Doctors need to be questioned more

My mom said, "I'm paying my doctor good money, so I'm going to do exactly as he says."

My wife responded, "I'm paying my doctor good money, so he's going to do things my way."

Classic. I had an elderly patient recently. When I asked her why she was going to a nursing home she said, "Because that's what my doctor wants."

"So, what if your doctor is wrong?" I didn't ask.

So what if your doctor is wrong. It seems too many people, especially the elderly, don't seem to question their doctors. Consider the following questions:

1. Why do you want me to take that pill?

2. So, why do I need breathing treatments?

3. And what is the science behind that?

4. Is that your opinion, or have you read that somewhere?

5. You want me to do what?

6. I'm taking 20 pills. Are all these really necessary?

7. Look, there's no need for you to massage my boobs. How about if I find a new doctor?

8. Why are you oxygenating my newborn baby with 100% oxygen when all the science showed 10 years ago that this can lead to cancer later in life even on otherwise healthy newborns?

9. How about a second opinion?

It's not just patients who need to question doctors too, but people right here in the medical field. For fear of being yelled at, or because we get tired of the infamous, "I am not going to do that, Rick Frea!" we RTs and RNs tend to just do what we are told.

Yet that's exactly why doctors end up with unfettered power. That's how we end up with no protocols. That's why we end up with patients being on medicine they don't need, and having procedures they don't need. Or going to nursing homes they don't need to be at.

There's a good word for this: Enabling. Both patients and medical staff enable doctors to get away with anything they want. This breeds ego. Enabling breeds ego. Thus, doctors have become elitists. They have become totalitarian. They are able to do without being questioned.

Another classic example of this was my dad went to the doctor a few years ago, and my dad smokes 1/2 a pack every couple days and he drinks 2-3 per day during happy hour at his retirement facility. My dad was honest about this with his doctor.

The doctor said, "You better quit drinking. Drinking is about the worse thing you can do for your doctor."

"Thanks for the advice," my dad said. Later, dad told me this story, and he said, "Rick, shouldn't a doctor be more concerned about the smoking. He never said one thing about me smoking, yet he was all hung up to dry about my drinking."

"Dad," I said, "There's absolutely nothing wrong with you having a few drinks a day. If anything, you ought to quit smoking. Smoking is waaaaaay more likely to kill you than happy drinking the way you do."

"That's what I thought," he said. "He's a good doctor, though. He's just got this thing about drinking. I bet he's never been had a drink. I bet he's never been laid before."

Dad and I enjoyed a laugh.

The medical field is a well respected physician, perhaps even too well respected. I don't mean to knock this respect, but I think too many physicians go so long without being held accountable that they develop egos the size of watermelons, and they start to treat people like truck engines instead of people.

With the advent of modern great science, updated research and studies, newer medicine, and the Internet, there's no reason anyone should remain ignorant about the medical field.

It's time we do our research, and/ or at least question doctors. Most doctors are brilliant and honest, but no doctor's power should go unchecked by you and me.

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Word of the Day:

Amorphous: Having no determined form, shapeless, unstructured, formless
The amorphous ego of the physician could be felt by all in the room.

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The 13 virtues of parenting

The 13 virtues of parenting are play, consistency, equanimity, taciturn, pithy, humility, complimentary, enterprise, commitment, sternness, firmness, cosmopolitan and prioritize.

These go along with Ben Franklin's 13 virtues and the virtues of respiratory therapy. Now, what could those be? Stay tuned, as I'll expound in a month or so.

We need to appreciate life in general

In the past 100 years there were many attempts at creating an ideal class in America. A few believed the best way to do this was to get rid of the rich (tax them and redistribute their wealth) and get rid of the underclass by allowing them to slowly die out. And, yes, this did happen in America.

Believe it or not, there were laws in 27 states in 1945 that made eugenics legal. This was actually an attempt by a society -- a movement if you may -- to create an ideal society. We learn in history class this was a movement that sweft through Europe with Hitler and Moussolini, yet we don't hear much about the American ideal class movement.

Eugenics was practiced on the mentally retarded, uneducated, malnourished, underclass, and even criminals. It was an attempt to rid society of these "undesired" class. I do not like the word "undesired," here, as you guys know I fully believe in the sanctity of life (with common sense), yet the word "undesired" was a word used to describe the underprivileged classes by famous writers back in the top half of the 20th century, including Orson Wells.

However, what Hitler did made Americans aware of what was wrong with eugenics. It was, as they say, inhumane.

There were also a few back in the first half of the 20th century who wrote about, or discussed, getting rid of older people who were a burden on society. You know who they're talking about, as your grandmother may be among this class in a nursing home somewhere.

Some argued that these folks are a drag on society, and cost way to much to keep alive. They, in essence, are responsible for the rising health care costs (however they would be wrong because the elderly are not the reason health care costs are so high -- it's government intervention. Yet that's something I've already written about).

Obviously, and thankfully, this group of progressives didn't succeed. However, there was actually discussion about this recently as Obama's Health care reform was working it's way through the legislature. There was discussion of meetings to decide whether the government should pay for certain people who are a burden on society. The exact name here slips my mind, yet I know this was discussed.

Whether this made the final bill I'm not sure we really know yet. Some say it's in there, and some say it's not. With a bill 2,000 pages long, it's easy to understand the confusion.

However, I think most of us (liberals, progressives, conservatives, libertarians, etc.) as Americans would agree we need to take care of our elderly, and love them, and appreciate their lives, as opposed to disrespecting the sanctity of life. Yet at the same time a little common sense is in order (like DNR orders).

Now you might not think of it this way, but another method to purify society and create an ideal class is through contraception and abortion. I never thought about it this way until I read about it in a book recently.

Back in the early 20th century there were women and men who championed birth control in underprivileged communities in order to get these folks to stop having children. The same actually occurs with abortion, as over 75% of planned parenthood offices are located around impoverished inner city areas. Coincidence?

As Americans we all need to condemn efforts to diminish the sanctity of life. However, to keep someone who is brain dead, or terminally ill, alive on a ventilator for extended periods of time seems to be something that shouldn't be done either. It's kind of a where-do-you-draw-the-line type of thing.

Thoughts?

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Word of the day:
Baleful: Harmful, ominous, malignant, or evil, perfidious, malefic;full of menacing or malign influences; pernicious

Round he threw his baleful eyes followed by his huge fists. Three nurses were quickly on the ground. The safety of the rest of the staff remained in question.

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Lanoxin and Coumadin now work as opiates?

The patient said: "Gosh, Rick!" She looked at me with big, happy eyes peering over the tight bipap mask. "Whatever that nurse gave me, whether it was xanax or morphine, really helped me relax. I feel so much better now. I feel like I can tolerate this mask, the flow of air, so much better now."

"Awesome," I said.

I made sure the patient was settled, made sure she didn't need anything further, left the room, and approached the nurse, "Yeah, she said whatever you gave her really helped her relax."

"Well," the nurse said, smiling, "It was either coumadin or Lanoxin, because that's all I've given her."

"Well, I guess whatever works," I said.

All pateints deserve equal respect

She's a 66-year old end stage COPD patient and she's highly demanding. She doesn't mean to be annoying, she's just scared. So my advice is: Give her what she wants. Spoil her. Cater to her.

But, gosh darn it, stop getting irritated with her. If she wants those darn things over her ankles that vibrate the blood through her legs to prevent blood clots, dog gonnit put them on. If she wants a glass of water, go fetch it. If she wants to be tucked in, just do it. If she wants her oxygen on 3lpm instead of 2lpm, then dog gone it just do it.

She was so upset when I entered her room. I said, "What's wrong."

"I'm mad!" She said.

"At me?"

"No. At the nurse. I wanted those things on my legs and have asked four times and she refuses. She also refused to tuck me in better, because I was highly uncomfortable. Finally I told her just to get out of my room."

"Is there anything you want me to get for you. I'll do anything you want," I said.

"No. I'm feeling pretty comfortably now," she said, and she looked it.

I understand completely how the nurse feels, because this patient is highly demanding. Then again, this lady becomes dyspneic every time she even moves in her bed. She is scared. She is dying. It just irritates me that someone wouldn't take an extra step to cater to this woman. Give her whatever she wants. Let's make her happy. Let's comfort her.

Isn't that our job? Isn't that what we're here to do? Even if it's not, I see no reason why this sweet old lady can't get what she wants, annoying or not.

Her treatments are ordered QID and Q2 prn. I see absolutely no reason why she needs a breathing treatment every hour. But she asked for one and I shall giveth. Inconvenient -- yes. The right thing to do is giveth -- absolutely.

And I shall sit in her room and visit with her because I have a feeling she likes the company. She smiles when I'm in the room, and perhaps she provides me a sense of I'm-doing-a-good-deed on an evening where I otherwise probably don't even need to be here.

The Modest COPDer

If I didn't see it first hand, I never would believe a person could be short of breath and not know it. Yet, from time to time, I have a COPD patient come to see me in the ER who is short of breath and not know it. It almost sounds amazing, yet it's a reality.

Once you think about it it makes sense. Imagine that you stopped smoking ten years ago, and before you quit you caused some damage to your lungs. You have COPD. So even while you quit, the disease process is slowly progressing. And, so, while you may become progresively more short of breath, the transgression may be so slow you may not even notice a difference.

So you finally come to the ER for some other reason, and the ER doctor listens to you, hears some noise that is not normal, has the RT give you a breathing treatment, and when the treatment is done you say, "Wow! I can breath much better. I didn't even know I was short of breath!"

This scenario sounds odd, but it happens from time to time. It happens because, as this article here notes:

"Researchers studying those with known risk factors recently found that approximately 10% of people over 40 are affected by the disease. Although test results suggested 20% of the people tested positive for a diagnosis of COPD, only 30% of those had a previous diagnosis or even a suggestion for a diagnosis. Since all of these participants had two major risk factors for COPD, the indication that so many of these people were undiagnosed is troubling to say the least."

I wrote about the Modest Asthmatic. What we have here is the modest COPDer. A sad but true reality.

If you have a bad heart, and you are diagnosed properly, your doctor can prevent your heart from getting worse. The same holds true for the lungs.

If you're having any degree of shortness of breath, wheezing, chest tightness, excessive cough or phlegm production year round, then you ought to see a doctor. He can provide you with medicine and therapies to slow the progression of your disease, allow you to live longer, and healthier.

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Word of the day: Apposite: Strikingly relevant, applicative, applicatory, apropos or suitable, apt; well-adapted; pertinent; relevant; an apposite answer. (From Dictionary.com: [Latin appositus, past participle of appōnere, to put near : ad-, ad- + pōnere, to put; see apo- in Indo-European roots.]

It was apposite of the respirator therapist to keep her mouth shut when the doctor ordred an Albuterol breathing treatment for the patient recently diagnosed with pneumonia.

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Emergency Room RT Consult

The following is an ideal emergency room RT Consult, or aerosolized medication protocol for ER, that we have been working on. If anyone has suggestions to make this even better, please feel free to suggest.

For a printable copy of this protocol, click here.

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EMERGENCY ROOM RESPIRATORY THERAPY CONSULT (RT CONSULT)

Protocol Content:

1. Scope: A Licensed Registered Respiratory Therapist (RRT) or Certified Respiratory Therapist (CRT) who has successfully completed and passed all competencies related to patient assessment and protocols. Although respiratory students and assistants may perform medicated aerosol therapy, they may not adjust therapy per protocol.

2. Emergency Room Aerosolized Medication Protocol

A. When a physician, physician’s assistant, RN, or RT orders RT Consult or RT to assess and treat, the RCP will be paged for a RT Consult. The RT may initiate this protocol working within the following guidelines.

B. Upon receiving the order, the respiratory therapist will assess patient and select appropriate therapy and medication.

C. The following conditions are accepted indications for bronchodilator therapy:

• a. Bronchospasm/ wheezing
• b. Asthma/ reactive airway disease
• c. Diminished lung sounds
• d. COPD
• e. Prolonged expiratory phase
• f. Obstructive defects of PFT
• g. Impaired mucous clearance

D. B. Medications available per protocol:

• a. Albuterol 0.25-0.5cc
• b. Duoneb 1 unit dose vial
• c. Atrovent 1 unit dose vial
• e. Xoponex 0.63-1.25mg
• f. Albuterol MDI

E. The following assessment and chart findings will be evaluated and documented as appropriate:

• a. Vital signs (HR, RR, BP)
• b. Current FiO2
• c. Pulse oximetry
• d. PEFR (if indicated)
• e. Patient assessment results (lung sounds, work-of-breathing, cough, secretions)

F. Peak Expiratory Flow Rates (PEFR) will be done on asthmatics before and after the initial treatment according to the patient’s tolerance to perform the maneuver, or this will be performed as soon as patient is able.

G. Following an initial assessment, an initial treatment will be given to patient’s who meet the indications for therapy. If patient does not demonstrate improvement in PEFR, relief in Dyspnea or reduction in expiratory rhonchi or wheezing, the treatment may be repeated. If necessary, a third treatment may also be given.

H. If there is no improvement after repeated treatments, the physician will be informed the patient is not responding to therapy. Further therapy will be given only with physician notification.

I. If respiratory therapy determines patient would benefit from a MDI bronchodilator for home use, and the patient meets the criteria for MDI use, an Albuterol MDI may be administered to patient, and patient will be instructed on correct use of this MDI. The recommended dose and frequency is Q4-6 hours as needed.

J. Criteria for MDI use:

• 1. Can physically perform the maneuver.
• 2. Can follow directions.
• 3. Is cooperative and alert.
• 4. Can take a slow deep inspiration.
• 5. Can hold breath for at least five seconds.
• 6. Is able to perform a return demonstration.
• 7. Respiratory rate less than or greater than= 25

3. Documentation:

A. Initial Assessment:

1. The respiratory therapist will write the order in the patients chart including medication, dose and frequency per RT Consult if the ordering physician did not already do so.

2. Initial orders written by the physician do not have to be rewritten by the respiratory therapist unless clarification or adjustments are required.

3. All therapy will be documented in the computerized charting system.

B. Re-assessments:

1. All patients will be assessed with every treatment to determine the patient’s current pulmonary status and effectiveness of the aerosol therapy.

2. Adjustments of the patient’s therapy will be determined objectively by changes in the monitored parameters.

REFERENCES:

1. Spectum Health (2005) Aerosolized Medication Protocol, Grand Rapids: Spectrum Health.

2. Northern Michigan Hospital (2004) Bronchodilator Protocol, Petosky, MI: Northern Michigan Hospital.

3. Covenant Health Care (2005) Respiratory Therapy Consult, Saginaw, MI: Covenant Health Care.

4. “Guidelines for Preparing a Respiratory Therapy Protocol.” Retrieved August 23, 2007, from http://www.aarc.org/members_area/resources/protocol_guidelines.html
5. “Respiratory Therapy Protocols.” Retrieved August 4, 2007, from http://www.st.alexius.org/about_stas/services/Resp_Care/protocols.asp?printable=1

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Word of the dayAttenuate: To make thinner or weaker; to make slender; to rarify; to enervate

A few stupid doctor's orders is all it takes to attenuate my energy supply.

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Whe is a good time to see a specialist for asthma?

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.

Your Question: I've been seeing the same doctor for a long time now, and am still having trouble with my asthma? When is a good time to recommend to my doctor I see a specialist?

My Humble Answer: Actually, that might be a good idea. The asthma guidelines note that if you are not meeting. The asthma guidelines notes the indications for when it's time to see a specialist for your asthma here. Click on that link and scroll down to page 68. Based on what you describe here, it might be time. Good luck getting your asthma under control.

Your Question: My husband coughs violently when using his rescue inhaler. Can this be remedied?

My Humble Response: This sounds like something he ought to discuss with his asthma doctor. It could be due to poor technique. He may want to check out this link to make sure he is using it correctly, or have his doctor or nurse watch him use it to see if he is using it properly. An inhaler should always be used with a spacer.

If that if not the problem, his doctor may want to do some tests to get to the root of the problem, or, perhaps, change your husbands medicine regime. For more information about asthma medicines, check out this link.

Or, perhaps your husband is being exposed to his asthma triggers. To learn more about this check out this link. For further information, check out this link.

Your Question: Can mould cause asthma?

My Humble Answer: Mould can be an asthma trigger. To learn what your asthma triggers are and how to avoid them, check out this link.

Your Question: Does asthma cause sore throat?

Or is there sometime a sore throat with having asthma. I'm 51 and wasn't aware of asthma till I was 42, and does putting on extra weight trigger these coughing attacks.

My Humble Answer: A sore throat does not always accrue when your having asthma, although it may be an early warning sign of an oncoming asthma attack that is unique to you.

Viral respiratory infections are one of the leading "trigger" of asthma.

Gaining weight is not an asthma trigger, yet it can cause you to feel winded. There have been many studies linking being "over weight" with worsening asthma.

One of the BEST ways of gaining control of your asthma is to exercise. No matter how bad your asthma is, you need to participate in some level of exercise.

I GUARANTEE if once you exercise a few weeks you'll see your asthma getting better, plus you'll feel better to boot.

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

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Word of the Day: Immutable: Not mutable; changeless; not changeable

Since facts are immutable, it cannot be denied that bronchodilators are only good for bronchodilating, and not for all the other 340 reasons they're ordered in hospitals.

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Incentives to quit smoking

Asthma and COPD Wisdom

If you want to smoke that's your right. Yet, if you have asthma, that alone is an incentive to quit smoking. This was the topic of a recent post at MyAsthmaCentral.com

Smoke and Have Asthma: Here's 20 Incentives to Quit
By Rick Frea, Monday March 01, 2010 @MyAsthmaCentral.com

So you've come to terms with the fact you have asthma, yet you continue to smoke. Even if you've tried quitting a hundred times, what follows are 20 incentives for you to never quit quitting.

1. Studies (like this) show that smoking has several irritants that increase the thickness of the air passages in asthmatic lungs, and increases the number of cells that produce mucous. This may explain why asthmatics who smoke experience increased asthma symptoms "such as increased shortness of breath and increased phlegm production."

The study showed that quitting smoking can reverse this thickness. Likewise, the study revealed that it does not matter how many years you smoked or how much you smoked. If you quit, your lung function will improve.

2. Studies like this show that chronic inflammation caused by smoking irritants can actually lead to adult onset asthma.

3. Smoking itself is an asthma trigger that can cause asthma exacerbations now and in the future, and can make ongoing asthma attacks worse.

4. The asthma guidelines from the National Heart Lung and Blood Institute note the #1 cause of severe asthma is smoking.

5. Likewise, according to "Egan's Fundamentals of Respiratory Care," 15-70% of those with COPD also have "reactive airways," which is asthma. So, if you continue smoking, you might move right into an even worse disease category.

6. It's a fallacy that asthma goes away with age. So, if you used to have asthma and smoke because you think you no longer have asthma (like former child asthmatics in denial), you are at an increased risk of developing severe asthma.

7. According to the Asthma Initiative of Michigan, smoke filled rooms can have up to six times the air pollution as a busy highway.

8. The American Lung Association (ALA) notes smoking is associated with 90% of lung cancer deaths, and it's also significantly increases your risk for heart disease, stroke and harms nearly every organ in your body. It's also associated with a host of other cancers and diseases.

9. Your smoking is dangerous to your your family members, friends and coworkers who inhale your second hand smoke. Even short-term exposure can potentially increase the risk of heart attacks and lung cancer.

10. Smoking around children increases the risk of lower respiratory tract infections like Respiratory Syncitial Virus (RSV) and bronchiolitis, which can lead to hospitalization and even death.

11. Second hand smoke has also been linked with increased risk of sudden infant death syndrome (SIDS).

12. Second hand smoke can cause an asthmatic to have an asthma attack. Likewise, it can actually cause healthy children to develop asthma.

13. Believe it or not, third hand smoke has also been linked to disease. This is the residue of cigarette chemicals that are left on your clothes, your furniture, and carpet. This can be inhaled even if a person hasn't smoked in the room for days.

14. The ALA notes there are over 4,800 chemicals in cigarettes, 69 of which are known to cause lung cancer via 1st, 2nd and 3rd hand smoke. Some of these chemicals include: Arsenic, Acetic Acid, acetone, Ammonia, Benzene, Butane, Cadmium, Carbon Monoxide, Ethanol, Formaldehyde, Hydrazine, Hexamine, Hydrogen Cyanide, Lead, Methane, Methanol, Naphthalene, Nickel, Nicotine, Phenol, Polonium, Steric Acid, Styrene, Tar, and Toluene.

According to this brochure from the Michigan Department of Community Health, here's the good news about quitting smoking: as soon as you quit smoking your body starts to fix itself.

Consider the following:

15. Within hours after you stop smoking, your carbon monoxide level falls to normal and the oxygen in your blood increases.

16. One day after you stop smoking your risk for heart attack starts to go down.

17. Two days after you stop smoking your nerve endings start to repair themselves so your senses of taste and smell start to return to normal.

18. Two weeks after you quit smoking your lungs are working 30% better than before

you quit.

19. Within 1-9 months lung function continues to improve, cough, sinus congestion, fatigue and shortness of breath all decrease as your lungs regain normal function

20. Within one year your risk of heart disease is cut in half, and within 15 years your risk of stroke, lung cancer and heart disease are that of a person who never smoked, and you can consider yourself fully healed.

So, now that you're ready to quit smoking, you can learn about the latest methods of quitting here. If you're interested in a great stop smoking kit, check out this link here.

Good luck.

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Word of the day: Alacrity: Cheerful eagerness, willingness, quick to act, swiftness; promptness or eager and speedy readiness; springliness; agility

When called STAT you should respond with alacrity. Although, abuse of the word STAT has sucked the alacrity out of the RT response time.

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A better plan may have prevented oil spill

On the political front

While this is a medical blog with an emphasis on the lungs, there are events that take place on a daily basis that do effect us on the medical front. So every Sunday I will attempt to write a post about the political front, particularly how it is effecting us in the medical community.

If nothing else, perhaps this will spice up the atmosphere here at the RT Cave a little bit -- or a lot, depending on how heated some of you guys are about politics.

For instance, this past week Big Oil was basically castrated, namely BP, for the explosion that resulted in the catastrophic oil slick in the Gulf Coast.

The truth is, it's a horrid event. It should never have happened. Animals have been harmed, beaches ruined, and economies destroyed. At least that's what we see with the naked eye.

Here is what we don't see. Every day 40 million gallons of oil are dumped into oceans, lakes and streams. Did you know that? And, of that 40 million 60% is naturally occurring; naturally seaping into the waters. Thirty-nine percent is natural run-off from boats and other water equipment, and 1% is from oil spills like that in the Gulf Coast right now.

Of that 40 million gallons of oil, most of it does not stay afloat as some will contend, but most swells and sinks to the bottom of the ocean, and much of the rest is eaten by bacteria which exists simply for this purpose. The rest washes ashore, hurts some animals, but you don't hear about it by the media. It's basically a normally occuring phenomena.

That doesn't justify what happened in the Gulf Coast, it simply allows us to see the big picture.

Still, the Gulf Coast oil spill (or leakage considering it's still ongoing) was a travesty, and should never have happened. Disasters can be prevented. Yet when they do occur, a plan can prevent them from getting out of control.

Yet blaming Obama, as the media did to Bush during the Katrina disaster, is frivolous at best. Obama is not to blame, any more than Bush was to blame.

However, I'm not saying politicians altogether are not partially at fault for this disaster, because they are.

So, why did it happen? Why wasn't there a plan in place to prevent that explosion? Why wasn't there a plan to fill the hole in the ship to stop the leak? Why wasn't there a plan to clean up the spill?

This isn't unlike what we do here in the medical field. Someone comes into the hospital following a train wreck, and we place the patient in critical care. He has a fever, a high respiratory rate, and thus he is at high risk for sepsis, ARDC, DIC, etc.

We have a plan. We anticipate the worst. We know such an event may result in further complications, so we do whatever we can to prevent it. We anticipate. We are proactive.

Plus we have the rapid response team, whereby if we see early signs the patient might fail (change in mentality, increase RR, increase HR, change on EKG, fever, etc.) we call in the team.

The goal here is that all events that might lead to failure show early signs, and if noticed, and aggressively treated, the event can be prevented. It makes sense, and it works.

Still, if a patient does go into respiratory failure, or cardiac failure, or both, we have a plan. We know exactly what to do. So, on this note, why didn't BP have a similar plan. If they did, why didn't they implement it? If they did, why is the slick still worsening? If they did, why didn't it work? I'm sure those are all questions presently being asked, or one would hope, by all the right people.

So, who really is to blame? Most like to toss the blame at the large company, or Obama, but the true blame goes to both BP and the government. It's a 50-50 split.

Here's my reasoning. In the past 40 years or so governmental officials have been increasing regulations on certain industries based on good intentions. The problem with good intentions is you're assuming you have the best policy, and you're also assuming there will be no consequences to your policy.

Yet, as we have learned, the more regulations we place on an industry, the more corrupt that industry gets.

As regulations go up, say on oil companies, every oil company has to pay for the regulations. The ones that can't afford it, the smaller firms, will eventually go out of business. What remains after the smaller competitive firms go under is only the large corporations (like BP) remain.

When I was an advertising student we were told never to wake up the sleeping giant. If a company was not advertising, don't provide it competition, or it will advertise, and it will squash you. Thus, many businesses are like behives, in that if you leave them alone they will leave you alone.

Another example here is the medical field itself. William Goldberg, in liberal fascism, writes that there are hundreds of medical industry lobbies, for specific diseases, specialties, and forms of treatment, each of which spends a fortune in direct and indirect lobbying and advertising. The only medical profession that spends next to nothing in Washington is Vetrinary care, because the government doesn't meddle with it.

Basically, Goldberg writes, "As the size and scope of government have grown, so have the number of businesses petitioning the government." Heck, there are over 35,000 lobbyists in Washington today, which has tripled since 1996 alone.

In a sence, all the BPs of the world end up with more power over the legislation, and very little competition. Thus, we see higher prices, and poorer service.

Actually, the same has happened to hospitals, as you may have noticed most of the smaller ones have been sucked up or closed shop.

So now you have only large oil companies left. And, to make sure government officials don't make more regulations that would effect their profits, they spend millions of dollars paying for lobbyists, and making donations to candidates. They also do this in an attempt to prevent these government officials from making new regulations that would increase their competition.

Legislators like this because they get votes. Likewise, by buying votes, big oil gets its way in Washington.

So here is the key lesson here: More regulation results in less competition, larger companies, and more lobbyists, and fewer of these companies following the regulations. This, as Thomas Jefferson once warned, this type of system should be avoided because it results in more corrupt business in the Capital. Large industries are now allowed, if not encouraged, to buy off Congressmen.

This is the kind of stuff that happens behind the scenes, and for that reason you don't hear about it in the news. If BP was less involved in politics and spent more of that lobby money on prevention and emergency plans, this disaster would not have happened.

Likewise, if the government were to set goals and incentives for oil companies instead of regulatory mandates (which you now know don't work), BP would have been prepared, and nature and shoreline economies wouldn't have been ruined, or at least a plan would have been in place to deal with such disasters.

That's my take, now it's your turn.

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Word of the Day: Enervate: To take energy from, to make weak and listless.
I was feeling quite enervated by the strain of work recently, which made the nice sunny day yesterday all the more rejuvenating. Enervate might be a good replacement for the word burnout.

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What would medical field be like if...

A lot of breathing treatments -- 80% I believe -- are not indicated. Could you imagine what the healthcare industry would be like if other therapies were abused as breathing treatments are?

Just think, what would the medical field be like if, just because someone had gas pain, the doctor said, "Well, I guess we better have that bowel removed."

Or, just because the patient was having trouble expectorating thick secretions despite a strong, agonizing cough, "Well, we better have RT come in here and suction this patient."

Or, every time a patient had a sat lower than 95 we gave lasix.

Or every time a patient had a headache we sent the patient to surgery for a lobotomy.

Thankfully abuse of those techniques have costly side effects. Breathing treatments are safe, and therefore -- much like EKGs -- are over ordered.

Perhaps the same is true of Tylenol.

My anwer to your RT Queries

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:

1. spiriva vs xopenex: Basically all you need to know about these two meds is that Xopenex is a fast acting bronchodilator that can provide instant relief from asthma or COPD. It is often called a rescue medicine because it works fast. It relaxes the air passages in the lungs. Xopenex is a medicine similar to Albuterol which is much less expensive and more commonly prescribed by physicians. Spiriva is a medicine that is also a bronchodilator yet it is referred to as a mild-bronchodilator. It has been proven to improve lung funciton in COPD patients, yet has not been proven to be of any benefit for most asthmatics. Spiriva and Xopenex (or Albuterol) are both recommended for COPD patients.

2. which is better advair or spiriva: I describe spiriva in the above paragraph. For COPD patients Spiriva and Advair and Xopenex can be used together. Advair is a preventative medicine that has both an inhaled steroid (Flovent) and a long acting bronchodilator. The steroid component treats and prevents inflammation, and the long-acting bronchodilator part treats and prevents bronchospasm.

3. blood gas interpretation made easy: This seems to be my most popular post.

4. even if you quit smoking, does copd stop progressing: I have been told that if you stop smoking you can prevent further progression of the disease. However, you cannot undue the damage that has already occured. While COPD is known to progress in many patients, this progression will be much slower in those who quit smoking.

5. when to stop ippb: I personally doctors should stop ordering IPPB altogether. However, it is recommended when an IPPB therapy is given that the treatment be 10 minutes long. Usually, however, most patients cannot make it that long with this annoying therapy.

6. what jobs can a respiratory therapist with bad knees do: I would guess doing pulmonary function testing wouldn't be too demanding on your knees. In the region where I live stress testing is a procedure performed by the RT department. Some RT departments do sleep studies.

Never quit quitting

So I had an early stage COPD patient today, and as is my job, I encouraged her to quit smoking. I didn't go as far to say she HAD to quit, but more so provided her with the ammo, and the incentive to do so, and pointed her in the right direction. That's, basically, how it goes. We RTs (as do RNs) plant seeds, and hopefully these seeds eventually blossom.

Yet this patient was adamant she wasn't going to quit smoking, "I love smoking. I have no interest in quitting. I love smoking when I have coffee in the morning, lunch, dinner, break at work. I just love it. Of course I know smoking is bad, but I don't want to quit. I know I should, but... you know."

"However, "I said, "Here is the information you need to quit. When you're ready to use it, you have it at your fingertips. Read up. Know what works best. Know the facts."

"Um, my doctor provided me with a pamphlet, and it said within 10 years your risk of other diseases goes down, but he said your COPD will keep progressing anyway. So I think: what's the point."

"I think you misunderstood your doctor. Either that or he's dead wrong. Because by all the facts I've read, your COPD will never go away if you quit, but it will be a lot easier to manage, progression will be slowed way down, and you will be able to live as you are now for a lot longer."

"Still," she said, "It's something I love to do. My daughter smokes too, and my husband. We just love doing it together."

Denial. The first step is admitting you have a problem. And that's the great thing about this country is you have a right to be stupid. However, I think this lady wants to quit, yet it's easier not to. It's easier to make excuses.

She said her grand daughter keeps trying to get her to quit. I said, "You should quit for her, so you can be around as she grows up."

"Yeah," she said, "But if it's gonna be, it's gonna be."

I told her I understand her completely. I remember teasing my grandpa when I was a kid, that he should quit. He said, "I'd rather smoke, enjoy life, and be happy, and die young than live to be 100 and not have enjoyed life as I do now."

I understand grandpa completely. However, when he started smoking, the facts about the dangers weren't plastered everywhere as they are today. There are way too many facts, too many studies, that show smoking, and second and third hand smoke, is dangerous. Too many studies that show quitting is beneficial in every single way you can think.

"I know I'm going to sound like a parent when I say this," I said, "But you're responsible for your decisions. I understand your quest to be happy, but there are other things you can do to find happiness than smoking."

"You're completely right," she said, "I'm glad I had this talk with you."

While I think she means well, I have seen too many ladies (and gentlemen) in her situation, and way too many decide that quitting simply isn't worth it. And I have to watch them die over the next few years. It's the sad truth of this job.

Yet it's our jobs to never quit urging them on.

RT consult or aerosolized medication protocol

I am presently working on writing the ideal RT Consult, otherwise known as an aerosolized medication protocol. Please help me out by adding any ideas or recommendations for the protocol below:

(For a printable copy of the protocol click here. For a printable copy of the forms, click here for side one and here for side two)

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RESPIRATORY THERAPY CONSULT (RT CONSULT)

Protocol Content:

1. Scope: A Licensed Registered Respiratory Therapist (RRT) or Certified Respiratory Therapist (CRT) who has successfully completed and passed all competencies related to patient assessment and protocols. Although respiratory students and assistants may perform medicated aerosol therapy, they may not adjust therapy per protocol.
2. Policy:

A. The Respiratory Aerosolized Medication Protocol will be initiated on patients ordered on aerosolized medications, or when a physician orders “respiratory consult”, or RT Consult, or when the physician writes for “RT to assess and treat.”

B. The physician will be notified when:

• a. The respiratory therapist wishes to initiate the protocol on a patient who is not currently on therapy.
• b. An initial therapy of Q2 or greater is indicated.
• c. If the patient’s condition is deteriorating requiring more frequent therapy other than the occasional PRN treatment, or patient feels no relief after 24 hours.
• d. The patient refuses therapy that is indicated.
  e. The respiratory therapist wishes to adjust any non-protocol medications.
• f. The goal of therapy is not clear.
• g. The respiratory therapist is unable to determine appropriate therapy.

C. A respiratory therapist may initiate this protocol on any patient when asked for an assessment of respiratory distress. One treatment may be given, if deemed appropriate by the therapist, prior to a physician’s order for RT Consult. Once the treatment is given, the physician will be contacted with the results of the therapy, and to obtain an order for RT Consult.

D. The respiratory therapist will assess, order, monitor, adjust and terminate the patients medicated aerosol treatments according to the patient’s clinical needs and protocol boundaries.

E. The physician may write an order for “No Respiratory Aerosolized Medication Protocol” or “No RT Consult” if he or she does not want this protocol to be used. The order for no protocol should include an explanation in the progress notes and therapy monitoring criteria.

F. All changes regarding patient’s therapy are to be recorded on the RESPIRATORY THERAPY (RT) CONSULT FORM.

G. When treatment is not indicated, patient will be assessed at least every six hours for 24 hours for changes in respiratory status and indications for aerosol therapy.

H. If, after 24 hours, treatment is not indicated and is being discontinued, this will be recorded in the OTHER RECOMMENDATIONS/NOTES section of the RT CONSULT FORM, and a courtesy call to the physician may be made.

I. The RT CONSULT FORM will be placed in doctor’s orders section of patient’s chart.

3. Respiratory Aerosolized Medication Protocol:

A. The following conditions are accepted indications for aerosol therapy:

• a. Bronchospasm/ wheezing
• b. Asthma/ reactive airway disease
• c. Diminished lung sounds
• d. COPD
• e. Prolonged expiratory phase
• f. Obstructive defects of PFT
• g. Impaired mucous clearance
• h. History of Pulmonary disease

B. Medications available per protocol:

• a. Albuterol
• b. Duoneb
• c. Atrovent
• d. Xoponex

C. This protocol will be initiated anytime there is a request for aerosol therapy. Upon receiving the order, the respiratory therapist will establish the goals and indications for therapy and perform an assessment.

D. The following assessment and chart findings will be recorded on the RT CONSULT FORM as appropriate:

• a. Vital signs (HR, RR, BP)
• b. Current FiO2
• c. Pulse oximetry
• d. PEFR (if indicated)
• e. Most recent ABG results
• f. Other diagnostic evauation (Chest X-Ray, lab tests, etc.)
• g. Smoking history
• h. Patient assessment results (lung sounds, work-of-breathing, cough, secretions)

E. Appropriate treatment and frequency will be determined using the GUIDELINES FOR AEROSOL THERAPY AND FREQUENCY on the reverse side of the RT CONSULT FORM. Using these guidelines, and based on a patient and chart assessment, an assessment total will be assigned and used to determine a triage #, and this triage number will be used as a guideline to determining therapy and frequency as follows:

• a. Triage #1 patients will receive treatments Q2 & PRN 0.5cc Ventolin and Q4 0.5mg Atrovent.
• b. Triage #2 patients will receive treatments Q4 and PRN 0.5cc Ventolin and Q8 0.5mg Atrovent.
• c. Triage #3 patients will receive treatments QID & PRN 0.5cc Ventolin and/or 0.5mg Atrovent.
• d. Triage #4 patients will receive treatments Q6 PRN 2.5mg Ventolin or 2 puffs Ventolin Q6 PRN if MDI criteria are met (see MDI criteria below), or consider discontinuing aerosol therapy. Also consider 2 puffs Atrovent QID or 2 puffs Combivent QID.

F. Changes in frequency may be made without direct physician consultation. The patient will be assessed with each treatment and as needed to ensure tolerance of these changes.

G. All non-acute patients who are on home-aerosolized medications may have therapy initiated by the respiratory therapist under this protocol. The dosage and frequency of each medication should remain the same as taken at home, unless the patient’s physician specifies otherwise.

H. Peak Expiratory Flow Rates (PEFR) will be done on asthmatics before and after the initial treatment and then done twice a day, preferably in the morning and evening, and more frequently if necessary or as appropriate. The patient’s tolerance to perform this maneuver should be taken into account and documented.

I. Once the level of care is determined, the respiratory therapist will initiate the program by documenting on the RT CONSULT FORM the drug, dose and frequency. The RCP will then sign his or her name followed by credentials. The physician’s name does not have to be included once he or she has initiated the protocol.

J. With any changes to therapy the RT CONSULT FORM must be completed.

K. The respiratory therapist will decrease frequency of treatments when the goals of therapy have been met in accordance with the GUIDELINES FOR DETERMINING AEROSOL THERAPY AND FREQUENCY.

L. Criteria for MDI use:

• a. Can physically perform the maneuver.
• b. Can follow directions.
• c. Is cooperative and alert.
• d. Can take a slow deep inspiration.
• e. Can hold breath for at least five seconds.
• f. Is able to perform a return demonstration.
• g. Respiratory rate <= 25

M. If a patient has MDI for medications approved per this protocol ordered for home use, and a breathing treatment is not currently indicated, and/or the patient wishes to continue this home routine, this MDI may be ordered for in hospital patient use if the patient meets the criteria for MDI use listed above. The order must be for the same med as the patient uses at home (or the generic equivalent as determined by pharmacy), and the same dose and frequency.

N. After the initial instruct on proper MDI use, and the patient demonstrates effective technique, the MDI may be turned over to nursing.

5. Bronchopulmonary Hygiene Protocol:

A. Indications: Productive cough, pneumonia, rhonchi on auscultation, history of mucous producing disease, patient unable to deep breathe and cough spontaneously, post-op, difficulty with secretion clearance with increased sputum production.

B. If these indications are met, Chest Physical Therapy (CPT) may be performed as tolerated by patient. The recommended frequency is QID and prn.

C. Re-evaluate patient every 24 hours.

D. Assess outcomes to determine if goals have been achieved:

• a. Optimal hydration with improved sputum production.
• b. Lung sounds from diminished to adventitious with rhonchi cleared by cough.
• c. Patient subjective impression of less retention and improved clearance.
• d. Resolution/ improvement in chest x-ray.
• e. Improvement in vital signs and measures of gas exchange.
• f. Post-op patient shows no signs of distress and demonstrates good cough and/or is able to move around in bed or room with or without assistance.

E. Discontinue therapy if improvement is observed and sustained over a 24-hour period, and record this in the OTHER RECOMMENDATIONS/NOTES section of the RT CONSULT FORM. F. Patients with chronic pulmonary disease who maintain secretion clearance in their own home environment should remain on treatment no less than their home Frequency.

6. Hyperinflation Therapy Protocol:

A. Indications: Atelectasis, decreased lung sounds; the goal is to prevent Atelectasis; the patient had thoracic or abdominal surgery; prolonged bed rest, restrictive lung defect.

B. If these indications are met, the patient may be provided with an Incentive Spirometer (IS) and educated on its proper use.

C. Once the initial instruct is provided to the patient, the IS treatment may be turned over to the care of the patient and/or RN to be performed by patient Q1-2 W/A.

7. Documentation: A. Initial Assessment:

1. A Respiratory Care Assessment will be completed for all patients ordered on RT Consult.

2. The respiratory therapist will document this assessment on the RT CONSULT FORM. On this form, the RCP will mark all indications for therapy, and circle all recommended medications indicated for patient, the recommended doses for each medication, and the recommended frequency for each medication.

3. If a physician did not initiate the protocol, the physician must be notified and an initial order received and documented in the patient’s chart or, if the physician is available, he or she may sign the initial RESPIRATORY THERAPY CONSULT FORM and no further order need be written.

4. All therapy will be documented in Meditech.

B. Re-assessments:

1. All patients will be assessed with every treatment to determine the patient’s current pulmonary status and effectiveness of the aerosol therapy.

2. Adjustments of the patient’s therapy will be determined objectively by changes in the monitored parameters, and by using the GUIDELINES FOR DETERMINING BRONCHODILATOR THERAPY.

3. The respiratory therapist will fill out a new RESPIRATORY THERAPY CONSULT FORM for all patients whose frequency or therapy is adjusted.

8. REFERENCES:

1. Spectum Health (2005) Aerosolized Medication Protocol, Grand Rapids: Spectrum Health.

2. Northern Michigan Hospital (2004) Bronchodilator Protocol, Petosky, MI: Northern Michigan Hospital.

3. Covenant Health Care (2005) Respiratory Therapy Consult, Saginaw, MI: Covenant Health Care.

4. “Guidelines for Preparing a Respiratory Therapy Protocol.” Retrieved August 23, 2007, from

http://www.aarc.org/members_area/resources/protocol_guidelines.html

5. “Respiratory Therapy Protocols.” Retrieved August 4, 2007, from http://www.st.alexius.org/about_stas/services/Resp_Care/protocols.asp?printable=1

6. Phillips, Jan, “Bronchopulmonary Hygiene Protocol,” May 5, 2003. Retrieved from http://www.aarc.org/resources/protocol_resources/documents/broncho_hygiene_algorithm.pdf
7. “Hyperinflation Protocol.” Retrieved from http://www.aarc.org/resources/protocol_resources/documents/AARCpedHyp.pdf
8. Phillips, Jan, “Hyperinflation Protocol,” May, 5, 2003. Retrieved fromhttp://www.aarc.org/resources/protocol_resources/documents/hyperinflation_algorithm.pdf

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Should I be worried about taking Advair? What asthma inhalers contain ethenol?

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.

Your Question: Should I be worried about taking Advair because of what I read in the news?

My Humble Answer: Advair is a medicine that if used properly, or exactly as prescribed by your doctor, can greatly improve your asthma. It has worked miracles for many asthmatics, including myself. So long as you use this medicine PROPERLY, and you pay attention to your signs and symptoms of asthma, and follow your asthma action plan to a tee, this medicine is safe.

I think the reason this medicine gets such a bad rap is some asthmatics rely on it too much, and don't pay attention to their early warning signs of asthma, and wait too long to call for help.

Still you'll want to be alert of possible side effects of any new medicine you take, especially withing the first 2 weeks. As with any medicine, you and your doctor will have to weigh possible side effects with benefits. As your doctor prescribed this medicine, he believes it's safe and may also benefit you.

Consider this my opinion. If you continue to have concerns, you should call your doctor.

For more information, you should check out this link by Dr. Mintz or this MyAsthmaCentral Sharepost by me.

Your Question: What brand inhaler has the most ethanol in it?

My Humble Answer: You can look at the package insert to see if the inhaler your doctor prescribes has ethanol in it. I'm not sure if the amount is listed. I think the inhalers that have ethanol in it are the newer ones with HFA inhalants. However, although I have done some research on this, I wouldn't consider myself an expert. You may be better off posing this question to your pharmacist, although he too may simply refer you to the package insert.

I actually did some research on this a while back. While what I found doesn't give a definite answer (that would make it too easy), it may lead you in the right direction. Check out this link.

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

Symbicort may provide new option for asthmatics

While the FDA is issuing warnings that scare asthmatics away from great asthma medicines like Advair and Symbicort, Europe has gone in the opposite direction. Still, there' hope the FDA might approve Symbicort as a single use inhaler. Read on, and I'll explain.

Symbicort May Offer New Option for Asthmatics

by Rick Frea, Monday, February 22, 2010 @MyAsthmaCentral.com

While it has not yet been approved in the United States, Symbicort may some day be available as a rescue inhaler as well as a preventative medicine. In this sense, it may be the dream inhaler we asthmatics have been yearning for.

In Europe, Australia, and recently Canada, Symbicort has been approved for this purpose. The program is called the SMART program, and you can read about it by clicking here.

According to asthmansw.org, SMART is an acronym for "Symbicort Maintenance And Reliever Therapy." The SMART program is explained here:

"It is a daily asthma management approach that allows you to use a single Symbicort inhaler as both a preventer and a reliever. Currently Symbicort is the only medication available for use as BOTH a maintenance preventer and reliever.

SMART works this way as it contains two different types of medicine in the same inhaler - a preventer (Pulmicort [Budesonide]) as the long-acting reliever which helps to control redness and swelling in the airways, and a reliever (Oxis [Eformoterol]) which can not only work quickly, but can also last a long time.

A person using the SMART approach to manage their asthma would take a maintenance dose of Symbicort, usually morning and night to maintain or establish asthma control AND they would also take additional inhalations of Symbicort as needed to relieve symptoms.

SMART is suitable for all people aged 12 years or older who are currently recommended to take combination medication for their asthma.

Symbicort has been available in Europe since since 2000, and was first made available in the U.S. in 2007 as a combination inhaler to compete with Advair (which presently is No. 1 in the U.S. market).

Symbicort works as a rescue inhaler because Formoterol starts to open the air passages in your lungs in two to three minutes as compared to 10 to 20 minutes for Serevent (the long acting bronchodilator in Advair).

Still, while it's approved as a rescue inhaler, the SMART programs limits the patient to eight puffs of Symbicort in any given day.

Likewise, it should always be used in concordance with an asthma doctor, and always as part of a physician directed asthma action plan like the ones linked to from this site.

By using Symbicort as a rescue inhaler, the asthmatic receives a boost of corticosteroid every time there is an asthma episode, instead of just using a rescue inhaler (like Albuterol). This basically allows the patient to increase his corticosteroid when he needs it, and decrease it when he's doing well. In this way the asthmatic has more control

Thus, "Studies have shown that people using Symbicort SMART - an additional way of taking the existing Symbicort inhaler - took no extra inhaled steroids and needed fewer oral steroids compared to traditional treatment methods. They also experienced fewer asthma attacks."

An Astra Zeneca sponsored study (the makers of Symbicort) noted the SMART program resulted in a 28 percent reduction in severe exacerbation compared to a regimine of using Symbicort twice a day while using something like Ventolin as a rescue inhaler in between.

According to this article at news-medical.net, researchers in the U.S. are reviewing data currently available and have "found no significant reduction in the number of asthma exacerbations that required hospitalization among the patients who used single inhaler therapy. However, the reviewers did find that fewer adults on single inhaler therapy had exacerbations needing a course of oral corticosteroids"

Researchers are also awaiting the results of five not yet to be released trials.

The pros of using Symbicort as a single inhaler are convenience, improved control, improved compliance, and that you will automatically be getting an additional boost of steroids right when you need it. This may especially benefit those who are compliant with their controller meds. (This asthma blogger does not like the SMART program).

A con of using Symbicort as a single inhaler is that for those who do not regularly use it, it usually takes two to three weeks for inhaled corticosteroids to start working, and therefore the added boost of corticosteroid may prove to be of no benefit.

So research is ongoing, and the debate, I am sure, will continue.

Whether the SMART program or something like it will ever be approved by the FDA is still open to debate. Yet if this is someday approved it will make available yet another alternative for physicians and asthmatics to try.

Are 12 hour shifts bad for the heart?

A new study, reported on here at CNN.com, has linked -- once again -- working too many hours with cardiac disease. Working overtime, as well as 10-12 hour shifts, have been, according to another study, linked with heart disease.

Most of us in the medical field work 12 hour shifts, and I know from personal experience at about the 8 hour mark pure exhaustion comes into play. By the time I get home, regardless of how busy I was during the day, I'm both physically and mentally exhausted.

Burnout is one of the major risks of working in the medical profession, and now we must think if this "burnout feeling" might be linked to stress that causes high blood pressure perhaps, and thus can lead to an ailing heart.

However, this study has some glaring holes in it. For one thing, the sample size is extremely small (less than 400). And it doesn't say how many 10-12 hours worked per week might lead to exhaustion or heart problems. So, considering most of us in the medical field work three 12 hour shifts, does this count? Is working only 12 hour shifts a week bad for the heart?

Or are they referring to 5 12 hour shifts, or 4, or 6, or 7 or...? Likewise, what kind of work is done? If I worked 12 hours and I basically sit there and watch a monitor for 12 hours, does that increase my risk for heart disease?

The answer is: we don't know.

Still, we should all be leery of this research, considering I've read more than one such study. To prevent heart disease, we all should eat well, exercise regularly, get plenty of rest (which includes days off and vacations) and see a doctor at least once a year.

Too much information

You can always tell the new RT from the experienced one. The new one is the one you'll hear asking, "So, how did you sleep last night?"

Thirty minutes later, after the patient finishes explaining all the reasons he did NOT sleep well, the RT leaves the patient's room. In this case, he left the room because I paged him, giving him a reason to leave.

When I took a sales class in business college years ago we were taught never to say, "How are you doing?" Well, in the medical field you have to ignore this rule, and actually ask.

Still, the answer you get isn't always the easy answer. Sometimes, more often than I care to admit, I get too much information (TMI). Thus, you learn not to ask a question unless you want to hear the answer.

So, we RTs come up with shortcuts. When I'm doing a procedure like an EKG, and all I have to do is type some reason on the EKG printout, I simplify the question: "So, in three words or less, why are you here?"

Yet, when you're assessing the patient, it's better to ask open ended questions like, "So, tell me what's bothering you?" You and I both know the answer isn't always pithy.

On another note, if you know the patient is quite loquacious, you can have one of your coworkers give you five minutes and then page you. Then, if you need it, you'll have an out.

I got busted educating a patient

So I had a patient who has asthma. He told me he wondered why he couldn't just get an inhaler like he has at home so he can just use it when he needs it.

He said, "Are there any studies that prove a nebulizer is better than an MDI?"

I said, "No. In fact, all studies I've ever seen show that so long as you are not labored an MDI with spacer is equally as effective as a nebulizer." I told him he ought to share this fact with his doctor, and request an MDI.

He did. When I came in tonight his order was changed from Q6 to Q4. Which kind of made me laugh, because this is exactly what I wrote about in "Real Doctor's Creed."

"If RRT annoys you, change Albuterol to Xoponex Q3-4, Atrovent Q6, and consider using Pulmicort, Intal and/or Mucomyst. This will make tx last forever (tee hee hee)."

In this case it wasn't RT, it was the patient who asked. However the doctor must have caught on that RT was educating behind his back.

Living with end stage COPD

As respiratory therapists we see, and often get to know pretty well, many end stage COPD patients. Yet, as we all know, end stage COPD "does not have to be a death sentence," writes Jane M. Martin in her post, "Healthy -- and Happy -- with 'End Stage' COPD?" over at the COPD Connection.

In her post, she provides the following tips for end stage or severe COPDers:

1. Stay well: As with asthma, COPD at any stage can be controlled. Control means that you are on the least amount of medication to maintain your own personal goals for your disease. Now, if your disease has progressed, you have to know your limits. But it doesn't mean you have to live in a shell.

So, staying well actually means knowing your limits, and knowing what you need to do to prevent a severe exacerbation of COPD. You must work with your doctor and take charge of your COPD. You must know your COPD triggers (which are similar to asthma triggers).

Likewise, Martin notes you'll also have to know your early warning signs that your COPD is starting to act up. I write about Early warning signs here.

2. Quit smoking: As you can see by this link, once you quit smoking you will prevent further lung damage, so that you can more easily learn to cope with and manage what you have -- with the help of your doctor of course.

3. Be informed: The best way to be a gallant COPDer, and to live the best life possible, you will need to stay in tune with the latest COPD wisdom. What are the latest meds? What is the latest COPD wisdom? What makes COPD worse? What makes it better? What is COPD? Get the facts. Check out this link and this.

4. Connect with others: You can also read COPD blogs to see what other COPDers like you are doing to cope, or participate in a community. For cool links, click here.

5. Get into pulmonary rehab: There is no better way to increase your quality of life, and prevent further delay, than by exercising. No matter how bad your COPD is, you should stay active. A good pulmonary rehab program is the ideal setting. Talk to your doctor about finding the program nearest you. This is also a good way to meet other COPDers.

6. Join a Better Breathers' Club : According to Martin, "At a Better Breathers' support group you will learn from guest speakers about staying healthy with COPD and meet people with similar concerns. Your spouse or support person might also connect with somebody who understands the unique issues of a caregiver/well spouse. Attending a breathing support group is free of charge and does not require a doctor's order. For the breathing support group nearest you call your local hospital, oxygen supply company, or go to the American Lung Association website. Click on "COPD Center" and go to Better Breathers Clubs. (http://www.lungusa.org/)."

7. Join an OnLine COPD community: I already provided links above. This is a great way to get to know other COPDers, ask questions, and stay in tune with your disease.

To learn more about COPD, click here.

Ventilator Management Protocol

I am presently working on writing the ideal ventilator management protocol to go with our extubation protocol. Please help me out by adding any ideas or recommendations for the protocol below:

(For a printable copy, click here)

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1. Scope: A Licensed Registered Respiratory Therapist (RRT) who has successfully completed and passed all competencies related to patient assessment and protocols. Certified Respiratory Therapists, respiratory students and assistants may not adjust Mechanical ventilators per protocol.

2. Policy:

A. The Mechanical Ventilator Management Protocol will only be initiated on patients ordered on Vent Management Protocol (VMP), or if the attending physician orders RT Consult on a mechanically ventilated patient.

B. The attending physician may write “discontinue Vent Management Protocol”
(VMP) or discontinue RT Consult at any time.

C. The physician does not need to be notified if:

• a. Weaning FiO2
• b. Increasing FiO2 if not going greater than 50%
• c. Increase in PSV of 5 or less to maintain adequate tidal volume
• d. Changing in and out of volume support

D. The physician will be notified when:

• a. The respiratory therapist wishes to initiate VMP on a patient who is not Currently on the protocol
• b. If the patient’s condition is deteriorating.
• c. The respiratory therapist is unable to determine appropriate therapy.
• d. If the FiO2 is greater than 60% and PaO2 less than 60mmHg or SpO2 less than 90% with

5cmH20 PEEP.

e. When pre-determined therapy limits are reached, i.e. FiO2, Vt, PEEP, RR, etc.

f. When PEEP greater than 5 is indicated.

g. If PEEP greater than5 has been approved, and now PEEP less than 8 is indicated.

h. A RR greater than 30 or less than 8 is indicated

i. A VT greater than 10 ml/kg ideal body weight or less than 6 ml/kg is indicated.

j. If VT or PEEP is indicated that results in PIP greater than or = 40 or plateau pressure greater than 30.

k. Weaning success or failure

l. Increasing FiO2 above 50% is indicated to maintain sats

m. Change in PSV greater than 5 cmH20 is made

n. A change in tidal volume is made

o. A change in respiratory rate is made

E. For continuous monitoring of ABG values, an arterial line should be introduced, and/or the use of non-invasive monitoring (SpO2 & EtCO2)should be employed. Non-invasive monitoring is preferred.

F. Modify ventilator settings as indicated to maintain target values.

G. Assure the non-invasive oxygen saturation (SpO2) and end tidal CO2 (EtCO2) values correlate with current ABGs.

H. If rate of greater than 30 is indicated, consider sedation prior to calling physician.

I. Maximum PIP is determined by increasing PEEP in increments of
1cmH20. Stop increasing when BP, HR, SpO2 drop, or PaO2/Fio2 Ratio = or less than 200. If the PaO2/FiO2 ratio increases you know PEEP therapy is working.

J. When considering the adjustment of FiO2, hemoglobin should be checked to ensure the absence of anemia. Hemodynamic data should be checked to ensure adequate circulation.

3. Ventilator Management Protocol: The following are guidelines for use in stabilization and management of the patient on mechanical ventilation:

A. The following values will be maintained, unless otherwise ordered by physician.

• a. Ph: 7.35 to 7.45
• b. PaCO2: 35 to 45 mmHg (EtCO2: 30 to 50 mmHg), unless the patients “usual” PaCO2 is chronically elevated.
• c. PaO2: 60 to 100 mmHg (SpO2 greater than 90%)
• d. In patients with COPD, adjust parameters to the patient’s “normal” values

B. Obtain ABG or non-invasive oxygen saturation (SpO2) and end tidal CO2

C. Adjust the ventilator settings to correct abnormal ABG and/or SpO2 and EtCO2 values.

a. Abnormal PaCO2 greater than 45 mmHg (EtCO2) values:

• 1. Increase rate in increments of 2 to obtain acceptable values.
• 2. Increase Tidal Volume by increments of 50ml to obtain acceptable values

b. Abnormal PaCO2 less than 35 mmHg (EtCO2) values:

• 1. Decrease rate in increments of 2 to obtain acceptable values.
• 2. Decrease Tidal Volume by increments of 50ml to obtain acceptable values.

c. Abnormal PaO2/SpO2 values:

• 1. PaO2 less than 60 mmHg or SpO2 less than90%, increase FiO2 in increments of 05% to obtain acceptable values.
• 2. For hypoxia (Sa02 less than 92%)requiring greater than 60% FiO2, increase PEEP in steps of 1 cmH20 at a time to PEEP max (specific Dr. order required)
• 5. With PEEP = or greater than 5 & PaO2 greater than 100 mmHg or Spo2 greater than 95%, decrease FiO2 in increments of 05% to obtain acceptable values.
• 6. If the SpO2 or PaO2 is not adequate after any weaning attempt of the Fi02, increase the Fi02 to the previous setting. Continue weaning the Fi02 as tolerated by patient.

D. Non-invasive monitoring or ABG criteria is not the absolute control for maintaining Ventilatory support. Sudden changes in cardiovascular status, respiratory rate, and color may mandate a change in ventilator parameters.

E. Once patient is stabilized, and once the problem that resulted in the need for Ventilatory support has been resolved, the patient should be continuously monitored for indications for weaning (See Ventilator Weaning Protocol).

4. Documentation:

A. Initial assessment

• a. An RT assessment will be performed within 15-45 minutes from start of ventilation.
• b. Assessment will include evaluation of the patient’s general appearance, blood pressure, heart rate, breath sounds, ventilating pressures, volumes and ABGs.
• c. Assessments may also include additional data, when available, such as EtCO2 and hemodynamic data.
• d. Ventilator checks will be completed every two hours and documented accordingly. Checks will include ventilator settings, pressures, and essential alarms
• e. Cuff pressure will be checked once per shift, and a minimum cuff pressure of 20 cwp will be maintained in order to minimize VAP.
• f. All therapy will be documented in computer charting.

B. Re-assessments

• a. Regular assessment of general appearance, vital signs, breath sounds and Hemodynamic stability should be evaluated prior to and during any ventilator adjustment.
• B. Adjustments of the patient’s therapy will be determined objectively by changes in the monitored parameters.

5. References:

1. Mechanical Ventilator Protocol, Retrieved from: http://rtcorner.net/rt_forms.htm
and http://rtcorner.net/rt_forms.htm

2. Mechanical Ventilator Protocols, Retrieved from:
http://www.aarc.org/resources/protocol_resources/documents/general_vent.pdf
3. CTICU Weaning Protocol, retrieved from: http://www.dhmc.org/webpage.cfm?site_id=2&org_id=116&morg_id=0&sec_id=0&gsec_id=5560&item_id=7386

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For a related article, check out "Ventilator Weaning Protocols" by Bill Croft @ rtmagazine.com

How long does Singulair take to start working?

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.

Your Question: I've started taking Singulair for asthma/allergies. When will I start seeing the effects?

My Humble Response: It usually takes 2-3 weeks to start receiving the desired effect. This is why you should never wait until you're having an asthma flare up to start taking this medicine, unless you're using it for exercise induced bronchospasm. This is an asthma controller medicine that must be in your system at all times to PREVENT asthma, and therefore you should take it even when you're feeling good. Otherwise, it usually takes 2-3 weeks to get into your system.

Your Question: Does asthma cause weight gain? My daughter is on steroids for her asthma, and she is gaining weight.

My Humble Answer: Asthma does not cause weight gain. However, systemic corticosteroids used to treat asthma (or other ailments) can cause weight gain.

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

Advair & Symbicort safe for asthmatics

As you can read here, the FDA has "finally" admitted that long-acting beta Adrenergic mecidines can cause asthma related deaths. I believe this to be a bad admission by the FDA as I explain in my most recent post over at MyAsthmaCentral.com

Don't be Afraid of Using Advair and Symbicort

by Rick Frea, Monday, March 29, 2010 @MyAsthmaCentral.com

So what's the deal with Advair and Symbicort? These meds have helped so many asthmatics finally gain control of their asthma, yet, with all the recent warnings, the FDA seems to be wary of these meds, and this is scaring people.

Should we be wary and quit taking them? Or, should we continue to use these meds to control asthma? I personally agree with Dr. Matthew Minz that you should fear not. Allow me to explain.
Both Advair and Symbicort contain a Long Acting Beta Adrenergic (LABA) to keep the air passages in your lungs from spasming. In Advair the LABA is Serevent, in Symbicort the LABA is Formoterol.
Some reports say LABAs are linked to worsening asthma and even death, such as this warning about Advair:

"University of Iowa researchers have added their voices to growing warnings about Advair, saying that drugs that use salmeterol in combination with an inhaled corticosteroid can make asthma more severe or even fatal."

Or this warning regarding Symbicort:

"Rarely, serious (sometimes fatal) asthma-related breathing problems may occur in people with asthma who are treated with drugs similar to the formoterol in this product. "

The most recent FDA recommendation notes this: "LABAs should be used for the shortest duration of time required to achieve control of asthma symptoms and discontinued, if possible, once asthma control is achieved."

So, should we be worried? In a recent blog post, Dr. Minz answers this question best:
"There is very compelling data that shows when asthmatics stop their controller medications, that bad things happen, including ER visits, hospitalizations, and even death."

He's also correct when he writes that fear generated about these meds may actually make things worse for asthmatics, especially if doctors and patients become afraid of these asthma controller meds that have helped many asthmatics gain control of their asthma.

Dr. Mintz also explains that the asthma death rate was increasing steadily until 1996/1997, and then the rate declined for the next decade. The decline started right about the time LABAs were introduced to the market. "Though one can not prove that the decline in asthma death rates are due to the use of LABA's," he writes, "it certainly can not be the case that LABA's cause asthma deaths."
He goes on to make a great case for why FDA Blows it on LABA Safety. A great read if you have time.
This blogger pretty much sums up my view on this matter. He notes how well Advair has helped his wife finally get her asthma under control. Yet, when he heard the latest FDA recommendation, he approached his wife and said, "Advair can lead to asthma-related deaths!"

His wife "lovingly assured" him that, "It gets rid of my symptoms! It makes me feel better! Asthma can lead to asthma-related death! "

I added the bold for emphasis. She is absolutely right: Asthma can lead to asthma- related deaths, and medicines like Advair and Symbicort are PROVEN (as you can see here and here and here) to greatly improve lung function in asthmatics and COPD patients.

Some authors (like this one) actually discuss taking Advair off the market.

Yet, in Europe asthma experts are less wary of LABAs, and even approved of the Symbicort-SMART program that allows asthma patients to use Symbicort as a controller medicine AND a rescue medicine (with a limit of eight puffs per day).

Recently, I wrote how researchers in the U.S. are studying Symbicort use as a "single inhaler" might work for asthmatics in the U.S. too. Although the results of most of the studies are still pending (you can read my post about Symbicort-SMART here).

So, if Advair works so well, and Symbicort is now used as a rescue inhaler in Europe, why all the worry in the U.S?

Well, the FDA likes to err on the side of caution. This can be good, but it also can scare doctors and patients away from meds that work -- like Advair and Symbicort.

I did discuss this with my doctor and he agrees with me. Advair is the first medicine that has fully allowed me to gain complete control of my asthma, and to stop taking it would be foolish. He said, "It's the new asthma miracle drug."

Be educated. I think over-reliance on bronchodilators and LABAs due to poor education is more likely to cause asthma related-deaths than the medicine itself, in most cases. So education is the key. Heed the warnings, yet know the facts.

Advair and Symbicort have been proven to have very minimal side effects so long as you rinse your mouth out after each use. Whenever you take a new medicine, you should always be vigilant for side effects (especially in the first two weeks), and notify your doctor immediately if you spot one.

Likewise, it is very important that you use all your asthma medications exactly as prescribed by your doctor, and follow your asthma action plan to a T. If you don't have an asthma action plan, you should talk to your doctor about creating one at your next appointment.

So, should you continue take your Advair? Definitely. If this is what works to control your asthma and allows you to live a normal life with this disease, don't stop taking it unless you have your doctor's permission.

And if you have uncontrolled asthma, and your doctor recommends you try Advair
r Symbicort, don't be afraid to try it. Just be careful as you would with any other new medicine.
Medicines are only to be used if the benefits outweigh the risks. With both Symbicort and Advair, the benefit is quite often good asthma control and a normal or improved quality of life.

So, as an FDA advisory committee reported back in 2008 (click here), "the benefit of Advair and Symbicort outweighed the risks of adverse effects in adults."

Advair and Symbicort are safe, and they work. Don't be afraid to use them.