missing?" for the 200th time, and I came across this post.

It turns out, the problem was as "they" say "simple to solve." I don't know why it didn't click earlier. I had added an element to the bottom of my post that was too wide. I deleted it a moment ago, and the right sidebar came back. Turns out the "element" I deleted somehow made the post too wide. I never had that problem before. I'll never have it again. And, I suppose, neither will you since your reading this post.

It's interesting -- isn't it? -- how blog problems seem so vexing to solve until you find the solution. Then you realize that all the help blogs you read that said "the solution is simple" or "I hit myself in the head and said "duh!" when I figured out what the problem was were right -- the solution was simple

Well, now that this problem is resolved, I'm going back to bed. I have to work tonight and I need my beauty sleep.

Weekly Asthma Q&A

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: my brother has asthmaim wordering if i should take him to the hospital???? hes only 1 year old and hez breathing really fast and wakes up ever 2min so should i take him to the hopital???????

My humble answer: Based on what you describe here, it would probably be a good idea to take him to the emergency room to have him checked out. A baby breathing fast with trouble sleeping can be a sign of something serious.

Question: Can you mix ipratropium and albuterol for the nebulizer?

My humble answer:
The answer is YES. You can mix them both up. However, if you have ever done this, you will note both these medicines come in individual amps with 3cc of normal saline (water) each. If you mix them up the breathing treatment will last a long time, like about 20 minutes. The reason is because you are breathing in the medicine along with 6cc of normal saline.

If you want to speed up the time spent taking a breathing treatment, ask your doctor to write you a prescription for Duoneb, which is a combination of Albuterol, Ipatropium Bromide, and 3cc of normal saline (water). This way you get all the benefits of both medicines in less than 10 minutes.

For the record, these two medicines are also combined in an inhaler too. It's called Combivent.

Question: HOW CAN YOU KNOW IF YOU HAVE ASTHMA? I think I have asthma, the doctor says that it is allegy not asthma, he gave me allegy medecine but I dont be cured. when I taKE salbutamol I feel better in My check. how can I know if I have asthama or not? how to know about the allegy.

My humble answer: Great question. I'm sure your physician is aware that about 70% of asthmatics also have allergies. Likewise, the fact that you get relief from your rescue inhaler is also an indication of asthma. However, those two things alone do not mean you have asthma.

So, based on the asthma guidelines, the following is how asthma should be diagnosed by physicians: recurrent wheezing, cough particularly at night, recurrent chest tightness. Likewise, symptoms occur with exercise, viral infections and exposure to asthma triggers.

Asthma can be diagnosed by your history of asthma-like symptoms (see above), family history of asthma (asthma is genetic), and a pulmonary function test that shows airway obstruction (this is the best diagnostic test for asthma).

There are two ways to determine if you have allergies. 1) you have allergy attack (sniffles, sneezes, etc.) when exposed to certain allergens (mold, pollen, flowers, dog, cat, etc.). 2) Allergy skin testing. This is the best way of learning if you have allergies so you can learn to avoid these things (or be treated for them).

Question: Intal is being discontinued. I am not able to take steroids. What is the best substitute for the intal inhaler?

My humble answer: Tilade is similar to Intal.

If you have any further questions email me, or Visit MyAsthmaCentral.com's Q&A section.