COPD patients may feel dyspnea in flight

If you have COPD you may have noticed that your breathing is a bit more difficult when you are flying. And this poses an additional challenge for you that people with "normal" lungs don't have to worry about.

In fact, a new study by Norwegian scientists revealed that COPD patients flying were over six times more likely to experience hypoxia (low oxygen in the blood) and feel dyspnea (feeling of shortness of breath) while flying.

One of the main reasons is because those with COPD already carry less oxygen in their arteries, which are the vessels in the body that carry freshly oxygenated blood to tissues. When the lung are chronically obstructed, less oxygen is able to get to the lungs, and this results in less blood to the arteries.

While under the pressure of the cabin of an airplane, the amount of oxygen in the air is already less than on the ground. For example, the fraction of oxygen inspired (FiO2) at ocean level is 21%. Yet the higher you go the lower the percentage of oxygen that's available to breath.

For example, at the top of a mountain, or in the cabin of an airplane, the FiO2 may be as low as 19%. This might cause dyspnea in a person with normal lungs. Yet in a person with COPD, who already has less oxygen in the lungs and arteries, this will almost certainly cause a feeling of shortness of breath.

Consider the following facts according to Egan's Fundamentals of Respiratory Care:

The air we inhale consists of 21% oxygen. In the medical arena we refer to this 21 percent as the fractional concentration of oxygen, otherwise known as the fraction of inspired oxygen (FiO2).

Thus, to compute the partial pressure of oxygen (PO2) you multiply the FiO2 by the total pressure of the atmosphere. A normal atmospheric pressure is 760 mm Hg at sea level.

Or, the formula would look like this:

• PO2 = 0.21 * 760 = 160 mm Hg

So the normal PO2 of oxygen we inhale is 160 mm Hg
Now, according to Egans, "At a typical cruising altitude of 30,000 feet, the barometric pressure outside the airplane cabin is about 226 mm Hg. Thus, the partial pressure of the inspired oxygen (PO2) would be calculated as such:

• PO2 = 0.21 * 226 = 47 mm Hg

"Thus, should the cabin depressurize, travelers inside would be exposed to this low PO2, most people would become unconscious within seconds, and will eventually die of lack of oxygen (anoxia)."
To fix this problem, the passengers would wear oxygen masks that supply 70% oxygen. This new formula would be calculated as such:

• PO2 = 0.75 * 226 = 158 mm Hg

This would supply enough oxygen to sustain life.
Still, as you go higher, the PO2 will decrease the higher you go because the barometric pressure changes. So COPD patients who already have a low PO2 inside their arteries are going to feel the effect of a lower atmoshperic PO2 as compared to someone with normal lungs and a normal PO2.
Consider that oxygen travels the path of least resistance. By this, the normal PO2 in the atmoshpere is 160, the normal PO2 in the arteries is 104, and the normal PO2 in the veins is 40. So oxygen travels easily from the air, to the lungs and arteries, and then from the tissues to the veins.
However, with COPD the PO2 in your arteries might be 60 instead of 104. So if the PO2 in the atmosphere is low, the PO2 in your arteries will be even lower. Hence, you may feel dyspneic before other passengers would.
It should be said here that the percent of oxygen in the air inhaled (whether it be 21% or 75%) does not determine how the oxygen works in the body. How the oxygen works is determined by the partial pressure of oxygen inhaled (PO2).
So, the lower the PO2 inspired the more dyspnea a person will feel. This is why mountain climbers and pilots sometimes carry extra oxygen with them. By increasing the FiO2, we can increase the PO2.
The barometric pressure
So if you are flying, and you have COPD, you may want to discuss the the airline the possibility that you might require oxygen in flight. If you already have oxygen at home, then you definitely want to either take it with you, or work with the airline to make sure oxygen is available to you in flight.

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Breathing treatments make no money for hospital

When it comes to your RT department boss being happy by the breathing treatment count, he is not happy because a breathing treatment means higher profits for the RT department and the hospital. That's not the case at all.

The truth is, he's happy because of the procedure count. Procedure count is important because the more procedures a department does, the more money is allocated to your department. Likewise, the procedure count has to be high enough to justify the allocation of a staff position.

That's right. In order for you to keep your job you have to do so much work. So the next time you or your co-worker complain about needless work, just think of it from this perspective. I like protocols, yet if we discontinue all needless procedures, we RTs will be our of work.

And trust me, I too am one to complain about needless work. For one thing it makes me feel like an assembly line worker: it diminishes self esteem, dignity and mercy. However, a job is a job. It pays the bills.

As far as reimbursement is concerned for a specific patient, it is a fact that it doesn't matter if you give 1 treatment or 100 to a patient on Medicare or Medicaid, because the Centers for Medicaid and Medicare Services (CMS) reimburses a flat fee for each diagnosis related group (DRG).

This is what happens when we allow the government to make the rules. This is what happens when the government is flipping the bill. So while your department charge for a breathing treatment might be $100, the only person paying that $100 is the person who has no health insurance.

Actually, the best health care reform would be to make it so that people without health insurance paid the same as those who do. This might help lower the cost of medicine as far as the customer is concerned, and it might just allow people visiting hospitals a better opportunity to pay the bill. It might prevent some health related bankruptcies.

On a related issue, Anthony L. DeWitt (AARC Times, December 2010), Whisteblowing 101, wrote that a hospital can bill for the 10 treatments that were ordered while the patient was admitted, and this will not be considered as fraud even if the treatments were not given.

The same principle applies: CMS reimburses a flat fee for a specific DRG (diagnosis). DeWitt writes that:

"In essence, the hospital is banking on being able to treat the patient efficiently and get them out of the hospital quickly. So whether the patient gets one treatment or 10 treatments, the cost to Medicare is the same because it's calculated on the basis of the diagnosis. Internally, the hospital can bill for 40 treatments never done, and it won't have any effect on the final bill to Medicare."

Poppycock? Why sure it is. Yet such is how it is when the government is in charge of flipping the bill. However, as goofy as this sounds, useless and un-indicated breathing treatments that burn you and me out might be what's keeping us on the job.


Something to think about anyway.


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Is itchy lungs normal with asthma?

The following is a q and a session from Myasthma central.com I though my fellow asthmatics might be interested in:

Your question: I have an itchy sensation in my upper back and chest. It feels like my lungs are itching yet I can't scratch it. Does this have something to do with asthma. I used to get this sensation a lot as a kid, yet accassionally as an adult. I just got over a week long dose of antibiotics for an infection that I think is resolved by now. What do you think?

My humble answer: I'd like to reiterate this could be normal with asthma. It could be that the infection in your lungs is breaking up and the secretions in there are irritating your airways, causing them to itch. I had this feeling many times too, although mostly as a kid. I think it's more common in kids because their airways are smaller (this is also why asthma tends to be worse in kids too).

It usually resolves with time, or sometimes with the use of your rescue medicine. However, if it doesn't, it might possibly be an early warning sign of an asthma attack, perhaps caused by a new onset of infection. So if it doesn't dissipate you may need to put your asthma action plan into action.

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Don't forget you have asthma

You outgrew your asthma, and now it seems as though it has gone away. In the past I wrote about asthma forgetfulness and recovered asthmatics. In a more recent post from AsthmaCentral.com I provide some reasons you MUST never forget you have asthma.

9 Reasons You Must Never Forget You Have Asthma

In the first season of "The Biggest Loser" one of the final contestants lost a ton of weight, and he proclaimed in his ebulient New York accent something like, "The best part of losing all this weight is: my asthma is gone. Gone! GONE!!!"

This happens to a lot of people. The reason is because asthma is a strange disease, in that it can be bothersome one minute, and then it can go into remission for days, weeks, months and even years. In essence, it can appear to be gone. Gone! GONE!!!

Yet it's not. And because it's not you must continue to know you still have asthma, and you should continue to work with your doctor. That's right: it's a myth that asthma goes away with age.

In some cases your asthma may get so much better your doctor may actually allow you to quit taking your asthma medicines. To learn when you can quit taking your asthma medicine check out this post.

The following are some reasons your asthma might seem to be gone, and why you must never forget you have it:

9. You are on the best asthma medicine: Some people have good control of their asthma because of the newer asthma medicines used to treat it. Thus, if you stop taking your asthma controller medicines your asthma may come back.

8. You never had asthma to begin with: Well, it probably doesn't happen to much any more, yet there are some diseases that can mimic asthma symptoms. To learn how doctors determine if it's asthma, click here.

7. You lost weight: Recent science has have proven that obesity not only can make asthma worse, it can also make asthma medicines less effective. So it only makes sense that shedding those extra pounds will make your asthma seem to go away. If you forget you have asthma, you may forget the importance of keeping off the pounds.

6. You are in better shape: Study after study has confirmed that exercise not only helps you maintain or lose weight, it also helps to make your heart and lungs stronger and work better. Good asthma control and exercise may go hand in hand.

5. As an adult you have more control: When I was a kid we had a dog, and getting rid of it was not an option because my brothers would have thrown a fit. We also had a Michigan basement (half of it was sand), and Lord knows there were many asthma triggers down there such as molds and fungus. In this way, I had no control of my surroundings, and this made my asthma worse. As an adult I have complete control, and have made sure to limit asthma triggers in my home. Thus, if you forget you have asthma, you may actually move into a home filled with asthma triggers.

4. You moved away from your asthma triggers: My asthma was bad when I was a kid, yet when I went off to college it seemed to disappeare. Chances are, in the confines of my dorm room, there were fewer molds and other asthma triggers. The result was fewer asthma triggers and fewer asthma symptoms.

3. You don't roll around in the dirt anymore: Well, it's true. When we're kids, we tend to play outside with our friends, and we're more likely to be exposed to our asthma triggers, like dusts, molds, etc. As we grow up we move away from the ground, per se. We don't roll around in the wood chips and dust under swing sets and porches.

2. Your Lungs become less sensitive as you age: So you're now able to sit in the hay shed without your asthma acting up. Chances are it's because as you grew older your airways became less sentitive to your old asthma triggers.

1. Your lungs get bigger as you age: William E. Berger in Asthma for Dummies, writes, "As children grow, their lungs and airways become larger. If the amount of airway obstruction stays the same, the blockage may proportionally constitute a smaller part of the total airway diameter, thus resulting in fewer symptoms as an adult.

It is very important that if your asthma is in remission (if you want to use that word), that you never forget that you still do have asthma. The reason is simple: if you forget you have asthma, your symptoms may come back.

So be smart, stay wise to asthma facts by continuing to hang out with us on this site, and you'll continue to maintain good control of your asthma. With time, your asthma may also appear to be gone! Gone! GONE!!!

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Here are my last wishes

Based on my own experiences with end of life care, I have discussed the following with my wife, who would be in charge of making decisions for me should I become incapable of such. I think it's important that every human adult have a similar discussion with someone to assure you don't end up a vegetable in the care of the government.

At this point in my life when I am relatively healthy, I do not want to be a DNR. If I stopped breathing, or if my heart were to stop, I'd like medical workers to do whatever they had to do to try to save my life. I call for this mainly because I value life and love life.

However, if I arrive in the hospital after CPR has been done on me for a half hour and my face is STILL blue by this time, just let me go. If you think I'm gonna not be me when I wake up, just do the humane thing and let me go.

I do not mind if I have to be on a ventilator for a few days in order to give medical professionals the opportunity to rest my body and treat the underlying cause of my problem. Yet if whatever caused me to be on a vent is terminal, then after a few days just pull the plug. Considering I have asthma, I do not want to suffocate.

Oh, and that's the next area of discussion. I do not want to suffocate at the end of my life. If I appear to you as a fish out of water, then give me all the oxygen I want and sedate me to the point I'm comfortable. Don't let me drown. Don't let me suffer in pain.

Also, if I so happen to by a CO2 retainer, and I need oxygen, make the doctor give me oxygen. Don't let the doctor deprive me of the main source needed to maintain life. Don't make him let me suffocate because of the hypoxic drive hoax.

If I have a chronic disease and am chronically addicted to pain killers or alcohol or other drugs as a result, don't allow a doctor to set me in a hospital bed and allow me to go through detox. Have him solve my underlying problem and then he can deal with the addiction. So make him give me some kind of sedative.

Now, if I have a CO2 greater than 80 (like say 190), again, don't let my doctor withhold sedatives because he's afraid my breathing will slow down and my CO2 will rise. Don't make me suffer this way.

This is especially true if I'm awake and fighting the RT and the RN and the DRs efforts to treat me. Say, for example, the doctor order is for me to be on BiPAP, and I keep refusing to keep the BiPAP mask on (which I can see myself doing), don't allow the nurse to hold my hands down while the RT forcibly puts the mask back on my face.

Please, if this is the case, just let me have my way.

Look, I don't mind if I need to be on a ventilator to get over the hump, and I don't think I even would mind being ventilator dependent so long as my brain is fully in tact. Yet I do not want either of the above if my brain is not intact.

In summary, if I'm blue oxygenate me. If I'm still blue, ventilate me. If I'm still blue, just let me go. And don't be blue yourself, because I'll be in a happier place. My time has come. And by me writing you this letter you should be at peace knowing I lived a good life and you prevented me from unduly suffering at the hands of medical professionals who have to do everything for fear of getting sued -- unless you step in.

Oh, and one more thing. Be good to the people caring for me, even if they aren't friendly. Don't be sue happy just because you're angry I died (because I don't want you to be angry. I want you to be happy for me). However, in the rare chance of medical neglect, feel free to do what you need to do.

Likewise, since I will no longer be using my body, don't let my body rot for no good reason if it can be of use to help someone else live a better life in the one they currently have. Don't be afraid to donate certain parts of my body to the Gift of Life.

I know it sounds kind of disgusting, yet I believe God's underlying mission for each of us in this life is to make life better for our fellow men and women. I know I've done my part on this earth by improving the lives of many in my own way (hence my blog family and my own family). So don't be afraid to let me make one final gift to a fellow human being.

There, I think I covered all the bases. Life is good. But life without a brain is not good. I'd much rather move on to be with the Lord than to be a vegetable in this one. Capish.

Now, I don't plan on dying any time soon. Yet I write this post because I've seen some horrible things in the hospital setting. Sure I've seen many miracles and have seen more good things than I'll ever see horrible things. Yet the end of life should be peaceful, and that's how I want mine to be.

Rules

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To: Bosses

From: Workers

Regarding: Rules

Message: Some rules are good. They keep people in line and create unity. Yet when there are too many rules, or when rules are created every time something undesirable occurs, rules cease to have an added benefit. In fact, rules are good up to a certain point of which you reach a point of diminishing returns.

What you have to remember about rules is that each one takes away a freedom; each decreases choice; each decreases individual thought; each decreases individual creativity; they decrease the incentive to think. And this is not good for a hospital, where critical thinking is essential.

Besides, it gets to the point that if you add so many rules it's hard to follow them all, and your staff will get sloppy with some of the laws. This will result in unhappiness on both your part and theirs, and ultimately low morale.

Keep in mind that people are smart and poeple make mistakes. We don't need rules to manage every aspect of our lives. While you might get upset over a crumb on the ground, to others this may not matter so much. So you don't need to make a rule that you can't eat in the break room

If you have a problem with one particular worker, talk to that person. Don't punish the entire department with new rules. And, likewise, if you create a new rule, take away an old rule that's no longer needed anymore. That would make more sense.

Sincerelly,

Staff

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Order sets are stupid, IMO

Based on my experience as a departmental representative at various administrative committees, I am privy to some wisdom not available to the general public. For instance, many hopitals have order sets that are hidden under the guise as protocols.

No, they are not protocols. Protocols increase personal accountability and responsibility. Protocols increase personal thought and intellectuality. Protocols preach individuality.

Yet order sets, while started with the intention of doing what is best by best practice medicine, generally make it so each patient is treated the same. Order sets take away personal accountability, individual thought, personal accountability and responsibility.

Protocols improve morale, and order set decrease morael. Order sets decrease morael because all we do is a bunch of procedures not because they are needed, or even becasue a doctor wanted them, but just because. Order sets are cook book medicine.

Order sets (which, again, go under the guise as protocols and guidelines) not only result in decreased morale, they increase the cost of medicine because, ahem, someone has to pay for all of this impracticle medicine.

CMS only pays a flat fee, and those obtaining CMS services get free healthcare (well, free to them anyway. We have to pay for their free). Therefore, the one's who will pay are those of us who pay premiums for health insurance.

We will pay more. This goes along with the premium hikes we will now have to pay because Obama care provisions to force insurance companies to pay for dependents until they are 25, and previous medical conditions (liabilities).

Consider the following:

1. Of the 20 EKGs I did today, only 15 were needed. All were ordered not by a doctor but by an order set.

2. Of the five ABGs I did today, none were needed. All were ordered not by a doctor but by an order set.

3. Of the 30 breathing treatments I did today 28 were not needed. All were ordered not by a doctor but by an order set.

4. Of the six stress tests completed in my department today, none were needed. All were ordered as a result of an order set.

Order sets wouldn't be so bad, but most of the items on them are pre-checked, at least at my institution. To not order something, the doctor has to scratch out the item and sign. And then risk a lecture by the Quality Review lady. So it's easier for them not to bother.

If order sets were as they were initially intended, a list of all possible procedures the doctor might want to order, then order sets wouldn't be so bad. Yet that's not how it is when you resign yours institution to cook book medicine.

Thus, most items on order sets are ordered whether needed or not. Common sense is not the result of an order set. Common sense and individual thought are down the drain.

The following are unintended consequences of order sets:

• Lots of not needed procedures
• Wasted money
• Increased workload for RTs
• Increased burnout
• Loss of confidence due to loss of ability to decide what patients need
• Loss of morale due to inability to use common sense
• Poor attitude at bedside because after the umpteenth not needed EKG or treatment you get irritated by it all. It becomes a job rather than a profession, like working an assembly line at a factory
• Poor patient care due to low morale and in a hurry to get all the procedures done
• Feeling of irritation by RTs because we're doing a bunch of BS
• Increased apathy

Yes, there are some advantages to order sets. Yet the disadvantages are way more than the advantages. There's an old saying: Something is worth the investment only when the advantages out weight the disadvantages.

And in this case, the few recommending these order sets (mainly people sitting at a desk in Lansing or Washington) have a clue of the negative consequences. Or do they? Perhaps the intent is to collapse the health care system. Perhaps that's the intent. If it's not, I have a hard time justifying it.

Thoughts?

Difficulty breathing through races? Why?

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

Your Question: my step son runs cross country but has a difficult time breathing through out his races we have tried zyrtec,claritin,cetirizine I know there is something that has to work but what.

Your Question:I can empathize with your stepson, because I've also been having a tough time with fall allergies, as I wrote about in my most recent post here. I find that even while new allergy medicines help, those pesky allergens still manage to find a way to cause problems.

The best thing to do is to discuss your concerns about your step son with his doctor (or have him do it if he's old enough). There are still other medicinal options available to you, as you can see in this post. Another option to discuss with your doctor is allergy testing and allergy shots, if you haven't done so already.

Obviously I can't diagnose your stepson, yet what you describe here makes me wonder if perhaps your step son might have exercise induced asthma or asthma in general. If this is the case, asthma preventative medicines might help.

At least these are some options to consider. Either way, you should definitely have a discussoin with his doctor, because there are options.

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

Smoking cessation good, but not if you don't smoke

At my hospital smoking cessation education is something we take very seriously. In fact, the order to do smoking cessation comes up on any patient admitted with CHF, COPD, MI, pneumonia, asthma and just about any other diagnosis under the sun.

This might sound like overkill, and it is. Yet our medical director wants us to do smoking cessation even if a person doesn't smoke. Thus, if they don't smoke, we're supposed to encourage them not to start, and we're supposed to inform them of the danger of not smoking.

I don't think this is a bad thing, yet where is the time do do all of this? If we're going to do smoking cessation on every patient, it's going to get to the point where the therapist dumbs down his presentation just to get it done and over with. In the end, a poor job will be the result.

Likewise, even while smoking cessation is deemed so important, we RTs have received no formal training to make sure we are providing the best education. Most RTs in my department that I talk to don't even know why we are doing it. I know because I ask around.

In fact, while smoking cessation is deemed so important, the hospital won't even splurge on a good smoking cessation packet. All they give us to give to the patient is a single sheet of paper with some basics about quitting smoking.

It's frustrating to me. It's frustrating because most of the patients who are ordered to get smoking cessation education have never smoked, or quit smoking years ago. So it seems quite frivolous and a waste of our time to HAVE to educate these people.

One man said to me, "I quit 75 years ago."

One patient has been admitted 4 times in the past month, and every time the order comes up automatically. I finally got irritated and started charting, "Smoking cessation done last visit." Yet I still, by hospital policy, have to bill the patient.

Of course the real reason we are doing all this education is not to help the patient. That's what we say, and that's what's said to us. But I know for a fact the real reason is because CMS reimburses for it, and when a patient is given smoking cessation, that helps to qualify the patient for reimbursement.

You see, everything in the new healthcare system comes down to money. No, it's not about saving the hospital money, because they (CMS) already only pay one lump sum regardless of how many things are done to the patient. In fact, it actually costs the hospital more money.

Yet our hospital wants to make sure the patient meets criteria and that the hospital is reimbursed for the patient's visit, and by charting smoking cessation for every patient admitted this is a step in assuring reimbursement criteria is met for that patient.

This is another perfect example of stupidity that results when we put the government in charge of anything.

Look, smoking cessations are good. Yet doing smoking cessations on people who never smoked or have already quit more than 6 months ago is a waste of time. IMO! Smoking cessation is good, but not if you don't smoke.

Breathing exercises for asthma

The following was a question and answer session from myasthmacentral.com I thought you'd be interested in.

Your Question: Have you ever heard of breathing exercises to control your asthma?
 My humble response:

Oh, yeah, I have a lot of experience with this. The ideal breathing method you should focus on is diaphragmatic breathing (you can google it). When you start to feel short of breath it's a good idea to stop what you're doing and concentrate on your breathing. Sometimes this is all that's needed to calm your asthma and/ or whatever anxiety comes with it. Another breathing technique that is more tailored to COPD patients is pursed lip breathing (you can google that too). This asthma and COPD result in air getting trapped in your lungs, this helps you to get the extra air out.

When I was a kid my thearpist had me doing some unique things, like blowing up balloons and stuff like that to strenthen my lungs. So there's actually a variety of breathing exercises good for asthmatics other than what I've mentnioned here. Relaxation exercises also work. I've hear dome say Yoga works too, however that's not up my ally.

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Alfie's Attack

A good book about asthma is essential when you want to communicate about this disease with your children. Such was the topic of a recent Sharepost from MyAsthmaCentral.com

Start the Asthma Talk with "Alfie's Attack!"

Getting children to understand about asthma is a tricky task. This is where a good children's book comes in handy. "Alfie's Attack! The Story of a Fish with Asthma," by David Bohline, should be a good tool to start the asthma talk with your child.

As a former child asthmatic myself, I remember thinking that when I couldn't breathe I felt like a fish out of water. Bohline uses this metaphor by writing about a fish called Alfie who has asthma.

Alfie comes upon a shark who also has asthma, and it is up to Alfie to save the day. The story emphasizes the need to know about your disease and to have a rescue inhaler available at all times. It also shows the importance of relaxing in order to control an asthma attack.

The story lacks in that it doesn't go into preventative medicine, avoiding asthma triggers, asthma signs and symptoms, and asthma action plans. Yet this book, in my opinion, is not so much about covering all the asthma topics as it is about simply a tool for starting a greater conversation with your child about asthma.

My asthmatic daughter loves it when I sit down with her before bed with a good book. When I pulled out the story about Alfie, she was excited and started reading right away. She read some, I read some, and when we finished we had a brief conversation about asthma.

It's kind of neat, actually, how that happens. We didn't go into much detail, as my daughter is only seven. Your conversation can be short and sweet as ours was, or you can go into greater detail. It depends on your child's personality.

When my daughter's asthma is acting up it's hard for me to tell, so I think it's important for her to learn how to communicate to me. So that's the angle I took in our pithy discussion. Yet her active mind soon drifted off, and I tucked her in for the night.

The book also comes with some neat Alfie stickers kids can put on their inhalers. Since my daughter doesn't like inhalers, she put them on her nebulizer.

This book also has some notes to parents at the back where they can learn about asthma basics. So not only is this book a conversation starter, but a start of the process of moms and dads improving upon their own asthma wisdom.

Considering I never felt my parents really understood my disease, to me it's important for any such conversation starter to also educate the parent, or at least start the learning process for both child and parent.

There were a few changes I'd make if I were writing this book. For example, Alfie obviously has control of his asthma. He's asthma wise.

Therefore, I think it would be neat if, along with the rescue inhaler later in the story, Bohline mentioned how Alfie uses preventative medicines every day to keep his asthma under control, and how he works hard to avoid his asthma triggers.

Regardless, it was a good read for us.

Alfie's Attack is a good children's book, and used in conjunction with other books such as Breathless Bethany Buttercup, and tools like the asthma wizard and Dusty the Asthma Goldfish, you should have many options available to start the parent-child asthma conversation.

Disclaimer: This book was provided by Vitality Books for review. I was under no obligation to offer a favorable review.

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Passionate Resignation versus passionate faith and hope

Most of us feel passionate resignation during the dog days of winter with no sunlight, short days, too cold to go outside. We tend to feel gloomy and often that reflects on our behavior toward ourselves and others.

Depressions are higher during winter months, episodes of cabin fever are high. Yet this is because many of us feel passionate resignation toward winter. Yet what we should feel is passionate hope and passionate faith, because we all know brighter days are coming. We all know the sun will rise again, spring will come, the days will get longer and warmer.

Yet it's hard to find passionate faith and hope during the winter. Yet those who do are happier and this resonates in their demeanor and how they treat others. A positive demeanor resonates a positive demeanor. When a baby smiles, for example, one has to work hard not to smile back.

Many people have passionate resignation about death. They see death as the end of their life and therefore the end of days are hard and often depressing and gloomy. And this resonates through us, and those around the dying with passionate resignation also feel gloomy.

Yet we should feel passionate faith and hope about death. We should know that with death is not everlasting nothingness, but everlasting life and life with peace and with Jesus. Studies show that people who believe in Jesus are happier and are happier patients (I wrote about this here). Those who are passionately faithful and hopeful about death resonate faith and hope and therefore happiness in others.

I had an experience with passionate resignation at work recently. I was at a meeting and I was feeling hopeless and lost because a doctor was refusing to allow RTs and RNs to use their individual thoughts and experience to the benefit of the patient

She said, "I don't want nurses deciding on their own what to do for the patient, when what they decide is against hospital policy." She was talking about order sets that mandate certain things be done to patients with a certain diagnosis.

I hate order sets because they decrease individualism. I think nurses and RTs should be allowed to make individual decisions based on the patient and given the circumstances. I wasfrustrated. I believe protocols are better because they encourage positive outcome based medicine to improve patient outcomes and improve RN and RT morale.

I wanted to quit dealing with the administration. I wanted to quit the committee. I actually wanted to walk out of the meeting, because if a doctor is going to have that attitude then what's the point of me even being there. Doctors thinking like that make us RTs feel passionate resignation. She actually believes people are stupid, and only an expert (her) should be able to make decisions. Everyone else is stupid.

Then I decided that passionate resignation only resulted in apathy, decreased confidence (I couldn't look at her let alone talk or negotiate with her), and no chance of progress. I decided it's better to have passionate faith and hope even though passionate faith and hope are hard to obtain. I took the harder path, the noble path, and the better path. This resonates hope and faith in others.

This is the only way to better patient care. We must have faith and hope. We must have confidence? We must have optimism? Lest we will fail and they will win.

I think one of the philosophic recommendations someone once told me about was to think positive thoughts about people before you approach them. you should do this especially with people of whom you do not agree with or care for. The idea here is if you think positively -- have hope and faith -- your good feelings resonate and you will be well thought of and liked and respected.

Plus by thinking good thoughts about the person (however hard that may be sometimes) you are less likely to allow them to drag you into their pessimistic and gloomy world, and the less likely you are to say something you might regret, something that might slow or stop progress.

Once people learn to respect you they will develop a feeling of passionate hope and passionate faith. We must all have passionate hope and faith. We must not take the easy path of passionate resignation. We must have faith and hope and know that death does not mean we are taken away from God and his people. We must know that with death comes eternal life.

We must not meet our fate with resignation. We must know the facts, and know what we believe in, and me must keep moving in a direction of hope and faith.

Argh!! A stupid doctor????

So I was teaching a class on neonatal resuscitation which so happened to have an array of doctors in attendance. So I thought this would be a prime opportunity to educate them about one of the myths about using 100% oxygen when positive pressure breaths are required on neonates.

So, I told this to one doctor. Then I set up a scenario where he was handed a blue and not breathing baby and told to use his skills to save this baby. When it came time to giving oxygen, he said, "I don't' care what the new studies say, ha ha ha!!!! I'm going to give 100% oxygen to all my neonate patients. So, give 100%!"

What do you do when that happens but smile, and cringe, and hope this doctor never has to take care of one of my kids.

The effects of drinking coffee

If you're like me perhaps you like a little caffeine from coffee to get your day started, and then a little more to keep it going, and then perhaps a little more to keep you awake during long night shifts. If so, you're among millions of Americans who do this.

According to Parenting Magazine's November 2010 issue, the following are some facts you might want to consider before you sip that extra cup of coffee. Now this wouldn't stop me, yet still it's good to know all the facts about what you're putting into your body so you can be responsible for your decisions.

So, that said, here are some facts:

1. 4-5 cups*: Can cause nervousness, insomnia, and irregular heart rhythms.
2. 3/5 - 4.5 cups: Produces higher insulin levels and reduces insulin sensitivity, increasing diabetes risk.
3. 2.5-3.5 cups: Increases risk of miscarriage and low birth-weight babies -- if pregnant, talk to doc.
4. 2-3 cups: Significantly increases blood pressure, potentially shortening your life span by 5 years.
5. 1.5 - 2.5 cups: Gives you more staying power for your fun
6. 1-1.5 cups: Boosts your alertness and mental performance

Once again old wisdom notes: anything in moderation is a good thing. Easier said than done, though. Right?

*1 cup = 6 ounces of brewed coffee

Are there different kinds of COPD?

Every day at COPDConnection.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 have asthma/copd,and basement 60%musty humidity. i want to move out of this house, but husband won't, what do i do about musty humidity?">COPD Connection.com we get lots of COPD related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Your Question: is dissiness a nicotine withdrawal symptom

My humble answer: I do not see dizziness listed as a withdrawal symptom. You can check out the symptoms in this quit smoking guide from the Michigan Dept. of Community Health or in this post. If you're feeling dizzy, and even if it is caused by quitting smoking, this can be a sign that something serious is going on, and you should call your physician.

Your Question: Are there different kinds of COPD?

My humble answer: Most of the time when a doctor is referring to COPD he is referring to either emphysema or chronic bronchitis. Yet occasionally asthma can fall into the COPD category when asthma becomes more severe. In most cases, however, when a doctor is referring to COPD he's referring either to emphysema and chronic bronchitis caused by smoking. Most people diagnosed with COPD usually have both chronic bronchitis and emphysema to some degree. I actaully go into this in more detail in this post.

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

Pneumonia readmissions on the decline

It appears Shoreline Medical is doing something right, at least when it comes to pneumonia readmission rates. As, compared to the national pneumonia readmission rate of 18%, our hospital had only a 2% readmission rate for the given time period of about a year.

Because of this, I was chosen to give a presentation to a group of respiratory therapy supervisors and managers. This was a unique and exciting opportunity for me, especially considering I was the lowest ranking RT at this meeting. Plus my boss chose me among all my peers to give the presentation.

I worked with the Quality Assurance Analyst for our hospital and created this really nice presentation. Then I spent quality time interviewing, going through charts, and researching all the things we do once a patient is diagnosed with pneumonia, and what we do to keep pneumonia rates down.

I actually learned quite a bit in this process about the administration side of things. What follows here is a summary of my presentation:

A goal at Shoreline Medical is that we all have our priorities in order.

Shoreline Medical is in a small town only a few miles off the shore of Lake Michigan. It's in a small town, a close nit community. And being a close nit community results in a close nit hospital. One of the reasons I chose to work here is because I felt Shoreline was kind of had a down home feel to it. Everyone got along, were good friends, had pot lucks, and stuff like that.

We started the process of getting our ducks in a row by focusing on the CMS Core Measures. To make sure all doctors, nurses and respiratory therapists are always thinking about the core measures, we are all in serviced on this every year by the Quality Assurance Department.

In the chart, before the doctor's orders section, is a bright orange laminated sheet that has all the core measures on it. This way, every time anyone looks at the orders he or she has to flip this page aside. And even if you don't read it, you know what's on it: the core measures. This is one simple reminder to everyone to focus on the core measures when writing and fulfilling orders.

The Core Measures for pneumonia are as follows:

1. Initial Antibiotic Timing (given within 6 hours)
2. Pneumococcal Vaccination if eligible
3. Influenza Vaccination if eligible (October to March)
4. Blood Culture drawn before initial antibiotics
5. Appropriate antibiotic selection
6. Smoking cessation advice and counseling given if indicated (if patient has smoked within the last 12 months)

The most important of the above are the pneumococcal Vaccination, Influenza vaccination and smoking cessation, as studies have linked all three with a reduction in secondary pneumonia. So our major emphasis was on these three.

These core measures are what works according to the most recent best practice evidence to improve patient outcomes and decrease costs for pneumonia patients. The question we had to ask ourselves is: how do we use these core values to get our ducks in a row

Data from our core values back in 2007 showed that Shoreline Medical was about 80% in all of these core measures except for antibiotic timing within 6 hours. In this, we had no data whatsoever, which means we probably didn't even do it.

Yet if you look at data from the first and second quarters of 2010 you can see that we are at or near 100% on nearly every core measure. When it comes to smoking cessation we were at 92%, yet that was basically due to a miscommunication between a doctor and a nurse. So even while we've improved, we still use this data to improve even further, as there is always room for improvement.

So basically back in 2007 we did not have all our priorities in order, and in 2010 we did. So how do we get our priorities in order?

Actually, if you look at pneumonia readmission data other than the above mentioned three month period our hospital at at 16.5%, which is no different than the U.S. National Rate. .

Yet from January to March 2010. During that span we had 52 pneumonia patients, and only one readmission rate.

These improved statistics based on the core measures show we are doing something right. They prove that we have our ducks in a row. The question you are asking is: how did we get our ducks in a row?

The first thing we did was back in 2007 we joined the Keystone Collaborative. We have a champion Internist, a physician from ER, and one from surgery and general practice as our champions. Then we have one nurse from critical care, the general floors, and one from the emergency room.

We also have a representative from lab, x-ray, pharmacy, quality assurance, computer analysis, respiratory therapy (that's me) etc., and we meet every month to analyze data from core measures to create and improve clinical pathways and order sets to improve patient outcomes and reduce costs for our hospital.

The key here is that we review modern wisdom and come up with better practices for our hospital. Anyone can do research, or come up with new ideas, and can share them with any member of the keystone

committee, and then this new wisdom is brought to and reviewed by the committee and changes are made as appropriate.

Basically the point of the Keystone Committee is to do what works and skip doing what's not working.

The following is our pneumonia order set:

Our order set includes the following as options for the doctor to check:

• Code status
• Vitals routine or ___________
• Record input and output, daily weight, pulse oximetry every shift
• EKG on admission
• Chest x-ray on admission and on day 3
• Lab work (if not already done): CBC, CMP, UA, Sputum for gram stain, culture and sensitivity, blood culture prior to administration of antibiotic (this has to be done within three hours of admission)
• AM labs_______________
• Oxygen at _______ lpm or per protocol or _________
• Respiratory treatments: Albuterol 2.5mg with 3cc normal saline Q6 hours, up to ____ hours prn
• Respiratory treatment: Atrovent 0.5 mg in 2.5 ml normal saline QID
• Antibiotic therapy (1st dose to be given in ER) or immediately after blood culture drawn)
• Community Acquired Pneumonia (non CCU): Levaquinn 500 mg IVPB Q24 hours times 3 days, then Levaquin 500 mg PO daily
• Community Acquired Pneumonia (CCU or stepdown patients): Rocephin 1 gm IVPB Q24 hours and Zithromax 500 mg IVPB Q24 hours and Levaquin 750 mg IVPB Q24 hours and Azactam 2 GM IVPB Q12 hours
• Nosocomial Pneumonis (check all that are indicated from list of meds and doses)
• IV Fluid ____________
• Tylenol 650 MG PO Q4 hours prn for pain
• Xanax 0.25 mg PO Q6 prn for anxiety
• Restoril 15 MG PO QHS prn for insomnia
• MOM 30 ML PO BID prn for constipation
• Robitussin 10 ml PO Q4 hours prn for cough

(I left a few things off, but that's basically the gist of it).

This is our pneumonia hymn book. It's all the things that the best practice evidence shows works to help pneumonia patients get well. It's one sheet of paper, which makes it very simple.

As you'll note, some of the things on here are automatically ordered -- the doctor has no choice. For instance, x-ray on admission and in the am times three days, and certain labs on admission and in the am.

The ER nurses are involved right away, because if that patient is in the ER at the five hour mark, they have to make sure a sputum is obtained, and that the patient has been given that initial antibiotic within 6 hours. They have a system to assure this is done, and checks and balances.

As soon as the patient is admitted, the orders are entered into the computer system, and reminders are automatically sent to all the respective departments as to what they have to do and when. In RT department sheets are printed off so we know what our role is for that patient.

For lab and x-ray, what they have to do is printed up on their respective printers, and plus the procedures they have to do are put on the tracker when they are due so they are reminded in that way too.

It's simple. This order sheet is our hymn book: it makes sure we are all singing from the same hymn book.

Then we have our extubation protocol (to see our extubation protocol click here). This order set is part of the ventilator bundle. It works similar to the pneumonia bundle, in that when it comes to intubated patients, it makes sure we are all singing from the same hymn book.

The neat things about our extubation protocol is that when we were in school in 1995 we learned that the cuff pressure should never exceed 20 cwp. Now we are taught to always exceed 20 cwp. The reason is to prevent aspiration , and to prevent ventilator acquired pneumonia.

Another thing to prevent pneumonia is that the circuit not be broken. To do this we use MDIs instead of nebulizers. Also, we do not disconnect the circuit to suction, and use in line suction catheters instead.

Another key is the daily sedation protocol. Every night around 2 a.m. we automatically take all our patients off sedation so that by 6 a.m. we can analyze the patient for readiness to wean.

Here comes another laminated sheet. As part of our ventilator protocol we have a sheet that acts as an algorithm to speed time from intubation to extubation. Actually, the key to a good extubation protocol is that as soon as the patient is intubated we start thinking about extubation.

If the patient can be extubated in 2 hours, now that's possible. Years ago if the attending went on vacation the other doctors didn't extubate because they didn't want to offend the attending. Sometimes we RTs would wonder why the patient was still intubated. Now, that never happens, or rarely happens.

Our Algorithm goes something like this:

Weaning Screen:

1. FiO2 less than or equal to 40%
2. PEEP less than or equal to 5
3. HR greater than 50 or less than 120
4. Temp. less than 100.5
5. SpO2 greater than 90 unless otherwise directed by physician
6. Systolic BP greater than 90
7. Minimal or no sedation
8. No Vasopressors
9. No signs of respiratory distress
10. Able to follow commands
11. Adequate cough
12. Secretion thin and minimal
13. Plateau pressure less than 30 cwp

If the answer is no, then you stop and reanalyze the next day. If the answer is yes, then you move on to the next step, which is to do a 5 minute spontaneous breathing trial (SBT). (ETT 8.0 or greater use a CPAP of 5 and PSV of 0, ETT 7.5 or smaller use CPAP of 5 and PSV of 5)

Now you do a second weaning screen based on the same criteria as above.

If the patient fails the screen, the SBT is stopped and patient returned to previous settings.
If the patient passes, the following is completed and analyzed:

1. NIF greater than 20
2. VC greater than 10 ml/kg
3. VT greater than 5
4. RR less than 30
5. VE greater than 5 and less than 15
6. RSBI (f/vt) less than 100

If the patient passes this criteria, continue SBT for 30-120 minutes. Then do another weening screen as mentioned above. If patient passes do an ABG and call physician for order to extubate.

So basically we no longer simply do weaning parameters every day, we are actually completely assessing the patient using the common sense, best practice evidence approach. Patients are getting extubated quicker, and VAP is now pretty much nonexistent at our hospital.

Another key is education. As soon as the pnuem order set is initiated the emergency nurse educates the patient about pneumonia. Then the nurse on the floor educates the patient, and then the RT is in the room every six hours, and he or she educates the patient some more.

We make sure not only do our patients learn about pneumonia, they also know about their disease. For example, if they have COPD we make sure they know the early warning signs of an exacerbation so they can nip it in the bud next time and don't have to be readmitted.

We make sure they know if they start to get more short of breath than usual, or have increased cough or sputum production, or change in color of sputum, that they call their doctor or come into the emergency room.

Plus, as soon as pneumonia order set is entered in the computer, an order for RT to do smoking cessation is printed off in the RT department. Several studies show that if when a patient is vulnerable, when he's sick in the hospital, that if someone nudges them to quit they are more likely to quit.

And then when the patient is discharged another paper is printed off that is a pneuminia fact sheet for the patient to take home with them. It is basically a reinforcement of everything they've learned about pneumonia, and is reviewed by the discharge planner.

It's also a reminder to the RN to make sure the patient has had his vaccines while admitted, and to reinforce to the patient that they get their annual pneumonia and flu vaccines.

So basically the pneumonia order set is our hymn book: it gets everyone on the same page from the RT to lab to nurse and x-ray and lab and doctor. We all know exactly what our role is for that patient

Another thing we have an emphasis no is good hand washing. We have signs over every sink that remind of the importance of hand washing. Another sign over every sink describes proper hand washing technique.

We also have hand sanitizer in every room and in various locations, and we encourage or professionals to use this between every patient, and after touching anything in the room, and before touching anything even on their own possession. We also encourage use of hand sanitizers before leaving the room, even if they ultimately wash their hands.

We have some of our nurses are anonymous spies who make note of who they see not washing their hands, or not doing so correctly. We have other pamphlets around the hospital that remind nurses, RTs, and even patients to keep your eyes open, and "It's okay to ask."

So good hand washing is key to preventing the spread of infection.

Another bonus at Shoreline is we are a close nit hospital. This results in really good communication. For example, if I'm in the room and I see something wrong with the patient, I talk to the nurse or sometimes I go right to the doctor.

Instead of the nurses calling the doctor and assuming they know what's wrong with the patient, they often call RT instead so we can use our experience and education to work with the nurse in deciding what needs to be done.

Likewise, many times the doctor calls me up and asks me what I'm thinking is wrong with the patient and what we should do. This is great for morale.


We also have a Rapid Response Team. And another thing is we have good support and encouragement. For example, if an RN calls me to assess a patient, and the patient is fine when I get their, is on the crapper or something, I don't say, "You stupid dummy. Why did you waste my time?"

Instead I say, "Hey, that's fine. You were being proactive. That's good. It's better to be safe than sorry. You did great."

Besides, it's better to be proactive than reactive. If you're proactive you are nipping it in the bud. If you're proactive you may stop the problem from occuring, and then you get no credit. But it's better to be proactive and get no credit becasue the problem never occured, than to be reactive. If you're reactive, that means the problem already occured.

It means the patient is already septic, or in failure, or whatever. If you're being reactive, it means the patient is already in need of critical care services, and may need to be in the hospital longer, and cost the hospital more. If your'e proactive, that means improved outcomes and reduced costs.

So it's better to be proactive than reactive.

So starting with the core measures, the keystone collaborative and weekly keystone meetings, to the pneumonia bundle, and then with the small town close nit touch, we have been able to get all of our priorities in order here at Shoreline Medical. That's how we did it.

Thank you. Any questions.

For more information, check out the following resources:

• AHRQ (Agency for Healthcare Research and Quality) http://www.ahrq.gov/
• MHA Keystone Center http://www.mhakeystonecenter.org/
• MPRO http://www.mpro.gov/
• Quality Net http://www.qualitynet.org/
• Blue Cross/Blue Shield www.bcbs.com/innovations

Will expired asthma medicine hurt me?

Your RT Question: My 1 year old baby had cold and cough. Doctor gave her medicine and ventolin respirator solution to use with nabolizer 0.3 ml . By mistake i didn't saw the expiry date the solution was alredy expired and now im woried as she inhaled it pls help.

My humble answer: Allow me to help ease your mind. I have on a few occassions used old and expired respiratory medicine and nothing bad ever happened. I did some research on this recently and learned as time goes by the medicine loses it's potency, yet it does not become hazzardous to your health. You can use old and expired asthma medicines, they just don't work as well. My experience is old and expired Albuterol works just fine, although the taste becomes pretty horrid. I can always tell if Albuterol is old by the taste -- kind of like rotten mints (although not close to as the normal taste of Aerobid).

So don't worry, your child will be fine.

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Asthma Scholarship Available

If you are a high school senior with asthma there is a scholarship available that you can apply for.  This was the topic of my most recent post at MyAsthmaCentral.com


Scholarship Available for High School Seniors with Asthma
February 22, 2011 @MyAsthmaCentral.com


If you're a senior in high school and you have asthma, you may qualify for the Will to Win Scholarship by Merck Respiratory.  Ten $5,000 scholarships are available.

Merck is promoting this scholarship to "encourage young people with asthma to lead active, healthy lives and pursue their dreams," according to willtowinscholarship.com.   

I know from personal experience how challenging it is to overcome the obstacles asthma creates.  And if you were able to overcome these obstacles to achieve excellence at school, Merck wants to reward you for this accomplishment.

To qualify, you'll need to have achieved a level of excellence in one of the following:

• Visual arts
• Community service
• Athletics
• Science

Likewise, you'll have to meet the following criteria:

• Demonstrate outstanding performance in one of the above categories
• Document a track record of achievements relevant to entry category
• Hold a minimum cumulative grade point average of 3.5 on a 4.0 scale
• Have received at least one award related to their entry category
• Include all appropriate signatures, as noted in the application (click here to apply)
• Be a U.S. citizen
• Acceptance to an accredited U.S. college
• Enrollment in college for the fall 2011 semester  

Merck Respiratory has been awarding scholarships to high school seniors with asthma seeking a higher education for 23 years.  This year a total of $50,000 in scholarships will be awarded, which include two $5,000 scholarships in each of the following categories (you can apply for only one):

• Performing Arts (dance, music, theater)
• Visual Arts (painting, drawing, sculpture, photography, film)
• Community Service
• Athletics
• Science

This seems like a good opportunity if you have asthma and are planning to attend college next fall.  If you excel in one of the above areas, you should definitely apply.

"So," the site notes, "whether you excel in the classroom or the community, in the arts or on the field or court, apply for a Will to Win Scholarship now. Take pride in your achievements today - it could help pay for college tomorrow. Ten $5,000 scholarships are available."

There are no application fees or similar requirements - all you need to do is fill out a scholarship application (available on the website) and submit this by the April 30 deadline with a list of accomplishments, high school transcript, letter(s) of support and your story of excellence.

You'll need to write a little story about how you were able to excel despite having asthma, your most significant accomplishment, or your goals for the future (it only needs to be two to three pages). 

If you've excelled despite having asthma, here's your opportunity to be rewarded for your hard work. Apply soon!
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Words mean things

Words mean things. That might sound simple, yet it's the truth. The way we use words, and often how we use words, sends a message. Sometimes that message is intended, and sometimes otherwise.

Read the words of Ecclesiastes 6:11, "The more the words, the less the meaning, and how does that profit anyone?" And Epictetus, the great philosopher of Ancient Greece, said, " First learn the meaning of what you say, and then speak.

Epictetus also said, "Keep silence for the most part, and speak only when you must, and then briefly." And he said, "Silence is safer than speech." Likewise, and my favorite Epictetus quote, is this:

"We have two ears and one mouth so that we can listen twice as much as we speak."

Ben Franklin was very cautious with his use of words, and resigned himself to think about what he said. In his autobiography he mentioned 13 virtues that he concentrated on in an attempt to make himself a better man. One such virtue is as follows:

"Silence: Speak not but what may benefit others or yourself; avoid trifling conversation."

Franklin also said, "Brevity is the soul of wit," and "He's a fool that cannon conceal his wisdom."

The Bible talks about words and the importance of limiting their use. In James (13: 19) it is written, "Everyone must be quick to listen, but slow to speak and slow to become angry."

Sirach (20: 23-24) notes that, "If you promise a friend something because you are too bashful to say no, you're needlessly making an enemy." Likewise, he notes, "Lying is an ugly blot on a person's character, but ignorant people do it all the time. A thief is better than a habitual liar, but both are headed for ruin. A liar has no honor. He lives in constant disgrace."

So when we do speak we must be careful to speak from our heart, to speak honestly, and to sincerely say what we mean and what we intend to do. To do otherwise would be disgraceful, and would lead to loss of respect.

Philosophers for thousands of years have observed that the man who says the least is most likely to be the most intelligent in the room, or at least give the appearance of intelligence, as the smart person knows to remain silent. Likewise, the man who speaks the least uses words that are the most potent.

It is better to read and to listen, than to speak. Most of what we say is not even necessary and trivial. Likewise, our words often come back to haunt us. So, as a proverb says, "If you are careful, you will not get into situations that require you to be brave."

So discretion is the better part of valor. Valor, as defined by Meriam-Dictionary means "strength of mind or spirit that enables a person to encounter danger with firmness : personal bravery."

Words mean thins: use them sparingly. Think before you speak. I think this should also include what we write on Facebook and what we send in our texts. If we are not careful, what what we communicate can come back to haunt us.

Treatments cause cancer later in life????

I know that there have been studies that show that giving oxygen, even for a short period of time, can increase a neonates chances of getting cancers.

So, does that mean that giving a breathing treatment with oxygen, even for the short 4 minute duration, is also increasing the child's chances of getting cancer? One would imagine so.

So, one would think this is something that would be investigated further. Breathing treatments, when given to small children, should probably be given with air.

Most hospitals probably don't have to worry about this, but some -- like ours -- don't have piped in air, and give all their treatments with oxygen.

So, by giving breathing treatments with 100% oxygen to a neonate, are we increasing that kids risk of getting cancer down the road?

Another thing to consider is this: If the hypoxic drive theory is true, and as many COPD patients are hypoxic drive breathers as some doctors would have us believe, then why have no patients ever dropped dead during a breathing treatment?

Just a thought.

The latest Hospital Statistics, RT and RN statistics

The following statistics are according to the American Hospital Association (AHA):

• Number of registered hospitals in the U.S...................5,795
• Total number of registered beds...................................944,277
• Total admissions..............................................................37,479,709
• Total expenses.................................................................$726,671,229,000

The trend in health care spending has increased exponentially since 1965 (see graph). Total health expenditures were:

• $41.6 billion in 1964
• $75.2 billion in 1970
• $232.9 billion in 1975
• $250.1 billion in 1980
• $420.1 billion in 1985
• $666.2 billion in 1990
• $1,101.9 billion in 1995
• $1,739.8 billion in 2000
• $7,681 billion in 2010 (16.2% of GNP)

Total cost of health care according to KaiserEDU.org:

• $253 billion in 1980
• $714 billion in 1990
• $2.3 trillion in 2008
• Total health care expenditures grew at annual rate of 4.4% in 2008 (slower than recent years, yet outpacing inflation and national income)
• Since 1991, employer sponsored health coverage has increased 131%, placing increased burden on employers and workers
• Medicare and Medicaid spending has increased 6.8-7.1% per year from 1998 to 2008, a little slower than the rate of private insurance spending

What is driving up cost of health care?

• Technology: Main contribute
• Prescription drugs: Main contribute, although in recent years spending on this has actually gone down, perhaps due to high cost to consumers
• Chronic disease: Better technology, medicine, and improve wisdom has increased life expectancy and increased time living with chronic disease. Place a lot of demand on health care industry, especially treating long-term illness and long term care. May be about 75% of health care costs
• Aging population: Health care costs rise with age. As baby boomers retired this cost will shift to private sector
• Administrative costs: 7% of health costs are marketing and billing expenses and cost of maintaining an administration. Add into this government administrative fees and this is an area that is increasing in costs (Now add in Obamacare).
• Free Medicine: Another usually overlooked cause of healthcare costs rising is when people receive it at no cost to them they tend to make more frequent trips to the hospital. This drives up the cost for people who do pay. If you look at the trends above, hospital costs and expenditures have skyrocketed since 1965, which was when Title XVIII of the Social Security Act was passed. In this sense, the government is responsible for much of the cost of healthcare, while other reasons tend to get the blame.
• Fewer payers per recipients: In 1965 there were 5 workers for every beneficiary of Medicare, by 2000 this was only 3, and by 2040 there will be only 1.9. This is mainly due to the fact that eligibility was set at 65 in 1965, and the life expectancy was 66. It was originally supposed to be only for those who outlived the life expectancy. In 2010 the eligibility age is still 65, and the life expectancy is 78. More and more people are outliving their expectancy, and are eligible longer, and the eligibility rate has never been adjusted.

According to Centers for Medicare and Medicaid Services (CMS), here's how U.S. heathcare 2008 dollars were spent (see graph )

• 31% hospital care (down from 40% in 1995 NHS stats)
• 21% doctor and clinic services (same as 1995)
• 10% prescription drugs
• 7% administration
• 7% investment
• 6% nursing home care (down from 7% in 1995)
• 6% other professional services
• 4% dental
• 3% gov't public health activities
• 3% other retail projects
• 3% home health

Why the cost of healthcare costs?

Who has healthcare coverage (% below will be greater than 100 because some people have more than one insurance coverage and are approximated):

• 86% of U.S. population has healthcare coverage
• 75% of those covered have private healthcare insurance
• 61% with private insurance are covered through employers
• 13% with private insurance purchase their own insurance
• 13% of population has insurance through Medicare
• 10% of population has insurance through Medicaid
• 4% of population has insurance through military or veterans programs
• 17% of population has no health insurance (up from 14% in 1995) This is about 50 million people.
• Under insured has grown 60% bankruptcies are due to medical expenses

The following facts regarding hospital admissions from the AHA:

• 35 million people are admitted to a hospital each day
• 118 million are treated in emergency rooms each day
• 481 million other outpatient services per day
• Hospitals deliver 4 million babies per year
• In 2006, hospitals provided $35 billion of services that were not reimbursed
• Hospitals employ more than 5 million people
• Hospitals are the 2nd largest private sector employers (behind restraunts)
• When accounting for hospital purchases of goods and services from other businesses, hospitals support 1 in every 10 jobs in the U.S.
• Thus, hospitals account for $1.9 trillion in economic activity
• 1/3 of hospitals lose money on operations
• Hospitals operating margins (money left over after paying costs) were 4.0 in 2006, down from 4.6% in 1996 prior to the balanced budget Act of 1997.
• Medicare and Medicaid paid for 55% of care provided by hospitals
• 64% of hospitals are paid less than cost of services provided by Medicare services
• The Medicare funding shortfall exceeds $18 billion
• Hospitals receive 86 cents for each dollar spent on a Medicaid patient
• 76% of hospitals are paid less than cost of services provided by Medicaid services
• The Medicaid funding shortfall exceeds $11 billion
• Medicaid and Medicare shortfalls have been found to add costs (12% in California) to private insurance programs to make up for the shortfall
• 47% of hospitals reported their emergency rooms were at or exceeded full capacity
• 56% of hospitals transport overflow patients to other hospitals
• There are 116,000 nurse vacancies
• By 2020 it's estimated there will be a nursing shortage of 1 million nurses

Nursing statistics from Minority Nurse:

• There are 2,909, 357 registered nurses in the U.S. (2010 statistics)
• Approximately 168,181 registered nurses are men
• Only 8% of nurses are under 30
• 30.1% of male nurses are under 40
• 26.1% of female nurses are under 40
• 65.7% of male nurses are under 50
• 57.4% of female nurses are under 50
• 56.2% of all RNs work for hospitals
• 10.7% of nurses work in community/public health community
• Average salary of full time nurses is $57,785
• Average salary for nurses with a Master's degree is $74,377
• Nurse practitioners average $70,581

Respiratory Therapy Statistics according to the American Association for Respiratory Care (AARC) and National Board of Respiratory Care (NBRC):

• There are 105,900 RTs working in the U.S.
• 75% of RTs work in the hospital setting
• 48 states regulate the practice of respiratory therapy
• Employment of RTs is expected to grow 19% from 2006 to 2016, or 211% from 2008-2018 (faster than average for all occupations)
• 25% reported making $7e,000 or more
• 50% reported making $60,000 or more
• 25% reported making $48,000 or less
• New RTs reported earning $42,078 to $42, 497
• Median annual wages for RTs was $52,200 in 2008
• The middle 50 percent earned between $44,490 and $61,720
• The lowest 10 percent earned less than $37,920
• The highest 10 percent earned more than $69,800.

Overall hospital workers (stats from ehow.com:

• The U.S. Department of Labor estimates there are over 700 different job categories in teh healthcare industry
• 661,000 doctors in the U.S. as of 2008 American Bureau of Labor Statistics (ABLS).Most doctors earn more than $150,000 annually
• Anesthesiologist mean salary $197,570 or $94.99 per hour (ABLS)
• Internists make $176,740 per year, or $84.90 per hour (ABLS)
• Family Practitionars make $161,490 annually or $77.64 per hour (ABLS)
• Obstetritians and Gynecologists make $192,780 annually or $92.68 per hour (ABLS)
• Pediatritians make $153,370 annually, or $73.74 per hour (ABLS)
• Surgeons make $206,770 annually or $99.41 per hour (ABSS)
• Psychiatrists make $154,050 annually or $74.06 per hour (ABLS)

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