Pride is important, and yet pride can drive you down to a miserable route in life. I say this because one must have a good opinion of himself in order to succeed in life. Yet too much pride can bring one down.
Think about it. In order to be confident and compitent you have to have some degree of pride. Likewise, in order to make it through life and to get to Heaven, you also have to be proud. Yet, then again, too much pride can earn you a fast route to Hell.
You must have respect for yourself. You must have respect for the people in your life. You must have respect for the possessions that are important in your life. You must appreciate what you have.
Yet if you have so much pride that you become arrogant, then that is not good. Arrogance means that you have so much pride in yourself that you suddenly think you are better than everyone else. You are the best. You are unique. You are all knowing. You are special.
A person with too much pride is a person with arrogance. A person who is arrogant thinks he knows what is best for everyone. Such a person believes that a person in Lansing, such a professional, should be making decisions for everyone else.
Of course when you are making deciscions for everyone else, you are assuming you are right. And you know what happens when you assume: you make an ass out of u and me.
Some psychologists believe that the opposite of pride is humility. Humility is the bringing down to earth of your thoughts of yourelf. Humility is when you put others before yourself. Humility is when you think that you are no better than anyone else.
Pride is having a high opinion of oneself. That can be good to a certain point. You have to feel good about yourself in order to succeed in whatever goals you want to succeed at. Yet at the same time you must have some degree of humility, or some self control.
Pride is a positive self evaluation. Smiles is pride. Lifting of the chin is pride. Slapping of high fives can be pride as in the celebration of victory.
Pride is good in that it can help a natin convince it's soldiers that it's nation is the best and is worth fighting for. It's good for a school in that having a positive opinion of your school can generate school pride that is needed to psyche up members of the team when trying to win a game, or generate good team spirit.
It's needed among fans to generate team spirit and support for a team. Likewise, National or state pride is needed to get soldiers psyched up about fighting a war or a battle. In this sense, pride is good. Pride,in this sense, can invole a feeling of accomplishment.
School pride can win a game, or it can convince a kid to study harder and to get a better GPA. Pride, in this sence, can make someone better. It can mae someone who is good better, and it can make someone who is not good try harder and more productive. Pride of a worker can make him a better worker.
Pride is good. Yet, again, too much pride is arrogance. To much pride can make one thing he is better than he thinks he is. Like a doctor who completes med school, he may think he knows more about the lungs than a respiratory therapist who does nothing but study the lungs for two straight years.
So since a doctor completes 8 years of school and several years of study, he can't possibly comprehend how someone with only an associate's degree can know more than he does in one area. Yet that's exactly what is when it comes to the lungs. RT Pride is so that since doctors won't let RTs use their education, RT pride is low. This equals low morale. This equals a lot of apathy among RTs.
It's a result of arrogance among doctors. I mean no disrespect to doctors, for they should be pride. Yet they should humble themselves enouigh to allow for the team approach. For the benefit of the patient, and the benefit of the PERSON who is the RT, the doctor needs to gain control of PRIDE and become HUMBLED.
That, my friends, is how you solve problems.
Sunday, July 31, 2011
Saturday, July 30, 2011
Do we really need more water?
A part of just about any body building or weight loss program has incorporated into it the recommendation that you drink 8 to 10 glasses of water each day. Some doctors now proclaim there is no evidence this does any good, and in fact it might actually do more harm than good.
Doctors have been pondering this issue recently, and one doctor wrote about it in the British Medical Journal. He wrote that many schools teach that you should drink more water because it's common sense, and it keeps your body working better, keeps your metabolism working, and it keeps your organs healthy.
Yet he writes there is no evidence to any of this. Likewise, he writes the number 8 to 10 is just a number that was made up. In fact, the person who first proposed this idea that we should drink more water to stay healthy, that it's common sense, was a person who worked for -- drum roll please -- a water bottling company.
One person made this claim and everyone else was quick to jump on it. However, in their defense, many weight loss gurus purport that many times people think they are hungry when they're actually thirsty, and if you keep your stomach full of water you'll resist the urge to eat during these periods.
This is a perfect example of people falling in love with an idea based on feelings -- it sounds like a good idea, and not so much fact. Besides, I've lost weight many times when I didn't go out of my way to drink as much water as the so called experts recommend many times.
Besides, if you drink too much water you'll just pee it out, and out with it will roll along key nutrients your body needs to function properly. Dehydration is bad, yet over-hydration is just as bad. Common sense is better. So if you're thirsty drink up. If you're not thirsty, don't worry guzzling that extra bottle of water because it won't do you any good anyway.
This is good new to most of us, because I'm sure I'm not alone in hating drinking all that water. Now we know there is no proof we have to drink 8-10 cups of water, and that common sense is a better choice. If you're drinking only when you're thirsty you're probably fine, common sense experts now say.
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Doctors have been pondering this issue recently, and one doctor wrote about it in the British Medical Journal. He wrote that many schools teach that you should drink more water because it's common sense, and it keeps your body working better, keeps your metabolism working, and it keeps your organs healthy.
Yet he writes there is no evidence to any of this. Likewise, he writes the number 8 to 10 is just a number that was made up. In fact, the person who first proposed this idea that we should drink more water to stay healthy, that it's common sense, was a person who worked for -- drum roll please -- a water bottling company.
One person made this claim and everyone else was quick to jump on it. However, in their defense, many weight loss gurus purport that many times people think they are hungry when they're actually thirsty, and if you keep your stomach full of water you'll resist the urge to eat during these periods.
This is a perfect example of people falling in love with an idea based on feelings -- it sounds like a good idea, and not so much fact. Besides, I've lost weight many times when I didn't go out of my way to drink as much water as the so called experts recommend many times.
Besides, if you drink too much water you'll just pee it out, and out with it will roll along key nutrients your body needs to function properly. Dehydration is bad, yet over-hydration is just as bad. Common sense is better. So if you're thirsty drink up. If you're not thirsty, don't worry guzzling that extra bottle of water because it won't do you any good anyway.
This is good new to most of us, because I'm sure I'm not alone in hating drinking all that water. Now we know there is no proof we have to drink 8-10 cups of water, and that common sense is a better choice. If you're drinking only when you're thirsty you're probably fine, common sense experts now say.
Friday, July 29, 2011
Philosophy Lexicon
1. Martyr: A person who punishes himiself; a person who sacrifices himself for the benefit of another person; a person who gives of himself for God; Jesus dying on the Cross was the best example of a perfect act of Martyrism. Those who do a job they do not like in order to feed his own family is an act of Martyrism; parenting; service; charity;
2. Charity: 1) Making sure the needs of everyone are taken care of 2) Anything you give: time, money, an ear, encouraging words, etc. 3) Any act of humility in a sense is a charitable contribution. It's anything that makes someone better.
3. Justice: Judging; Making sure no one is taken advantage of
3. Justice: Judging; Making sure no one is taken advantage of
4. Problem solving: These are the choices we make in order to make a bad situation better, or to make an unhealthy person healthy. There are basically two methods. One is to have leaders tell people what to do. The problem with this is everyone is treated the same and creativity is stifled. Also, this means that the patient is often treated by someone not near the problem. Examples of this are doctors who don't like the team approach, totolitarian doctors (see below), and order sets (see below). Another approach is to encourage individualism. This method allows people close to the problem to do what they see is best to remedy the situation. Examples of this are protocols and guidelines. For more on problem solving click here.
6. Compassion: This is when you put other people before yourself, you become humbled (see below), you are not arrogant,
7. Arrogance: 1) Putting yourself before others; you think you know it all; you think you are better than everyone else; your goal in life is to expand your ego. 2) Thinking you know all
12. Humble (Humility): 1) Capitalist doctors. People who understand they don't know it all. 2) If you are humble, the chances are you will be compassionate. 3) see humility.
14. Hope: It is no way to lead the world into the future. Hope will die with you. It's good to have faith, yet hope will only lead a nation to destruction because those who hope are not doing. Those who hope are dreaming of a better world. Yet if there is one thing we should know as Americans is that dreams do not come true unless we act on them. Hope never solved any problem. Hope traps people right where they are, good or bad. When you're hoping you are staying in your home, doing nothing, but thinking -- hoping. There is no action with hope
15. Desires: There is action with desire. Desire is when you want something and you go out and get it. The founding fathers wanted freedom, and they gathered together, fearing death, and went out and sought and obtained it. They didn't do it by sitting at home. They did it by grabbing a pen and a gun and seeking it.
16. Family: 1) All those who are the descendants of a common progenitor. For those who follow thte Bible that would be all who are in the lineage of Adam or, even more specific, Abraham. 2) Jesus would describe the family as all of us living in unity. A more specific definition of family is a group of people with a common goal or job or some sort of commonality. In this way, RTs are members of the RT family, and RNs are a member of the RN family.
17. Challenge: Any obstacle that stands in your way, and the attempt to get through or past it makes you a better person or family.
18. Creative Destruction: In order for newer and better and more productive companies who make more useful products to enter the market, those companies that are antiquated and have less popular products have to close their doors.
19. Compassion: 1) Have sympathy by those stricken by misfortune 2) One of the keys to likability. If you are a nice person, this will make up for many of your flaws. 3) Putting yourself second. Humility. Charity. 4) Treating people as people and not as an object. See empathy.
20. Kindness: Be friendly
21. Humility: 1) Know you are not better than any one else. 2) Putting other people before yourself and admitting you don't know all
22. Gentleness: Kindly and respectful in your approach and touch
23. Patience: Give people time to come together, especially when you don't see eye to eye.
24. Tolerance: This is key when you have a complaint against another
25. Forgiveness: Don't hold grudges. You have been forgiven many times. No one is perfect.
26. Love: Add this to all the above, as it binds everything together in perfect unity
27. Peacefulness: Try to be as one body
28. Thankful: Appreciate everything you have obtained in life. Be thankful for Christ's message with all its richness must live in your hearts.
29. Teacher: Instruct one another with all wisdom.
30. Praise: Sing, read and worship the Lord with Thanksgiving in your heart. Everything you do or say, then, should be done in the name of the Lord Jesus, as you give thanks through him to God the Father.
31. Tact: Doing the right thing at the right time.
32. Trivial matters: Something insignificant
33. Rules: 1) A regulation governing conduct. A principle that controls what you can do or say, and controls how you do what you do and say what you say. The more rules there are the less freedom you have. 2) 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 because people start to ignore them. 3) Each new rule takes away a freedom; diminishes individual thought and creativity. 3. See law of diminishing return.
34. Law of diminishing return: Rules are good up to a certain point where they start to come back to haunt you. People will respect a certain number of rules (they expect some rules), yet when there are too many rules it becomes hard or nearly impossible to follow them all. To many rules become a nuisance. When this point is reached, chaos may ensue.
35. Chaos: A state of utter confusion or disorder. This is a condition that may result from too many rules.
36. Hidden anarchy: When rules are ignored when the bosses aren't around. This often results in a sort of chaos for an institution, yet it may result in equanimity and peace among workers.
37. Avoiding judgement: Accepting people for what they are
38. The root of all evil: Pride
39. Charitable Contribution: See charity. Any act of humility. Anything that makes someoen else better
40. Unprofitable servant: A person who can only do what is expected and nothing more. We all have a task that we are to accomplish, and we accomplish it, and then we are done. In that sense, we are unprofitable. This is a means for us to keep things in proper perspective; to be humble.
41. Empathy: Having emotions for the people around you. Understanding the feelings of other people. See compassion and charity.
42. Smart: It's making an informed decision based on facts. It's not determined by education, in fact, education can corrupt you. Common sense is smart. Education, years on this planet, experience, has nothing to do with how people think. I think it has more to do with idealism and realism.
43. Realism: Knowing that perfection is not possible; that an ideal world is not possible; knowing there will always be bad guys; knowing there will always be stupid people; knowing people will always die; knowing there will always be poeple of all shapes and sizes; common sense.
44. Idealism: Thinking perfection is possible. The way the world would be under ideal circumstances. Anybody with an average brain can see idealism. It's making decisions based on feelings. For examle, it feels good to give a breathing treatment to the patinet who's short of breath. Yet anyone can see the consequences to idealism. Fo example, RT burnout and RT Apathy due to all the unecessary treatments that result.
45. Frustrating: Talking to people who think they are right yet they are wrong based on the facts.
46. Idiot: A person who thinks they know what they are doing, who insists he is right, and yet you know that facts don't back him up. I'll let you provide your own example
47. Outcast: Someone who is mocked and laughed at because he questions someone else's views; A person with the facts on his side when the facts are not accepted by the majority;
48. Ignorance: Whay you don't know. It's what you don't know. It's not a bad thing so long as you admit what you don't know.
49. Wisdom: Knowing what you don't know and what you do know and being able to tell the difference
50. Wise: A person with wisdom
51. Sage: An older person who is wise by age and experience.
52. Realist: See realism. A person who believes perfection is possible. They belive a euphoric world is possible. They are always making rules and policies in an attempt to create an ideal world, even if there is no proof their rules and policies will work -- even if there are facts that they don't work. They believe one or two experts can decide what's best for everyone, and it's these experts who create ordersets, policies and guidelines that everyone has to follow.Even if they are wrong they won't admit it. They may have screwed the heck out of the healthcare industry with their policies, but they won't admit it. They are the ones who passed Obamacare in an attempt to create equality in healthcare. They are the ones who created DRGs . They are the one's who decided to give away free healthcare to the poor and have caused ERs to become flooded with people who don't need to use the ER. Their policies have improved patient care and reduced the cost of Medicare and Medicaide, yet it's increased hospital costs and caused apathy and burnout among the masses. They are the reason for increasing healthcare costs and the nonexistent healthcare crisis. Idealists don't like it when you come up to them and are truthful. They say that when you do that you are confrontational. You are causing confrontation. Yet if you're afraid of confrontation you're an enabler. The realist at the bedside giving the treatment sees the truth, that the treatment did nothing. Their goal is euphoria in the healthcare industry; an ideal system by their definition of ideal. A scientist will not take this route. Perfection.
53. Idealist: See idealism. Judgemental. Basing decisions on proven fact and science. They ask questions like: Does this make sense? Is this science we're dealing with? Does this patient really need a bronchodilator? Is the U.S. healthcare system really as bad as they say it is? If the answer is no, then we don't do it or don't mess with it or don't waste our time.
54. Confrontational: A person who's willing to risk becoming an outcast in order to question stupidity. Antonym: Enabler.
55. Consequences: The things that happen as a result of your actions, personal decisions, or choices. Some may be good and others not so good.
56. Sheep: It's what you become when you never question and never judge.
57. Euphoria: What idealists yearn for and think is posible if they make more laws.
58. Laws: See Rules. The help people to know what to do. Each law takes away another freedom.
59. Lie: An untruth. Not the truth. Convincing yourself bronchodilators treat all lung ailments and annoying lung sounds.
60. Politics: Defending stupidity and ignorance to keep the peace.
61. Slippage: Failure to maintain an expected level, fulfill a goal, meet a deadline, etc.; loss, decline, or delay; a falling off -- dictionary.com. When a person does something he that is completely out of character. Slippage might be what you would call it when a person who is normally quiet and reserved bursts out of his shell and tells you all the things he hates about his job; or a person who is respected in the community gets drunk and starts talking about how many women he has gone to be with.
62. Mean: A person who is too judgemental; realist
63. Nice: A person who isn't judgemental enough; idealist.
64. Tact: Doing the right thing at the right time.
65. Trivial matters: Something insignificant
66. Tactless: Doing the wrong thing at an inappropriate time
67. Tact: Doing the right thing at the right time.
68. Trivial matters: Something insignificant
52. Realist: See realism. A person who believes perfection is possible. They belive a euphoric world is possible. They are always making rules and policies in an attempt to create an ideal world, even if there is no proof their rules and policies will work -- even if there are facts that they don't work. They believe one or two experts can decide what's best for everyone, and it's these experts who create ordersets, policies and guidelines that everyone has to follow.
53. Idealist: See idealism. Judgemental. Basing decisions on proven fact and science. They ask questions like: Does this make sense? Is this science we're dealing with? Does this patient really need a bronchodilator? Is the U.S. healthcare system really as bad as they say it is? If the answer is no, then we don't do it or don't mess with it or don't waste our time.
54. Confrontational: A person who's willing to risk becoming an outcast in order to question stupidity. Antonym: Enabler.
55. Consequences: The things that happen as a result of your actions, personal decisions, or choices. Some may be good and others not so good.
56. Sheep: It's what you become when you never question and never judge.
57. Euphoria: What idealists yearn for and think is posible if they make more laws.
58. Laws: See Rules. The help people to know what to do. Each law takes away another freedom.
59. Lie: An untruth. Not the truth. Convincing yourself bronchodilators treat all lung ailments and annoying lung sounds.
60. Politics: Defending stupidity and ignorance to keep the peace.
61. Slippage: Failure to maintain an expected level, fulfill a goal, meet a deadline, etc.; loss, decline, or delay; a falling off -- dictionary.com. When a person does something he that is completely out of character. Slippage might be what you would call it when a person who is normally quiet and reserved bursts out of his shell and tells you all the things he hates about his job; or a person who is respected in the community gets drunk and starts talking about how many women he has gone to be with.
62. Mean: A person who is too judgemental; realist
63. Nice: A person who isn't judgemental enough; idealist.
64. Tact: Doing the right thing at the right time.
65. Trivial matters: Something insignificant
66. Tactless: Doing the wrong thing at an inappropriate time
67. Tact: Doing the right thing at the right time.
68. Trivial matters: Something insignificant
My solution to fixing the healthcare industry
Running a medical care facility is as complicated as caring for an end stage COPD patient. While a doctor will need to find the right balance of medicines to deal with all the facets of lung disease -- bronchospasm, heart failure, anxiety -- hospital administrators need to find the best potion to keep the hospital afloat.
Finding the best potion is accomplished by balancing the following core goals:
In reality, the difference between order set and protocol is similar to the difference between capitalism and socialism. One allows for individualism, and the other creates equality. While one might "sound" like it solves problems better, the other actually does.
So what are hospitals presently doing right, and what can they do better? To answer these questions we must first have some definitions:
Order set: Synonym: Social Justice, socialism. Every patient with a given diagnosis (DRG) is treated the same. Once a patient is admitted with a certain DRG, these sets pre-determine what you order for that patient. The purpose of these is to make sure best practice medicine is followed for every patient. Basically, a committee -- usually in Washington -- determines what is best for the patient, and this assumes that the caregivers at the bedside are not capable of critical thinking. Another advantage of order sets, and the reason they are being initiated in most hospitals, is to make sure intensity of service is met. This assures that the patient will meet reimbursement criteria. In the past physicians were presented with a sheet that listed all the options. Today, however, many of these options are pre-checked and automatically ordered whether the doctor wants to or not. The reason for this is to make sure reimbursement criteria is met (see below).
Cook book medicine: Treating all patients the same. This is generally the theme created to describe order sets, especially order sets that have pre-checked boxes that result in procedures being automatically ordered for a particular DRG.
Protocol: Synonym: Capitalism, individualism. Every patient and every patient situation is treated individually and uniquely given the patient status and the wisdom of the caregivers. The institution has set guidelines, and the caregivers use their education and wisdom to solve the problem at the bedside. Given proper training and well written protocols, best practice medicine should occur by default because protocols encourage critical thinking.
Ideally, according to Egan, a protocol would work like this:
1. Benefits the patient: The medical professionals working with the patient (RT and RN) decide what the patient needs at the moment the care is needed.
2. Less calls to physician: Doctors will receive fewer irritating phone calls
3. Improved morale and apathy: RTs and RNs will be able to use the wisdom they obtained by education and through experience, and this will improve their dignity, mercy and self worth.
4. Less burnout: With only those patients who need therapy receiving it, there is a good chance the RT or RN won't feel so run down and overwhelmed, and the patients who truly need their services will benefit as a result.
Reasons your hospital might choose not to use protocols:
1. Procedure counts: RT bosses need procedure counts to justify staffing load. They fear, and often needlessly so, that protocols will result in less work for the department
2. Reimbursement criteria: Quality Assurance (see below) wants to make sure government quotas are met for each given patient. If the RT decides a patient doesn't need certain procedures (such as bronchodilators), then the hospital may not be reimbursed. This is one of the main reasons many smaller hospitals avoid protocols (note: see reimbursement criteria below).
Order set/ Protocol combination: This is where a hospital committee creates order sets for a given DRG yet allows the medical staff freedom based on well designed protocols to use critical thinking in determining what is best for the patient. Once order sets are initiated, the caregivers at the bedside (RN and RN) decide which ones are to be followed and how. For example, a post operative order set may include an incentive spirometer order. By using the protocol, the RT will decide whether the IS is appropriate, or if cough and deep breathing might be better for that particular patient. An Albuterol breathing treatment is another example. A pneumonia order set may automatically order Q6 breathing treatments. The RT will give an initial breathing treatment and monitor it's effectiveness. If there is no benefit to the patient and the patient the order would be changed to as needed or discontinued. This would save the hospital money (treatments are $80 to 100 each) and allow the RCP an opportunity to help patients with greater needs.
Order sets are the current trent. Personally, I think these have some advantages. It assures that best practice medicine is followed. So, what is best practice medicine?
Best practice medicine: Based on scientific evidence, this is what is proven to work for a given DRG. For example, breathing treatments improve work of breathing for asthmatic patients and should be ordered. Likewise, oxygen should be an option. This also focuses on preventative medicine. Incentive Spirometers use is proven to reduce post operative pneumonia and atelectasis, and therefore an IS order is automatic with post operative order sets.
Intensity of Service: Basically, does the patient meet reimbursement criteria? Is the patient sick enough to be admitted? Doctors would prefer to use their own judgement to decide which patients go home and which patients are admitted for observation. Yet the Centers for Medicare and Medicaid Services (CMS) will refuse to reimburse the hospital for a patient admission unless the patient is sick enough to need certain pre-determined procedures. For example, if a patient admitted with asthma didn't receive any breathing treatments, then why did he need to be admitted? If no treatments are given, CMS has a right to refuse reimbursement. Order sets make sure what is required is given regardless of need.
Keystone Committee: This is a committee formed to make sure intensity of service is met, reimbursement criteria is met, and best practice medicine is met for each DRG. The goal is to reduce costs for the hospital, make as much money for each DRG, and to provide best practice medicine for each DRG that results in improved care for the patient.
Core Measures: These are measures set by the Keystone Committee that work as goals for the hospital to improve patient care and reduce costs. They are based on best practice medicine and reimbursement criteria.
Quality Assururance (QA): This is the fastest growing area of the medical field, especially since the passing of Obamacare. This is the department responsible for checking charts and making sure core measures are met. The goal here is to make sure the hospital is making as much money for a given patient as possible. They also work on committees with other department heads in the hospital to create methods of assuring best practice medicine and reimbursement criteria is met. T'his is a noble department set to make sure the patient is getting the best care possible and the hospital is making a profit. However, because of government regulations on the medical field and new regulations imposed by Obamacare, one of the main emphasis's of late is on meeting these regulations.
This department hides under the guise of best practice medicine, although their real intent is always to make sure the patient is profitable. They're often referred to as the nitpickers of the hospital, or the people who make sure we dot all our i's and cross all our t-s per se.
Quality Assurance Analyzer: This is one member of the QA team who is a former nurse who has the responsibility of reviewing charts to make sure intensity of service is met for each patient. They carry a book around with them created by an independent company that lists all the orders for a given DRG that must be ordered for that patient to meet reimbursement criteria. It is illegal for the QA analyzer to tell a doctor the patient doesn't meet criteria because a certain order was not made. For example, it is illegal for the QA analyzer to observe treatments were not ordered for an asthma patient and to tell the doctor he must order them so the hospital gets reimbursed. However, doing this is part of their job.
Reimbursement criteria: This is criteria set by CMS that must be met for each DRG. If not, CMS has a right to reject reimbursement for that patient. If CMS deems a patient was not sick enough to be admitted, they will not reimburse the hospital. It does not matter that the doctor was worried about the patient and wanted him admitted for observation. This is one of the main reasons many procedures are added to order sets that are not needed: Ted stockings for every patient, neuro checks every two hours, IVs, EKGs every morning times 2 days for chest pain patients, bronchodilators for RSV patients and pneumonia, etc. We must also note that the purpose of reimbursement criteria is to reduce cost to the government, not to reduce cost to the hospital. Since these actually increase the number of procedures ordered to meet criteria, this actually results in increased cost to hospitals.
The only way to reduce costs when you have order sets is to also add protocols.
Public relations: Creating a good image of the hospital in the community and among staff working for the facility.
Diagnosis Related Group (DRG): This is a diagnosis related group and each patient is assigned one. Based on the DRG chosen, the hospital will receive a set payment. Because hospitals know in advance how much they will make for that patient, this may help determine the type of care this patient receives. Because there is a flat profit, hospitals therefore have an incentive to do only those procedures that are essential. Thus, the fewer procedures the hospital does the more money the hospital will have once the bills are paid. This is an incentive to do more with less. One of the best ways to do more with less is to have order sets and protocols.
What are the current trends?
The current trend is for hospitals via keystone committees (or something similar) to create order sets for every DRG. In the past this included a list to remind a physician of his options. However, more recently it's evolved into simply checking options so that nothing is missed. The goal is to meet core measures.
However, we must keep in mind that while the intent is to improve quality and decrease costs, it is my assessment that due to government intervention, not enough common sense is involved in the process. The emphasis is moving away from protocols and toward order sets that make certain orders are mandatory regardless of need.
The result of this is the following:
However, due to government regulations and reimbursement criteria, hospital committee members are forced to make reimbursement criteria a top priority, and, unfortunately, this comes at the expense of patient outcomes and worker morale. Due to order sets that pre-mark and automatically have certain procedures ordered, this results in the staff becoming overwhelmed.
A good example of this is if a patient is admitted with sepsis, COPD, pneumonia, asthma, heart failure and anxiety. The order sets for all those DRGs must be followed. The unit secretary can be bogged down for hours just on one patient, and implementing those orders will bog down a single nurse, and often require a second nurse and a nursing assistant.
With limited focus on creating protocols, there are no methods of getting rid of redundant and unnecessary procedures. This results in staff being overwhelmed, it causes burnout, and it results in apathy. Due to the recession, most hospitals are unable to hire new nurses to help out. Burnout, decreased morale and increased apathy is the result.
This effects public relations too, because a staff that is burned out is going to have a poor view of the institution and the administration, and will be less likely to spread a positive word about the hospital. This makes the job of public relations more complicated.
With any future approach to medical care, you'll obviously want to continue positive trends and get rid of what doesn't work, and add what has worked at other hospitals. The problem is due to government intervention, most hospitals are a) forced to set core measures based on reimbursement criteria, and b) forced to do things the same way.
This takes away individualism. Since all hospitals are doing things the same way, this decreases the implementation of new out of the box ideas that might revolutionize the medical industry in the future. If forces hospitals to focus in one area (reimbursement) and slack in others (worker morale).
I think Keystone Collaborative Core Measures have improved patient care. One recent study shows that critical care core measures have reduced ventilator acquired pneumonia and reduced readmission rates for pneumonia and COPD. Yet gains in this area have not improved worker morale and have not improved hospital image within the institution and the community.
Likewise, when worker morale is low, so too is patient morale. On top of this the patient is needlessly having to be awakened every time a staff has to come into his room to do a certain procedure. Apathetic and overwhelmed RTs and RNs aren't going to care about working together to make sure the patient isn't awakened every hour. Apathetic and overwhelmed staffers are simply going to do what they have to do to get their assigned work done.
They, in essence, become overwhelmed button pushers and automatons. They become robots. This is bad because these RNs and RTs are right at the bedside and provide an image to the patient of the hospital.
I believe the best way to accomplish all of the above four hospital goals this is via the following:
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Finding the best potion is accomplished by balancing the following core goals:
- Improving patient care
- Reducing costs
- Creating a good image of the institution
- Maintaining a good morale among employees
What is the current trend?
The current trend is to focus on 1-3 above, and to incorporate employee morale into a public relations campaign which involves things like midnight meals provided by administrators, summer parties, Christmas parties, giveaways, and having administrators participate in meetings. While this is a step in the right direction, it has done nothing to improve morale. However, studies show the current trend has improved patient care.
All of the above goals can be accomplished through the creation, implementation and monitoring for the following methods:
- Order sets
- Protocols
Quite often these two terms are used as synonyms, and more frequently an order set is called a protocol. I think this is done more as window dressing, because most people in the medical profession believe every patient and every situation must be treated individually. It didn't used to be this way, yet this is the current trend.
In reality, the difference between order set and protocol is similar to the difference between capitalism and socialism. One allows for individualism, and the other creates equality. While one might "sound" like it solves problems better, the other actually does.
So what are hospitals presently doing right, and what can they do better? To answer these questions we must first have some definitions:
Order set: Synonym: Social Justice, socialism. Every patient with a given diagnosis (DRG) is treated the same. Once a patient is admitted with a certain DRG, these sets pre-determine what you order for that patient. The purpose of these is to make sure best practice medicine is followed for every patient. Basically, a committee -- usually in Washington -- determines what is best for the patient, and this assumes that the caregivers at the bedside are not capable of critical thinking. Another advantage of order sets, and the reason they are being initiated in most hospitals, is to make sure intensity of service is met. This assures that the patient will meet reimbursement criteria. In the past physicians were presented with a sheet that listed all the options. Today, however, many of these options are pre-checked and automatically ordered whether the doctor wants to or not. The reason for this is to make sure reimbursement criteria is met (see below).
Cook book medicine: Treating all patients the same. This is generally the theme created to describe order sets, especially order sets that have pre-checked boxes that result in procedures being automatically ordered for a particular DRG.
Protocol: Synonym: Capitalism, individualism. Every patient and every patient situation is treated individually and uniquely given the patient status and the wisdom of the caregivers. The institution has set guidelines, and the caregivers use their education and wisdom to solve the problem at the bedside. Given proper training and well written protocols, best practice medicine should occur by default because protocols encourage critical thinking.
Ideally, according to Egan, a protocol would work like this:
- Therapy can be adjusted more frequently in response to changes in patient status.
- Physicians can still be contacted for major changes, but not minor adjustments, thus reducing nuisance calls.
- Consistency of therapy can be maintained and nonpulmonary physicians can use appropriate up-to-date methods by simply requesting that protocol therapy be used.
- RCPs (Respiratory Care Practitioners) become actively involved in achieving good patient outcomes instead of performing rigid tasks. This enhanced responsibility attracts and retains better educated and qualified practitioners.
1. Benefits the patient: The medical professionals working with the patient (RT and RN) decide what the patient needs at the moment the care is needed.
2. Less calls to physician: Doctors will receive fewer irritating phone calls
3. Improved morale and apathy: RTs and RNs will be able to use the wisdom they obtained by education and through experience, and this will improve their dignity, mercy and self worth.
4. Less burnout: With only those patients who need therapy receiving it, there is a good chance the RT or RN won't feel so run down and overwhelmed, and the patients who truly need their services will benefit as a result.
Reasons your hospital might choose not to use protocols:
1. Procedure counts: RT bosses need procedure counts to justify staffing load. They fear, and often needlessly so, that protocols will result in less work for the department
2. Reimbursement criteria: Quality Assurance (see below) wants to make sure government quotas are met for each given patient. If the RT decides a patient doesn't need certain procedures (such as bronchodilators), then the hospital may not be reimbursed. This is one of the main reasons many smaller hospitals avoid protocols (note: see reimbursement criteria below).
Order set/ Protocol combination: This is where a hospital committee creates order sets for a given DRG yet allows the medical staff freedom based on well designed protocols to use critical thinking in determining what is best for the patient. Once order sets are initiated, the caregivers at the bedside (RN and RN) decide which ones are to be followed and how. For example, a post operative order set may include an incentive spirometer order. By using the protocol, the RT will decide whether the IS is appropriate, or if cough and deep breathing might be better for that particular patient. An Albuterol breathing treatment is another example. A pneumonia order set may automatically order Q6 breathing treatments. The RT will give an initial breathing treatment and monitor it's effectiveness. If there is no benefit to the patient and the patient the order would be changed to as needed or discontinued. This would save the hospital money (treatments are $80 to 100 each) and allow the RCP an opportunity to help patients with greater needs.
Order sets are the current trent. Personally, I think these have some advantages. It assures that best practice medicine is followed. So, what is best practice medicine?
Best practice medicine: Based on scientific evidence, this is what is proven to work for a given DRG. For example, breathing treatments improve work of breathing for asthmatic patients and should be ordered. Likewise, oxygen should be an option. This also focuses on preventative medicine. Incentive Spirometers use is proven to reduce post operative pneumonia and atelectasis, and therefore an IS order is automatic with post operative order sets.
Intensity of Service: Basically, does the patient meet reimbursement criteria? Is the patient sick enough to be admitted? Doctors would prefer to use their own judgement to decide which patients go home and which patients are admitted for observation. Yet the Centers for Medicare and Medicaid Services (CMS) will refuse to reimburse the hospital for a patient admission unless the patient is sick enough to need certain pre-determined procedures. For example, if a patient admitted with asthma didn't receive any breathing treatments, then why did he need to be admitted? If no treatments are given, CMS has a right to refuse reimbursement. Order sets make sure what is required is given regardless of need.
Keystone Committee: This is a committee formed to make sure intensity of service is met, reimbursement criteria is met, and best practice medicine is met for each DRG. The goal is to reduce costs for the hospital, make as much money for each DRG, and to provide best practice medicine for each DRG that results in improved care for the patient.
Core Measures: These are measures set by the Keystone Committee that work as goals for the hospital to improve patient care and reduce costs. They are based on best practice medicine and reimbursement criteria.
Quality Assururance (QA): This is the fastest growing area of the medical field, especially since the passing of Obamacare. This is the department responsible for checking charts and making sure core measures are met. The goal here is to make sure the hospital is making as much money for a given patient as possible. They also work on committees with other department heads in the hospital to create methods of assuring best practice medicine and reimbursement criteria is met. T'his is a noble department set to make sure the patient is getting the best care possible and the hospital is making a profit. However, because of government regulations on the medical field and new regulations imposed by Obamacare, one of the main emphasis's of late is on meeting these regulations.
This department hides under the guise of best practice medicine, although their real intent is always to make sure the patient is profitable. They're often referred to as the nitpickers of the hospital, or the people who make sure we dot all our i's and cross all our t-s per se.
Quality Assurance Analyzer: This is one member of the QA team who is a former nurse who has the responsibility of reviewing charts to make sure intensity of service is met for each patient. They carry a book around with them created by an independent company that lists all the orders for a given DRG that must be ordered for that patient to meet reimbursement criteria. It is illegal for the QA analyzer to tell a doctor the patient doesn't meet criteria because a certain order was not made. For example, it is illegal for the QA analyzer to observe treatments were not ordered for an asthma patient and to tell the doctor he must order them so the hospital gets reimbursed. However, doing this is part of their job.
Reimbursement criteria: This is criteria set by CMS that must be met for each DRG. If not, CMS has a right to reject reimbursement for that patient. If CMS deems a patient was not sick enough to be admitted, they will not reimburse the hospital. It does not matter that the doctor was worried about the patient and wanted him admitted for observation. This is one of the main reasons many procedures are added to order sets that are not needed: Ted stockings for every patient, neuro checks every two hours, IVs, EKGs every morning times 2 days for chest pain patients, bronchodilators for RSV patients and pneumonia, etc. We must also note that the purpose of reimbursement criteria is to reduce cost to the government, not to reduce cost to the hospital. Since these actually increase the number of procedures ordered to meet criteria, this actually results in increased cost to hospitals.
The only way to reduce costs when you have order sets is to also add protocols.
Public relations: Creating a good image of the hospital in the community and among staff working for the facility.
Diagnosis Related Group (DRG): This is a diagnosis related group and each patient is assigned one. Based on the DRG chosen, the hospital will receive a set payment. Because hospitals know in advance how much they will make for that patient, this may help determine the type of care this patient receives. Because there is a flat profit, hospitals therefore have an incentive to do only those procedures that are essential. Thus, the fewer procedures the hospital does the more money the hospital will have once the bills are paid. This is an incentive to do more with less. One of the best ways to do more with less is to have order sets and protocols.
What are the current trends?
The current trend is for hospitals via keystone committees (or something similar) to create order sets for every DRG. In the past this included a list to remind a physician of his options. However, more recently it's evolved into simply checking options so that nothing is missed. The goal is to meet core measures.
However, we must keep in mind that while the intent is to improve quality and decrease costs, it is my assessment that due to government intervention, not enough common sense is involved in the process. The emphasis is moving away from protocols and toward order sets that make certain orders are mandatory regardless of need.
The result of this is the following:
- Increased workload on all staff
- Increased ordering of procedures that are not needed
- Increased burnout
- Decreased critical thinking
- Decreased morale
- Increased apathy
- Decreased dignity, mercy and feeling of self worth
- Worsening of patient care (due to burnout and apathy)
What is the best approach to take in the future?
I believe the best approach to accomplishing the four core goals for hospitals is to take a combination approach to public relations, order sets and protocols. I believe order sets will assure core values are met, and protocols will assure costs are reduced and morale is improved.
With a fine balance of public relations, order sets and protocols, the following will be the result:
With a fine balance of public relations, order sets and protocols, the following will be the result:
- Improved patient care results in improved patient satisfaction and outcomes
- Improve individual choice results in improved worker morale and feeling of self worth
- Reduce unnecessary procedures lessens burnout and reduces apathy
- Improved option results in a reduction of redundant and unnecessary phone calls to physicians
- Increase critical thinking at the bedside likewise improves patient care, reduced calls to physicians, and improved worker satisfaction
- Improved morale would result in better word of mouth advertising by staff and physicians
A good example of this is if a patient is admitted with sepsis, COPD, pneumonia, asthma, heart failure and anxiety. The order sets for all those DRGs must be followed. The unit secretary can be bogged down for hours just on one patient, and implementing those orders will bog down a single nurse, and often require a second nurse and a nursing assistant.
With limited focus on creating protocols, there are no methods of getting rid of redundant and unnecessary procedures. This results in staff being overwhelmed, it causes burnout, and it results in apathy. Due to the recession, most hospitals are unable to hire new nurses to help out. Burnout, decreased morale and increased apathy is the result.
This effects public relations too, because a staff that is burned out is going to have a poor view of the institution and the administration, and will be less likely to spread a positive word about the hospital. This makes the job of public relations more complicated.
With any future approach to medical care, you'll obviously want to continue positive trends and get rid of what doesn't work, and add what has worked at other hospitals. The problem is due to government intervention, most hospitals are a) forced to set core measures based on reimbursement criteria, and b) forced to do things the same way.
This takes away individualism. Since all hospitals are doing things the same way, this decreases the implementation of new out of the box ideas that might revolutionize the medical industry in the future. If forces hospitals to focus in one area (reimbursement) and slack in others (worker morale).
I think Keystone Collaborative Core Measures have improved patient care. One recent study shows that critical care core measures have reduced ventilator acquired pneumonia and reduced readmission rates for pneumonia and COPD. Yet gains in this area have not improved worker morale and have not improved hospital image within the institution and the community.
Likewise, when worker morale is low, so too is patient morale. On top of this the patient is needlessly having to be awakened every time a staff has to come into his room to do a certain procedure. Apathetic and overwhelmed RTs and RNs aren't going to care about working together to make sure the patient isn't awakened every hour. Apathetic and overwhelmed staffers are simply going to do what they have to do to get their assigned work done.
They, in essence, become overwhelmed button pushers and automatons. They become robots. This is bad because these RNs and RTs are right at the bedside and provide an image to the patient of the hospital.
I believe the best way to accomplish all of the above four hospital goals this is via the following:
- Reduce government regulations on healthcare industry that discourage innovation and create an emphasis on reimbursement criteria over patient outcomes and worker satisfaction
- Continue the Keystone Collaborative to set core measures that focus mainly on best practice medicine and less so on government regulations and reimbursement criteria.
- Creating a combination of order sets that remind doctors of the core values
- Creating protocols to allow point of care fine tuning of order sets to meet patient needs and improve worker satisfaction which will in turn result in improved patient satisfaction with the hospital
- Reduction of costs because only procedures that are needed will be given
It's a tough balancing act to find at potion that works to improving patient care, reducing costs while creating a positive work environment that lends itself to good worker morale, and lends itself to good word of mouth advertising to compliment a positive public relations campaign.
Yet I truly believe less government intervention will result in more creativity by individual medical institution in accomplishing the four goals: improving patient care and outcomes, reducing costs, creating worker satisfaction, and improving the hospitals image.
A combination of core measures that result in a positive balance of order sets and protocols that assure best practice medicine is met at the same time as worker and patient satisfaction is accomplished.
It is possible to accomplish all the above goals at the same time, yet it will take a collaborative effort on the part of hospital administrators, nurses, respiratory therapists, patients, and Congressmen and Senators on both the state and federal level.
The goal should involve increasing individual thought, and decreasing cook book medicine.
Thursday, July 28, 2011
Smoking linked with alzheimers and dementia
I thought this study was interesting, it shows that smoking cigarettes increases your risk of developing all of the following:
The study findings are similar to previous studies that show smoking is linked with alzheimers and dementia. Now the conundrum is determining the why smoking affects brain function. However, experts do believe that smoking causes "inflammation and oxidative stress — cell damage from toxic free radicals in the body — conditions that are associated with the onset of Alzheimer's," according to study researcher and scientist Rachel Whitmer.
The study also determined that those who smoked less than half a pack a day did not have an increased risk for developing alzheimers or dementia than those who never smoked.
Other studies were done in the past that showed that the more cigarettes a person smokes the greater the risk of developing mental deterioration, although this current study was the most thorough and most conclusive.
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- Lung cancer
- Heart disease
- Stroke
- Emphysema
- Infertility
- Alzheimer's disease.
The study findings are similar to previous studies that show smoking is linked with alzheimers and dementia. Now the conundrum is determining the why smoking affects brain function. However, experts do believe that smoking causes "inflammation and oxidative stress — cell damage from toxic free radicals in the body — conditions that are associated with the onset of Alzheimer's," according to study researcher and scientist Rachel Whitmer.
The study also determined that those who smoked less than half a pack a day did not have an increased risk for developing alzheimers or dementia than those who never smoked.
Other studies were done in the past that showed that the more cigarettes a person smokes the greater the risk of developing mental deterioration, although this current study was the most thorough and most conclusive.
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Wednesday, July 27, 2011
Ventilator Set-up Protocol
In order to prevent ventilator acquired pneumonia many hospitals are creating ventilator protocols. There are three types of ventilator protocols:
1. Set up : Provides guidelines for initial settings
2. Maintenence: Allows you to make changes based on gases, SpO2 and EtCO2
3. Weaning: Allows you to always be thinking about extubating
For an example of a maintenance and weaning protocol click the links provided above. Below is an example of a set up protocol:
Here are the initial vent settings allowed per protocol:
1. Set up : Provides guidelines for initial settings
2. Maintenence: Allows you to make changes based on gases, SpO2 and EtCO2
3. Weaning: Allows you to always be thinking about extubating
For an example of a maintenance and weaning protocol click the links provided above. Below is an example of a set up protocol:
Here are the initial vent settings allowed per protocol:
- FiO2: 40%, and increase to main SpO2 >92% (or as specified by physician).
- VT: 6-10 ml/kg IBW (for Acute Lung Injury or ARDS use 6 ml/kg IBW)
- PRVC: 10-14 BPM
- PEEP: 5
- ABG within 30 minutes post set-up
- Automode: per RT discretion
- Maintain cuff pressure >20
- Suction and send sputum to lab
- Perform oral care Q2 hours
- elevate head of bed 40 degrees
Ventilator settings are then managed in accordance with the ventilator management protocol and the extubation protocol.
Tuesday, July 26, 2011
What is persistent asthma?
Your question: What is persistent asthma? And what is a good treatment for it?
My humble answer: Actually, I'm going to quote a doctor for the answer to this question. Dr. James Thompson M.D. in his post, "Combination Inhalers for Asthma Control: The New Kid on the Block," provides the following definition tio persistent asthma:
When is asthma persistent? Great Question!
Asthma is persistent when any one of the following is true:
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My humble answer: Actually, I'm going to quote a doctor for the answer to this question. Dr. James Thompson M.D. in his post, "Combination Inhalers for Asthma Control: The New Kid on the Block," provides the following definition tio persistent asthma:
When is asthma persistent? Great Question!
Asthma is persistent when any one of the following is true:
- There are limitations in normal routine (work/school) because of asthma. For example, huffing and puffing as you walk up one flight of stairs, noticing classmates or coworkers gliding by with ease.
- Symptoms of asthma (cough, wheezing, shortness of breath, or chest tightness) occur more than two days per week.
- Reliever inhaler is required more than two days per week (don't count the inhalations taken to prevent exercise-induced asthma).
- Night time awakenings from asthma symptoms occurs more than two nights per month.
- Lung function is less than 80 percent predicted by lung function test (Spirometry or Peak Flow Rate).
- There has been more than one severe asthma attack in the last 12 months.
- Bronchodilator inhaler (Every asthmatic should have one on hand at all time)
- Singulair (if this alone does not control your asthma, move on to #3 below)
- Inhaled corticosteroid (if this does not control your asthma, move on to step #4 below)
- Combination inhaler (if this doesn't control your asthma, seek an asthma specialist)
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Monday, July 25, 2011
RT Questions that concern this RT
1. Where have all the RT bloggers gone? Has there been a crack down on RT blogs? If not, then why all of a sudden are there only a few of us. I've noticed several of the best RT blogs are gone. It's true we bloggers tend to be honest here in the blogosphere, yet this is considered good therapy for RT apathy. I certainly would hate to hear my fellow bloggers quit because they were forced to shut up. While RT is a good career, there are definite problems that should be vocalized. If we don't speak about the things that are wrong, then how will they ever get better?
2. Why the sudden boost in the patient load? It seems the number of patients has skyrocketed this year, and it doesn't seem to want to let up. Is this a result of the weather? Is this a result of the recession caused depression? Is it doctor fear to send patient's home so they all get diagnosed with pneumonia and admitted for observation and ordered on breathing treatments?
3. Why the spike in breathing treatments ordered? It seems the treatment load has spiked this year as well and isn't letting up. This has resulted in high burnout rates and RT apathy. What is the cause? Is it the weather causing more sick people? Is it stupid doctor orders? Or is it all the new order sets resulting in unnecessary breathing treatments? I do know that many hospitals have created new order sets, many of which require all patients with that particular DRG to get breathing treatments to meet the new government criteria for reimbursement. Is this the reason why?
Let me know what you think.
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2. Why the sudden boost in the patient load? It seems the number of patients has skyrocketed this year, and it doesn't seem to want to let up. Is this a result of the weather? Is this a result of the recession caused depression? Is it doctor fear to send patient's home so they all get diagnosed with pneumonia and admitted for observation and ordered on breathing treatments?
3. Why the spike in breathing treatments ordered? It seems the treatment load has spiked this year as well and isn't letting up. This has resulted in high burnout rates and RT apathy. What is the cause? Is it the weather causing more sick people? Is it stupid doctor orders? Or is it all the new order sets resulting in unnecessary breathing treatments? I do know that many hospitals have created new order sets, many of which require all patients with that particular DRG to get breathing treatments to meet the new government criteria for reimbursement. Is this the reason why?
Let me know what you think.
Sunday, July 24, 2011
The definition of family
You might think of a family as those of whom you live with, such as your wife and children, or your mother and father and siblings and yourself. Yet that is but one example of a family. That family is the smallest sample size. It is considered the traditional family.
The true definition of family is all those who are the descendants of a common progenitor. For those who follow thte Bible that would be all who are in the lineage of Adam or, even more specific, Abraham.
Jesus would describe the family as all of us living in unity. A more specific definition of family is a group of people with a common goal or job or some sort of commonality. In this way, RTs are members of the RT family, and RNs are a member of the RN family.
Yet all RTs and RNs are members of the medical care giver family. And we are all working for the common goal of making the world a better place; of helping people in need. In essence, that really should be the common goal of all people.
So we are all one big family. It is not easy living as a family. Consider for example last Christmas. How many of you can say that you did not have a fight with one of your siblings or your parents or spouse around Christmas time. If you did not say yes, then chances are you are fibbing. Because Christmas is a very stressful time
If you're like me, you open up new boxes of toys that need to be assembled, and you don't read the directions. So my wife lectured me about how I need to read directions -- after I was finished and had a screw leftover.
A lot of people think the first family doesn't have a lot of tension because they are sheltered and pretty much get whatever they want. Yet I bet Obama and his children fight behind the scenes. What we see is the glory side of their lives; the side they want us to see.
Most people are like me and have an insular view of the family of Mary and Joseph and Jesus. We see them as being the perfect family because they are the family of God and protected by His angels. Yet there were many stresses during those days, many far worse than what we face today. Consider the following words of my priest:
So he called for a census. Back in those days the census takers did not go to your house, you had to go to theirs. So Mary and Jesus had to go to town with little Jesus. On the way they had the fear of robbers. Once in town they feared someone might try to kidnap the child.
Every year, according to the Gospel of Paul (Paul 2: 41-49) Mary and Joseph had to take their family to Jerusalem for the Passover Festival. One year when Jesus was 12 and the festival was over, Jesus disappeared. Mary and Joseph searched frantically for three days thinking perhaps Jesus was kidnapped to be sold as a slave.
They ultimately found him at a Jewish Temple and Jesus said, "Why did you have to look for me? Didn't you know that I had to be in my Father's house?"
Yet that was little assurance to the parents.
So the family is a unity, and we work together for the common goal, and we rejoice together and we share the common fears at the things that try to attack our goals and set us back in our objectives.
You can see here that all families face challenges, and therefore must work together in perfect unity to conquer the challenges and make the world better than when we left than when we entered. Ultimately, we nurses, doctors and respiratory therapists are a part of this big family, and our goal is to make the world better one breathe at a time.
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The true definition of family is all those who are the descendants of a common progenitor. For those who follow thte Bible that would be all who are in the lineage of Adam or, even more specific, Abraham.
Jesus would describe the family as all of us living in unity. A more specific definition of family is a group of people with a common goal or job or some sort of commonality. In this way, RTs are members of the RT family, and RNs are a member of the RN family.
Yet all RTs and RNs are members of the medical care giver family. And we are all working for the common goal of making the world a better place; of helping people in need. In essence, that really should be the common goal of all people.
So we are all one big family. It is not easy living as a family. Consider for example last Christmas. How many of you can say that you did not have a fight with one of your siblings or your parents or spouse around Christmas time. If you did not say yes, then chances are you are fibbing. Because Christmas is a very stressful time
If you're like me, you open up new boxes of toys that need to be assembled, and you don't read the directions. So my wife lectured me about how I need to read directions -- after I was finished and had a screw leftover.
A lot of people think the first family doesn't have a lot of tension because they are sheltered and pretty much get whatever they want. Yet I bet Obama and his children fight behind the scenes. What we see is the glory side of their lives; the side they want us to see.
Most people are like me and have an insular view of the family of Mary and Joseph and Jesus. We see them as being the perfect family because they are the family of God and protected by His angels. Yet there were many stresses during those days, many far worse than what we face today. Consider the following words of my priest:
"This Solemnity of the Holy Family celebrates and remembers the nuclear family of Jesus, Mary and Joseph. We behold the wonder of this family unit in their love and devotion for one another, and they stand before our eyes as a model for our own familial relationships. It is too easy of many of us to look and say, "Well, that was them! Such an attitude is a mistake to that the Holy Family endured so many of the same challenges that many families today face: economic stress and poverty, forced to being refugees and having to fend for themselves in a foreign country, fear of terrorism from a tyrannical government, "tongue-wagging" from gossipers, fear for the safety of their child in a dangerous world. Yet, in the face of all of this, they remained faithful to God and each other. many of us are challenged in living harmonious family lives; we need to look to the example of the Holy Family to be reminded of what we could experience in the family dynamics of our own."Consider that King Herod feared that someone would take power from him, because his power was a gift from the Roman Emperor. He was the Roman declared "King of Judea," yet as soon as he learned of the birth of Jesus, the true King of the Jews, he had the light of day scared into him.
So he called for a census. Back in those days the census takers did not go to your house, you had to go to theirs. So Mary and Jesus had to go to town with little Jesus. On the way they had the fear of robbers. Once in town they feared someone might try to kidnap the child.
Every year, according to the Gospel of Paul (Paul 2: 41-49) Mary and Joseph had to take their family to Jerusalem for the Passover Festival. One year when Jesus was 12 and the festival was over, Jesus disappeared. Mary and Joseph searched frantically for three days thinking perhaps Jesus was kidnapped to be sold as a slave.
They ultimately found him at a Jewish Temple and Jesus said, "Why did you have to look for me? Didn't you know that I had to be in my Father's house?"
Yet that was little assurance to the parents.
So the family is a unity, and we work together for the common goal, and we rejoice together and we share the common fears at the things that try to attack our goals and set us back in our objectives.
You can see here that all families face challenges, and therefore must work together in perfect unity to conquer the challenges and make the world better than when we left than when we entered. Ultimately, we nurses, doctors and respiratory therapists are a part of this big family, and our goal is to make the world better one breathe at a time.
Saturday, July 23, 2011
Dr's Creed: The Bouncing Molecule Theory
Warning: What follows is top secret information surreptitiously leaked to me via one of the nations elite pulmonologists from an elite teaching hospital. Read at your own risk. This is not edited.
Appendix 2
Hypoxic Drive Theory proved by the Bouncing Molecule Theory:
It has been brought to my attention that many respiratory therapists (RT)have been complaining about the Hypoxic Drive Theory, that it's nothing more than a hoax initiated by RTs from the olden days pent on creating a need for their existence.
Many of you have written me about how their incessant attacks on the theory we have such a dogmatic view on is an insult to our intelligence and an insult to the medical profession and to medical schools that teach it.
Yet fear not, my friends, because researchers at the Weaners Medical and Research Center have come up with a new theory that we will now take as fact, and toss into the face of arrogant and apathetic therapists alike.
After studying the lungs of three possums forced to smoke three packs of cigarettes a day for 32 years,it was observed that too much oxygen in their lungs created a wall of sorts, and causes CO2 molecules to literally bounce off this wall and back into the blood stream.
This bouncing effect is what therefore causes CO2 to increase when oxygen is too high. Thus, in effect, this new theory provides proof that it is better to allow Chronic Obstructed Pulmonary Disease (COPD) patients to suffocate due to hypoxemia than to oxygenate them.
Please feel free to use this new theory as ammo against arrogant and apathetic RTs. Any further questions please refer to the 1961 version of the Physicians Medical Journal that we feel there is no need to ever update.
Sincerely,
Dr. Al Buterol
Infernal Medicine
Weiners University of Cyanosis
Chairman, PSECOTIC
Physicians (who) Swear Effective Clinical Oxygen Therapy Increases Carbon dioxide
Friday, July 22, 2011
Order sets
Order set: Synonym: Social Justice, socialism. Every patient with a given diagnosis (DRG) is treated the same. Once a patient is admitted with a certain DRG, these sets pre-determine what you order for that patient. The purpose of these is to make sure best medicine practice is followed for every patient. Basically, a committee determines what is best for the patient, and this assumes that the caregivers at the bedside are not capable of critical thinking. Another advantage of order sets, and the reason they are being initiated in most hospitals, is to make sure intensity of service is met. This assures that the patient will meet reimbursement criteria. In the past physicians were presented with a sheet that listed all the options. Today, however, many of these options are pre-checked and automatically ordered whether the doctor wants to or not. The reason for this is to make sure reimbursement criteria is met (see below).
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Cook book medicine: Treating all patients the same. This is generally the theme created to describe order sets, especially order sets that have pre-checked boxes that result in procedures being automatically ordered for a particular DRG.
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Thursday, July 21, 2011
New test may detect early emphysema
One of the interesting things about obstructive lung diseases like asthma, chronic bronchitis and asthma is that there is no concrete test that says: that guy has asthma, or that gal has COPD. Yet that might all change in leu of new research at the University of Iowa.
As of right now the only true method of diagnosing emphysema is by autopsy. Although signs and symptoms such as increased shortness of breath and barrel chest, and pulmonary function testing, can help a doctor to diagnose this lung disease.
Yet U of I researchers now believe a CT Scan that that measures blood flow in the lungs (you can see an image here) may detect early emphysema. This is significant, because this test may provide an option for doctors to help them determine if their patient is at an increased risk for further loss of lung tissue if they continue to smoke cigarettes.
I can think of no worse way to die than to suffocate to death. Emphysema patients gradually become more and more dyspneic (feeling of air hunger) as time goes on, especially if they continue to smoke. The end stages of this disease can last for several years, resulting in permanent air hunger. I have seen first hand many patients in this condition. It's not a pretty sight.
As an asthmatic myself I know what it's like to not be able to breathe, yet the nice thing about asthma is that the airflow obstruction in the lungs is completely reversible. With emphysema, the lung damage is permanent, and the airflow obstruction is only partially reversible. This results in permanent dyspnea that -- if you continue to smoke -- progresses over time.
So this test is significant because it could provide doctors with the evidence they need to tell their patients that if they continue to smoke they will continue to destroy lung tissue. It will also allow physicians to distinguish emphysema with chronic bronchitis.
Likewise, according to lead study author Eric Hoffman, Ph.D., UI professor of radiology, internal medicine and biomedical engineering. "Our discovery may also help researchers understand the underlying causes of this disease and help distinguish this type of emphysema from other forms of chronic obstructive pulmonary disease. This type of CT scan could even be a tool to test the effectiveness of new therapies by looking at the changes in lung blood flow."
Scientists also have little knowledge about by what mechanisms obstructive lung diseases such as emphysema develop, although this new research suggests that loss of blood flow occurs before loss of lung tissue.
Likewise, "although the underlying causes of emphysema are not well understood, smoking increases the risk of developing the disease," Hoffman said. "Our study suggests that some smokers have an abnormal response to inflammation in their lungs; instead of sending more blood to the inflamed areas to help repair the damage, blood flow is turned off and the inflamed areas deteriorate."
Tissue is destroyed because the human body naturally works to optimize gas exchange, so when one area of the lung becomes permanently blocked, the body blocks blood flow to that area of the lung so it can be sent to areas of the lung where gas exchange can occur.
If blood flow is returned to the inflamed area the damage can be repaired by increased blood flow "that brings oxygen and helpful cellular components to the site of injury," notes the press release.
Likewise, "This study suggests that the ability to distinguish when to turn off or when to ramp up blood flow is defective in some people -- probably due to genetic differences. If this genetic difference is coupled with smoking, which increases lung inflammation, that could increase the risk of developing emphysema."
This is very interesting research and it will be interesting what happens from here.
(The above information was obtained from this press release)
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As of right now the only true method of diagnosing emphysema is by autopsy. Although signs and symptoms such as increased shortness of breath and barrel chest, and pulmonary function testing, can help a doctor to diagnose this lung disease.
Yet U of I researchers now believe a CT Scan that that measures blood flow in the lungs (you can see an image here) may detect early emphysema. This is significant, because this test may provide an option for doctors to help them determine if their patient is at an increased risk for further loss of lung tissue if they continue to smoke cigarettes.
I can think of no worse way to die than to suffocate to death. Emphysema patients gradually become more and more dyspneic (feeling of air hunger) as time goes on, especially if they continue to smoke. The end stages of this disease can last for several years, resulting in permanent air hunger. I have seen first hand many patients in this condition. It's not a pretty sight.
As an asthmatic myself I know what it's like to not be able to breathe, yet the nice thing about asthma is that the airflow obstruction in the lungs is completely reversible. With emphysema, the lung damage is permanent, and the airflow obstruction is only partially reversible. This results in permanent dyspnea that -- if you continue to smoke -- progresses over time.
So this test is significant because it could provide doctors with the evidence they need to tell their patients that if they continue to smoke they will continue to destroy lung tissue. It will also allow physicians to distinguish emphysema with chronic bronchitis.
Likewise, according to lead study author Eric Hoffman, Ph.D., UI professor of radiology, internal medicine and biomedical engineering. "Our discovery may also help researchers understand the underlying causes of this disease and help distinguish this type of emphysema from other forms of chronic obstructive pulmonary disease. This type of CT scan could even be a tool to test the effectiveness of new therapies by looking at the changes in lung blood flow."
Scientists also have little knowledge about by what mechanisms obstructive lung diseases such as emphysema develop, although this new research suggests that loss of blood flow occurs before loss of lung tissue.
Likewise, "although the underlying causes of emphysema are not well understood, smoking increases the risk of developing the disease," Hoffman said. "Our study suggests that some smokers have an abnormal response to inflammation in their lungs; instead of sending more blood to the inflamed areas to help repair the damage, blood flow is turned off and the inflamed areas deteriorate."
Tissue is destroyed because the human body naturally works to optimize gas exchange, so when one area of the lung becomes permanently blocked, the body blocks blood flow to that area of the lung so it can be sent to areas of the lung where gas exchange can occur.
If blood flow is returned to the inflamed area the damage can be repaired by increased blood flow "that brings oxygen and helpful cellular components to the site of injury," notes the press release.
Likewise, "This study suggests that the ability to distinguish when to turn off or when to ramp up blood flow is defective in some people -- probably due to genetic differences. If this genetic difference is coupled with smoking, which increases lung inflammation, that could increase the risk of developing emphysema."
This is very interesting research and it will be interesting what happens from here.
(The above information was obtained from this press release)
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Wednesday, July 20, 2011
Dr's Creed: How to diagnose and treat ER patients
So you've suffered through Medical School and are now a real ER doctor. Don't worry, you don't have to remember all that crap you learned in school. We've devised a cheat sheet that should help you diagnose and treat patients. It's like taking cake from a baby. Just cut this out and paste it on the back of your keyboard for easy reference.
What's wrong with your patient. We simply limiting it down to 10 diagnoses.
Emergency Room Physician Cheat Sheet
How to diagnose and treat
How to diagnose and treat
What's wrong with your patient. We simply limiting it down to 10 diagnoses.
Trouble Breathing:
1. Asthma:
- The patient does not smoke and peak flows improve with bronchodilator.
- If you need to admit the patient call it exacerbation of asthma
- If you need to intubate call it status asthmaticus
- Treatment corticosteroids and breathing treatment and follow asthma order set
2. COPD:
- The patient smokes (peak flows may increase, but most of time they don't)
- If coughing up phlegm = bronchitis
- If no cough and barrel chest = emphysema
- If CHF (see below) = end stage COPD
- Treatment corticosteroids and breathing treatment (and lasix if CHF) and follow COPD order set
3. Heart Failure: If fluid in the lungs (BNP greater than 1,000)
- Patient smokes = end stage COPD/ CHF and right heart failure I(write cor pulmonale every 10 patient just to mix it up)
- If patient doesn't smoke = CHF or left heart failure
- Treatment diuretics and bronchodilator breathing treatment and follow CHF order set
4. Pneumonia:
- Crackles or atelectasis in any one lobe of lung (or two lobes or three lobes). Also, this is the default diagnosis when you have no idea what's wrong with patient because it's easily reimbursable and pays well
- Treatment: Antibiotics and bronchodilator breathing treatments (diuretics if pulmonary edema)
5. Pleuro effusion:
- Line in lung on x-ray
- Treatment chest tube and bronchodilator breathing treatments and follow pleural effusion order set
6. Pneumothorax:
- Trachea shift and you can see line of pleural sack in lungs on x-ray or if you put in a chest tube and you see bubbling in the air seal chamber.
- Treatment is chest tube and bronchodilator breathing treatments and follow pneumnothorax order set
7. Pulmonary Embolus:
- Patient dyspnea unexplained by any other means
- D-dimer is high and ultrasound shows PE and ABG
- Treatment is blood thinners and bronchodilator breathing treatment and follow order set
8. Exacerbation of...:
- If patient already has an underlying condition, just add "exacerbation" to that underlying condition. Examples include: Exacerbation of Cystic fibrosis, exacerbation of pulmonary fibrosis, exacerbation of bronchiectasis, exacerbation of lung cancer, etc.
- Follow order set for that particular disease
9. Mycardial Infarction:
- Follow ACLS protocol
- Treatment: MI and chest pain order set
General Disorders:
10. Diabetes:
- High glucose, decreased mental status
- Follow diabetes order set
11. Stroke:
- Follow ACLS protocol
- Treatment: Follow ACLS protocol and stroke order set
12. Dysthrymias:
- Read EKG
- Treatment: Follow order set for whatever EKG says
- If symptoms admit patient and order an EKG every 2 hours and every morning for three days
- If no symptoms order a holter monitor and send patient home
13. Pain:
- See location of body and where symptoms occur
- Follow order set for general pain
- If patient in agonizing pain, or labs are way out of whack (labs out of whack are indicated by a red color) or you're worried, call surgeon or bone doctor (osteopathic medicine)
14. Other:
- If you're generally worried about patient, admit patient with diagnosis of pneumonia (see above)
- Call family physician or Internal medicine
Acute Lung Injury Ventilation Strategy
For patients suspected of being in Adult Respiratory Distress Syndrome (ARDS), you will want to implement the Acute Lung Injury Strategy.
What patients should be included in the ALI Strategy?
A. Acidosis Management: pH 7.15-7.30
Oxygenation Strategy: Goal PO2 55-80 and SpO2 88-95%
A. Lower PEEP higher FiO2 Strategy:
A patient meets weening criteria when:
What patients should be included in the ALI Strategy?
- PaO2/ FiO2 > 300
- Bilateral, patchy, difuse infiltratees on x-ray
- Non cardiogenic pulmonary edema
- No evidence of left atrial hypertension
- Tital Volume: 6-10cc/kg ideal body weight
- Select any mode
- Check after each change in PEEP or Static Pressure
- If greater than 30 decrease Vt by one until Static Pressure less than 30
- If less than 25 and Vt less than 6 ml/kg idw, increase Vt by 1 until static pressure is 25 or Vt is at least 6 ml/kg ibw
- If less than 30 and breath stacking, increase Vt in increments of 1 until Static is greater than 25 or Vt greater than 6ml/kg ibw.
A. Acidosis Management: pH 7.15-7.30
- pH less than 7.30 = increase rate until pH greater than 7.30 or pCO2 less than 25
- Maximum set rate is 35
- If pH remains less than 7.15, Vt may be increased in 1 ml/kg steps until pH greater than 7.15.
- Static Pressure limit of 30 may be exceeded
Oxygenation Strategy: Goal PO2 55-80 and SpO2 88-95%
A. Lower PEEP higher FiO2 Strategy:
- FiO2 30% = PEEP 5
- FiO2 40% = PEEP 5-8
- FiO2 50% = PEEP 8-10
- FiO2 60% = PEEP 10
- FiO2 70% = PEEP 10-14
- FiO2 80% = PEEP 14
- FiO2 90% = PEEP 14-18
- FiO2 100% = PEEP 18-24
- FiO2 30% = PEEP 5-14
- FiO2 40% = PEEP 14-16
- FiO2 50% = PEEP 16-18
- FiO2 60-80% = PEEP 20-22
- FiO2 90% = PEEP 22
- FiO2 100% = PEEP 22-24
A patient meets weening criteria when:
- FiO2 less than 40 and PEEP less than 8
- PEEP and FiO2 are lower than the previous day
- Acceptable spontaneous breathing efforts
- Systolic Blood Pressure greater than 90
- No neuromuscular blocking agents on board
Tuesday, July 19, 2011
Can you die from asthma/
I normally don't like to use other people's words to say something I want to say, yet I was reading the comments to this post over at MyAsthmaCentarl.com and the conversation ended up with the question many asthmatics ask: Can you die of asthma?
James Thompson, MD, who happens to be a fellow asthma experts (well, he's a well established asthma doctor, so he's actually far more expert than I'll ever be), gave an answer so brilliant that I couldn't possibly word it better, so I wont. Dr.Thompson's answer to this question is:
James Thompson, MD, who happens to be a fellow asthma experts (well, he's a well established asthma doctor, so he's actually far more expert than I'll ever be), gave an answer so brilliant that I couldn't possibly word it better, so I wont. Dr.Thompson's answer to this question is:
If I were forced to give a one word answer I would say, "Yes". Fortunately I can elaborate and tell you that although asthma can be fatal, the majority of people with the diagnosis of asthma do not die. In the early 1990s there were more than 5000 deaths per year attributed to asthma in the United States. Data from the about three years ago approximated about 4000 deaths annually (and falling). The bad news is that there are still people that die from asthma. Furthermore, the more than 20 million people that have asthma in this country are more affected by the impact of the disease on their quality of life.
Mortality and morbidity (in other words death and poor quality of life) are greatly reduced when asthma management is appropriate. Well controlled asthma leads to minimal impairment from breathing problems no limitations on activity, and a duration of life that is equal to someone who does not have asthma.
So, yes you can die from asthma, but good asthma management can prevent it.
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