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Wednesday, November 30, 2011

What is short of breath?

I ask people all day long "Are you short of breath?"  Yet every once in a while someone asks, "What's that?"

Most of your chronic lungers know what it is.  Yet we RTs give breathing treatments to people all day long that you know are not short of breath, and never have been.  They have no lung disease and never have.  These are your folks who might ask:  What is shortness of breath?

Shortness of breath (SOB):  It's a subjective measure.  It's how your breathing feels to you.  Do you feel winded?  Do you feel you can't get air in?  Do you feel dypneic.

Dyspneic:  A feeling that you can't catch your breath.  It's the medical description of shortness of breath.  Prior to modern times dyspnea was defined as breathing with a conscious effort. 

I've been an asthmatic and RT for so long I guess I just assume people know what it is.  Yet, understandably so, some people have no reason to know the definition.

Short of breath should have been described on day #1 of this blog.  Yet here I am well into year #4 of doing this, and here is your definition.


Sunday, November 27, 2011


Satan is the evil man in the sky we don't want to spend time with after we die.  We also want to resist the temptations he places before us each day of our life.  Yet who really is this guy?

Sure most of us know that Satan is the Devil*.  He was actually created by God as a good angel, and it was by his own choice that he became evil.  He was inherently good as all of God's creatures are good, and he became evil by his own doing.

Usually scriptures do not give names to devils, and one of the few exceptions is where the Bible describes how after 40 days and 40 nights of fasting Jesus is hungry and is tempted by the Devil, or Satan.  Sometimes he's referred to as Lucifer, or 666.

Yet in reality the word "Satan" is a Hebrew noun that means an adversary, tester, accuser.  It was translated into Greek as "Diablolos" which essentially means the same thing.  "Diabolos" as translated into English as "devil." 

So the Devil is essentially referring to one person, although in reality it is many people.  It refers to the many situations and people that tempt us to sway from the principles that keep us on the straight and narrow.

It's also the "Devil" that is used to keep societies on the straight and narrow.  The founding fathers, even those who Deist, knew about the importance of religion in order to keep society functioning.

They knew that the only way to make a new nation last was to create values and principles among the people.  And that is why God was referred to so much by them.

They knew that faced with the fear life in Hell with Satan, that people would choose the better path in life. Have you been tempted by the devil lately?  Chances are you have. 

*The above definitions came from "The Little Black Book:  six- minute meditations on the Sunday gospels of Lent (Cycle A)," by the Catholic Church Diocese of Saginaw.  Your definition may vary slightly.

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Saturday, November 26, 2011

Things only an RT would say

I just finished giving the lady's mom a breathing treatment when she said, smiling, "So you just gave that so my mom meets criteria, right?"

I said, "You have GOT to be a respiratory therapist."

"I am," she confirmed.

Some things only an RT would say, and that's one of them. Here are some other things only an RT would say:
  1. I have the ABGies
  2. That breathing treatment's not needed
  3. Now that the patient has allbetterol in his system he's good to go
  4. The hypoxic drive theory is a hoax
  5. Xopenex is the same as Albuterol
  6. Bronchodilator abuse
  7. All that wheezes is not asthma
  8. All shortness (dyspnea) of breath is not asthma
  9. The only reason the treatment helped that patient with dyspnea was the oxygen boost
  10. I only work so I can have days off
  11. I'm not smart enough to be an RT (or maybe I'm smart enough not to be an RN)
  12. I love being an RT
  13. I hate being an RT
  14. That patient does not need suctioning
  15. Suctioning an awake and alert patient is unethical
  16. Most of what we do is a waste of time or delays time
  17. You don't intubate a number
  18. Q4ever treatments
  19. Doctors don't wean on weekends or after office hours
  20. Oxygen does not treat anemia
  21. Breathing treatments do not cure rickets
  22. Ventolin is like scrubbin bubble therapy.  Doctors think it gets deep into the lung and scrubs them clear of all lung ailments.
  23. Doctors think Ventolin prevents everything from asthma to rickets, from atelectasis to pneumonia
  24. Ventolin does not even get deep enough in the lungs to treat pneumonia
  25. There's no smooth muscle and no beta receptors in the alveoli
  26. Are you short of breath?
  27. Let me listen to your lungsounds
  28. Let me get you a stool, a fan and a table to lean on
  29. I walked 20 miles at work today
  30. You want a what...!!!
  31. The patient had no history of short of breath, has no lung disease, doesn't smoke, has clear lungsounds, a normal x-ray, and yet I had to give a treatment anyway
  32. I can't find (feel) a pulse
  33. Take in a deep breath... and blow, blow, blow, blow.....
  34. This EKG will be quick and easy.... unless you're a hairy man, then it'll be painful
  35. If you need me I'll be in the waiting room watching TV

Friday, November 25, 2011

dnr vs full code

I often get asked what the difference is between full code and DNR.  So I'm going to take a moment to define these two terms.

Full Code:  You do everything possible and necessary to save the life of the person.  This means if the patient stops breathing you'll intubate and put the patient on a ventilator, and if his heart stops you'll do chest compressions with ventilations.  You will also provide medications necessary to try to save that person.  Any patient who does not have a DNR order is considered full code.  If you don't know if the patient is a DNR, then you consider the person a full code.

DNR:  This stands for do not resuscitate.  This means if the patient's heart and breathing stops you do not perform any heroic efforts.  You do not intubate or ventilate.  However, you will still care for the patient and do whatever is necessary to help the patient get better.  The only things you don't do is heroic activity.


Thursday, November 24, 2011

Happy Thanksgiving

Surely I get to work on Thanksgiving, and I'm thankful for that.  I'm thankful for all the great people I work with, and for all the great food.  I'm thankful for the wonderful conversations I had today with all my wonderful patients.  I'm thankful that my kids all called to talk, even my one year old (although all I heard out of him were the beeps of the buttons).  I'm thankful for the profession of respiratory therapy that allows for me to work in a clean environment, and provides me the opportunity to blog when my work is done.  I'm thankful for bosses who are cool about it.  I'm thankful for where I am in life.  I'm thankful for all the great folks who tune into my blog, whether it be by chance, an occasional peak, or on a regular basis.  I'm thankful for a good life.  I'm thankful for the Internet, Google, and Blogger for making all this possible.  I'm thankful for God and this life and everything that's lead to me being able to sit here typing at this computer console at this moment.  Thank you readers.  Happy Thanksgiving!

Wednesday, November 23, 2011

Should hyperventilating patients breathe into a bag?

I remember it used to be advised that when a person is hyperventilating that they breathe into a paper bag.  Yet according to new medical practice guidelines this is not only no longer recommended, it is considered malpractice to recommend it to a patient.

Dr. Jeff Clawson, in his article, "Stand By The Protocol:  Some advice should stay in the bag," The Journal of Emergency Dispatch ( Sept./ Oct., 2011, pag7), explains that if you have otherwise not assessed the patient, you have no idea why the patient is hyperventilating. 

Dr. Clawson opened up this topic to discussion, to which one responder explained hyperventilating can be a symptom of a variety of underlying problems, such as:
  • Asthma attack 
  • Pulmonary emboli
  • Heart attack
The responder explained that breathing into a paper bag when you have an underlying pulmonary problem can cause hypoxia and can make the patient's condition worse, and even cause death. 

The concept behind breathing into a paper bag is the belief that if a person is hyperventilating he is blowing off too much carbon dioxide (CO2).  If a person is breathing into a bag he will be rebreathing CO2 and thus bringing his CO2 level back to normal.  It's believed this might help stop the hyperventilating.

Another responder noted the following fact:  "I would also add that true hyperventilation, left untreated in the pre-arrival environment, is benign." 


You do not have to intubate if you have a good airway

Other than certain ethical issues, the things that irritates this RT more than anything are when certain medical workers become rapt on the idea they have to intubate right away during a respiratory or cardiopulmonary arrest.  The patient turns blue and they think intubate.  The neonate needs CPR and they think intubate.

An intubated patient is easier to ventilate that's no doubt, yet more often than not the process wastes valuable time better spent giving breaths, giving chest compressions, and giving medicines.  In most instances, I think intubation can wait until you have the situation under control.

In fact, we'll just jump to the case here and come out with RT Cave Rule #52:
RT Cave Rule #52:  So long as you have a good airway and ventilations are effective, intubation can wait until the patient is stabilized.
Under stress of a code intubation is often the first thing to come to mind.  It shouldn't be. The first thing to come to your mind should be "are we ventilating?"  If yes, leave well enough alone and move on to the next question:  "are we circulating blood?"  If the answer to both these are yes, then you can intubate.

Now obviously there are exceptions to this rule, such as obstructed airway.  Yet this would still fall under rule #52 which states, "so long as you have a good airway."  If you don't have a good airway, then you can rush to intubate.  In that case, you have to intubate.

Some people might contend another exception is overdose and high risk for aspiration.  Yet I would never recommend intubating such a patient.  Why you ask?  Because sticking a hard, metal object through someone's gag reflex is the perfect way to get someone to vomit.

But you don't have to intubate a neonate you just started doing chest compressions on.   I sat and watched a doctor doing this, and also watched as the pulse oximeter went from 90 to 80 to 70 to 60.  I verbalized these falling heart rates and the doctor said, "Don't worry about it."

Sorry, but I was right and that doctor was wrong.  He spent way too much time trying to intubate, and his attempt, even while he had noble intentions, was inappropriate.

Monday, November 21, 2011

More Asthma Terms

The following post was published at MyAsthmaCentral April 11, 2011 by Rick Frea:  "Asthma Terms You Should Know:  Part 2."

One of the first priorities of anyone new to this asthma thing is to improve our asthma wisdom. We need to know as much about this disease as possible. By this we improve our ability to get it under control, and keep it that way.

That in mind, I've created an asthma lexicon of terms every asthmatic should know. Consider this part 2 of my post of a few years ago aptly titled "An Asthma Lexicon: Important Terms You Should Know."

So here's today's terms:

AcuteIt's happening right now.

ChronicIt's going on all the time. Permanant.

Allergy(Synonym: atopy) It's estimated 75 percent of asthmatics also have this. It's an abnormal reaction to an allergen. A normal reaction would be no reaction at all. The first time your body comes into contact with the allergen (dust mites for example) your body develops a defense against it. When the allergen is reintroduced your body attacks it the same as it would an enemy bacteria or virus. The reaction includes inflammation of the respiratory tract, eyes or skin. This often results in nasal congestion, itchy eyes, runny nose, wheezing (asthma), and skin rash.

Allergen: Anything that induces an allergic reaction. Common ones include dust mites, cockroach urine, molds, fungus, and animal dander. For a more detailed list of allergens and asthma triggers, check out this link.

Hypersensitivity: Extremely sensitive, as in sensitive to an allergen. The air passages (bronchioles) of asthmatic lungs are often hypersensitive to various asthma triggers, and they may become acutely inflamed (swollen) as a result of such contact. See allergy.  This increased sensitivity may also be due to chronic inflammation of the air passages (which can be improved with corticosteroids).

InflammationSwelling and redness caused by some irritation. In asthma there is some chronic swelling of the air passages, and when exposed to asthma triggers this inflammation may become worse, or acute. Acute asthma is your asthma attack.

Rhinitis: (Synonym: hay fever) Inflammation (swelling) of the mucus membrane inside the nasal passage.

Sinusitis(Synonym: sinus infection) Inflammation of the sinus passages

Beta Agonist: (Synonym: bronchodilator, rescue medicine) This is a medicine that has an affinity to beta receptors that line the respiratory tract, particularly the bronchioles. Once attached to the beta receptors a reaction occurs that relaxes the bronchiole muscles and opens up the air passages. This makes breathing easier. Examples include Ventolin and Xopenex.

Long Acting Beta Agonist (LABA): These work the same as Beta Agonists only the medicine can last up to 12 hours. Common examples are Serevent (a component in Advair) and Formoterol (a component in Symbicort).

Corticosteroids: (Synonym: steroids, glucocorticosteroid) A medicine often used to reduce inflammation in the air passages. Common examples include Flovent (a component in Advair) and Budesonide (a component in Symbicort).

Metered Dose Inhaler (DPI): (Synonym: puffer, inhaler, breather, rescue inhaler, atomizer) An easy to use and convenient to carry device used to aerosolize asthma medicine such as beta agonists and inhaled corticosteroids. It consists of the medicine mixed with a propellant held under pressure inside a metal cannister and a plastic sleeve with a little mouthpiece. When you press the canister medicine is sprayed and can be inhaled. For more information click here.

Dry Powdered Inhaler (DPI): The medicine is in powder form and usually comes in a device such as a discus or other device. The medicine is usually held inside a capsule that is crushed when you twist the device. The powder is inhaled when the patient places his mouth over the mouthpiece and inhales. For more information click here.

Nebulizer: (Synonym: Updraft therapy, Aerosol, Magic Mist, breathing machine, breathing treatment, peace pipe) This is a small cup that you put liquid medicine into, and once hooked up to an air source (like an air compressor) and pressurized air causes the liquid to become aerosolized and reduced to a fine mist that can be inhaled. Such treatments usually last five to 10 minutes. This is ideal for anyone who has trouble using an MDI. For more information click here.

If you come across an asthma term you want defined, leave a note in the comments below, or ask a question in our Q&A section.


Saturday, November 19, 2011

Faux (pseudo) pneumonia

With pneumonia as the most reimbursable diagnosis, that makes pneumonia that most common fake diagnosis written on charts.  I call it faux (pseudo) pneumonia.  You can call it fake pneumonia.  I like faux for fun.

You know the patient doesn't have real pneumonia because no x-ray is done, and if one is done it's normal. The patient's lungsounds are normal or not consistent with pneumonia.  White blood cells are within normal range, and do not indicate an infection. 

So the patient is sick enough to be admitted, yet doesn't meet criteria.  Therefore the diagnosis of faux pneumonia is made. 

A good example of this is an Alzheimer's patient was recently released from the hospital and sent to a nursing home. The home refused to admit the patient because he was combative.  Not knowing what else to do with the patient, we readmitted him to the hospital with faux pneumonia.


Friday, November 18, 2011

How to deal with hotheads at work

For the first time in a while I arrived at work feeling completely refreshed.  The patient load was way down and the milieu of the RT Cave was relaxed.  All was going well until my boss handed me a sheet of paper with a few errors I made the last day I worked.

No big deal, I thought.  With lots of time before my first treatments were due, I wandered to the lab to result an ABG I did two days earlier.  The process was a little more complicated than I expected on the new system, yet after clicking a few icons the job was done.

The lab boss was sitting there so I thought I'd go out of my way to tell him the job was done.  I confidently said, "Hey, Mike, I fixed the ABG that was non-resulted."

"So how did that error get made?" he said. 

"It was just me being incompetent," I said in my normal fun tone.  As he spoke this I started wishing I hadn't said anything.  I could see horns growing on either side of his head -- red horns.  His hand moved quickly from the keyboard to the pitchfork -- also red.  Steam started billowing from the tops of the horns.

"You know that's a serious issue that needs to be dealt with," he whined.  "You really are incompetent if you're making errors like that.  That's two days a doctor didn't have those results.  That's unacceptable!  What are you going to do to make sure something like this doesn't happen again."

One mistake doesn't constitute a crisis!  I wanted to say.  Yet common sense took over my thoughts and what came out of my mouth instead was:  "You have a good day too."  I turned and walked away."

The truth was the doctor was handed the results by me, yet I didn't want to humor him with that information.  The fact the ABG wasn't resulted only meant it wasn't in the computer. 

This brings us to RT Cave rule #49:
RT Cave Rule #49:  One mistake does not constitute a crisis.  One mistake is a normal human error, and several mistakes may be considered a crisis that needs to be dealt with.
I knew from personal experience that dealing with a hot head during a hot situation never works.  A better solution is what I did next.  I went upstairs and went straight to my bosses office, handed him the receipt of the correction and said, "I told Mike I fixed this and he was sort of a hot-headed jerk about it."

I had to do that because that prevents Mike from going to my boss and getting the upper hand.  It was my way of staying on offense and staving off a worse situation.

Then I told my co-workers.  Then during lunch I was sitting at the table munching away on a carrot when Mike came into the cafeteria.  "Hey, there he is!  There's the hot-headed head of lab.  There's the guy who called me incompetent.  Should I wave!"

A good laugh ensued.  Yet more important, I had gained the sympathy of my fellow co-workers.  If Mike did anything to further this incident, I had the support and sympathy of my boss and co-workers.

I suppose the moral here is that hotheads never win.  So We'll make that RT Cave Rule #49:
RT Cave Rule #50:  Hotheads never win.  Getting hot says more about your incompetence in dealing with stressful situations and resolves nothing.  It merely results in you looking like the bumbling moron you are.
Likewise this also brings us to RT cave Rule #51:
RT Cave Rule #51:  When dealing with a hothead, it's best to shut your mouth and walk away.

Thursday, November 17, 2011

The Natural Progression of COPD

I saw this curve at my pulmonologist's office about 16 years ago yet I couldn't remember what it was called until I saw this while surfing the Internet.  It's called the Fletcher and Peto Curve.

I think this curve is neat because it shows that we will all develop COPD if we live long enough, yet usually never enough damage will occur so it will present with symptoms.

Yet you can see that the longer you smoke the faster your lung function declines. However, quitting smoking, at any point in your life, can improve your lung function, thus helping you to live a longer life with COPD.

Essentially, this curve shows that smoking essentially speeds up the aging process, and that fewer cigarettes you inhale the longer you will live.

The American Thoracic Society published a good article on the curve called "Natural Histories of Chronic Obstructive Pulmonary Disease" in 2008.  The article was written by Stephen I. Rennard and Jorgen Vestbo, who explained that the curve was the result of a 1976 study by Fletcher and Peto who studied the lung functions by measuring the FEV1 of a variety of participants, some who smoked and others who did not.

The result was this chart that shows the natural progression of COPD.  The writers propose that this curve comes with limitations as it only measures FEV1, yet even so, it still provides us with a vivid picture of just how effective cigarette smoke is at reducing lung function. 

It would be neat to see a similar curve showing the progression of lung function for those who inhale second hand smoke.


Wednesday, November 16, 2011

WHO spins facts about 2nd hand smoke

My uncle, who so happened to be a chain smoker, educated me one day about the fallacy that 2nd hand smoke caused cancer. He was a chain smoker, and he already had a lung removed, yet he still felt the facts were so that it was worthy to note the "bullshit that THEY teach kids these days."

At the time I just blew my uncle off as a smoker who didn't want to admit the truth. Yet being the person I am (and perhaps partly through his example), I decided a better response to his little speech was to do my own research.

In doing so I came upon this study that was independently funded by the World Health Organization (WHO). The study was a review of many other studies on the subject, and the goal was to prove that 2nd hand smoking causes cancer.

Ironically, the study proved the opposite: that 2nd hand smoke does not cause cancer. Yet since the study didn't show what they wanted, they didn't release it. They didn't do this because one of the goals of the progressive WHO is to create an ideal world. And in an ideal world people don't smoke because smoking kills.

Now it is still true that 2nd hand smoke is unhealthy, and most studies about it show this. Yet it is just about a proven fact now that 2nd hand smoke does not cause lung cancer. The WHO was hoping this study would help justify their attempts to get rid of smoking worldwide through higher taxes and laws banning it in public places.

The ultimate goal of the WHO is to ban smoking altogether, yet because of the U.S. Constitution, this is nearly impossible to do because people have a Constitutional right to be stupid so long as they don't infringe on the rights of others. Ideally, the Constitution protects us from each other, and not necessarily from ourselves. So if we want to smoke, so be it.

Of course another reason progressives want to get rid of smoking altogether is because another goal is universal healthcare. They don't want to pay for the health consequences of personal choices that are bad, like smoking.

This is yet another reason I'm opposed to universal healthcare, and even Obama care, because if someone is paying your bills, they have a right to tell you what to do. In other words, you are a slave to the person you are in debt to.

Thus, every time a new law is made, you lose another freedom. Every time we receive another government entitlement, we lose another freedom. So if we continue to allow our government to create more government programs, we will eventually be slaves to the state. The same thing happened in ancient Rome, and destroyed that republic.

The WHO once again has ignored the above mentioned study as it released a new study that shows that 2nd hand smoke kills up to 600,000 people each year, and this accounts for 1% of all deaths each year. You can read the report here.

The report notes that, "Researchers estimated that annually second-hand smoke causes about 379,000 deaths from heart disease, 165,000 deaths from lower respiratory disease, 36,900 deaths from asthma and 21,400 deaths from lung cancer."

In lei of the previous study by the NWO that showed 2nd hand smoke does not cause lung cancer, can we now assume the NWO is conveniently ignoring this study. Their ultimate goal is to get rid of smoking, regardless of facts.

This almost makes one wonder about the true intentions of progressives. Are they after what's best for the people, or the government? I almost think they want to get rid of smoking so the government doesn't have to pay for diseases caused by smoking.

So they raise taxes. They also create more rules or laws that ban smoking in public places. All of this with the intent of forcing people to quit, as opposed to people quitting by individual choice. Progressives don't believe in individual choice, the believe in the state making choices for the people.

Of course, as I've written before, too many rules (laws) and too high of taxes result only in people finding ways to get around the taxes or rules. It creates a world of cheaters and liars, because the natural tendency of human beings is to make their own decisions. People don't like people telling them what to do.

A great example of this is in New York where taxes are high on cigarettes and public smoking is not legal, a black market for cigarettes has been created, as you can read here.

I have no vested interest in people smoking. Well, I say that knowing that my career as an RT is mainly funded by patients who smoke. Yet I don't want people to smoke. It bothers my asthma when people smoke around me. It threatens the health of my kids.

So I don't want people to smoke. I want people to quit. I want my dad to quit, yet he has made the personal choice to smoke. And, yes, he does get cigarettes illegally over the Internet because he can get the cheaper that way.

Second hand smoke is bad as you can see by any link that lists the hazards of second hand smoke, such as this and even the WHO itself as you can see here.

You should educate your patients about the dangers of 2nd hand smoke. If someone says they quit smoking, make sure they know to not let others smoke around them. Yet also don't get all your wisdom from one place, and decide for yourself what is fact and what is not a fact.

Because Lord knows it's hard to get all the facts even from sources we otherwise think are trustworthy. Now I'm certain the American Cancer Society and other such resources are trying to provide honest facts. Yet they, like you and me, get their wisdom from sources they hope are being honest with us.

This is a perfect example of why I created this blog. You and I are interested in facts and then we make an educated decision, rather than just believing everything we read. While we might not have much of a choice what we do as RTs, we can be smart.

Tuesday, November 15, 2011

Facts about 2nd hand smoke

Here are some facts about 2nd hand smoke. This list may be different from other lists because I'm basing my list on facts obtained from studies and not my own personal opinion and vested interest.

Note, however, that I want people to quit smoking, and I want people who do not smoke to be protected from 2nd hand smoke. However I do not believe there should be any attempt by any government to force people to quit smoking other than through education.

It is my belief that most people are smart, and provided with facts they will make the best decision for themselves. I do not believe facts come from organizations and companies that in some way profit from smoking. I also do not believe the facts come from organizations like the World Health Organization (WHO) either.

In a way this is frustrating, because ideally we should be able to get all our facts from such organizations as the WHO, our government, or at least from the Media. Yes it's true, even the media can't fully be trusted.

So this is why we must keep our minds and ears open and get our news from a variety of sources. While I do not pretend to know all the truths, I do like to lay out all the facts so we can all make an educated decision. This, after all, is the goal of the RT Cave.

We do, however, agree that 2nd hand smoke is bad, even though all the information we receive might be twisted in one way or another. That in mind, here are some facts about 2nd hand smoke.
  1. 2nd hand smoke may not cause lung cancer, as you can see by this WHO study. Despite this, the WHO notes that 2nd hand smoke kills as many as 600,000 people each year, as you can read here. We're neutral here, so you decide.
  2. There are over 4,000 chemicals in cigarette smoke, and over 250 of them are known to cause damage to the human body such as aging the body, thinning the skin and arteries, destroying cilia in the lungs, etc. This effect is just as damaging to those who breath second hand smoke as those who inhale the smoke directly.
  3. It causes 600,000 premature deaths each year
  4. It causes hardening of arteries and heart disease (about 46,000 deaths annually)
  5. It increases your risk for stroke and brain aneurysms (thinning arteries)
  6. It increases your risk for getting chronic obstructive lung disease, especially if you have asthma
  7. It increases your risk for getting pneumonia
  8. It shortens your lifespan (yes, even if you inhale someone else's smoke)
  9. Separate areas in a building to not decrease your risk for second hand smoke related exposure. This is why smoking sections have no effect.
  10. Ventilation systems do not decrease your risk of inhaling 2nd hand smoke. Smoke can get from a smoking area to a non smoking area even if there's a door between rooms.
  11. 40% of children are exposed to smoke at home.
  12. 31% of smoking related deaths occur in children
  13. 2nd hand smoke greatly increases the risk of sudden infant death syndrome
  14. 2nd hand smoke increases risk your child will develop asthma
  15. Kids exposed to 2nd hand smoke are 1.5 to 2 times more likely to smoke themselves
  16. Results in increased sick days and lost wages
  17. Increases economic costs to society by forcing all of us to pay for the care of smoking related diseases and smoking cessation programs
  18. Decreases lifespans (each cigarette takes 7 minutes off your life)
  19. The World Health Organization notes that, "More than 94% of people are unprotected by smoke-free laws. However, in 2008 the number of people protected from second-hand smoke by such laws increased by 74% to 362 million from 208 million in 2007. Of the 100 most populous cities, 22 are smoke-free. (Note here, however, that a government has the job of protecting us from each other, but not from ourselves)
  20. Other breathing problems in non-smokers, including coughing, mucus, chest discomfort, and reduced lung function
  21. 50,000 to 300,000 lung infections (such as pneumonia and bronchitis) in children younger than 18 months of age, which result in 7,500 to 15,000 hospitalizations annually
  22. Increases in the number and severity of asthma attacks in about 200,000 to 1 million children who have asthma
  23. More than 750,000 middle ear infections in children
  24. Pregnant women exposed to secondhand smoke are also at increased risk of having low birth- weight babies.
  25. It may be linked to breast cancer
  26. Causes premature death and disease in children and in adults who do not smoke.
  27. Smoking by parents causes breathing (respiratory) symptoms and slows lung growth in their children.
  28. Secondhand smoke immediately affects the heart and blood circulation in a harmful way. Over a longer time it also causes heart disease and lung cancer.
  29. The scientific evidence shows that there is no safe level of exposure to secondhand smoke.
  30. Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces (a cause of occupational asthma) despite a great deal of progress in tobacco control.
  31. The only way to fully protect non-smokers from exposure to secondhand smoke indoors is to prevent all smoking in that indoor space or building. Separating smokers from non-smokers, cleaning the air, and ventilating buildings cannot keep non-smokers from being exposed to secondhand smoke.
  32. Driving in a car with the cigarette dangling out the window does not mean other people in the car will not be exposed to 2nd hand smoke
The following are facts about 2nd hand smoke some may not want you to know:
  1. 2nd hand smoke may not cause lung cancer, as you can see by this WHO study. Despite this, the WHO notes that 2nd hand smoke kills as many as 600,000 people each year, as you can read here. We're neutral here, so you decide
  2. The WHO also learned that parents smoked had had a 22% better chance of NOT contracting lung cancer than did adult children who came from homes where both parents did not smoke. WHO tried to hide this fact
  3. The WHO has a vested interest in getting people to quit smoking because they believe governments should have universal health care, and smoking would therefore increase economic costs to various governments.
  4. Despite what the WHO mentioned above, some studies show that technology such as air filtration systems in bars to filter as much as 100% of 2nd hand smoke from the atmosphere of the building. So ventilation systems can be effective.
  5. The number of deaths caused by 2nd hand smoke is often exaggerated. The study showing 2nd hand smoke does not cause lung cancer, and the fact 2nd hand smoke is still attributed to 2nd hand smoke, is a perfect example. The WHO and the Environmental Protection Agency have invested interests in exaggerating these numbers.
  6. Most people do not approve of smoking bans in public places. For example, in New York 85% said such laws went too far (however, personally, I believe such laws are necessary and Constitutional. The Constitution gives lawmakers the right to protect us from each other. However, I think such laws should give businesses the right to be smoke free or not smoke free and the people can choose whether or not to go to the businesses that allow smokers inside. Let the market decide and not some lawmaker in Washington).
  7. There are no studies that show people miss more work due to 2nd hand smoke. There are many reasons people miss work, and none could be ruled out. It could be second hand smoke, but there's no real evidence to show this.
  8. There is no real proof smoking increases medical costs. There is no proof these people would have had medical problems regardless whether they smoked or not. There is proof that people who smoke and have increased health problems have bad genes, so perhaps these people would have had bad health regardless that they smoked (or inhaled 2nd hand smoke).
  9. Even scientific studies are interpreted by people who have biases. Questions can be asked to generate a certain response. Studies can be interpreted with bias. In this way, sometimes statistics can be skewered.
  10. It is a fact that some studies show 2nd hand smoke causes certain diseases, and similar studies that show the opposite. As we can see by the WHO, the ones that are inconvenient to the biases of the organization are ignored and those that prove the bias are reported.
  11. The smoking industry lied about the dangers of 2nd hand smoke until recent years. This is why some smokers have succeeded in suing these companies.
  12. The U.S. government knew prior to WWI that smoking was dangerous to people's health, yet still gave out free cigarettes to soldiers in WWI and WWII. The U.S. government succeeded in getting America addicted to cigarettes knowing it was bad in order to help the smoking industry in order to boost the economy. This is a fact. Look it up for yourself.
  13. In 1929 a study was published in Germany linking cigarette smoke with lung cancer (see here).
  14. Automated cigarette machines were invented in the late 19th century which made it easy to make cigarettes. The industry soon took off, and it boomed with the help of the U.S. government
The above facts were obtained from common wisdom, the World Health Organization, the American Cancer Society, Citizens Freedom Alliance, Inc,

Monday, November 14, 2011

Why do humidity and cold air trigger asthma?

Both humidity and cold air are common asthma triggers.  The question is why?  This was a topic I delved into in a recent post at

Here's Why Humidity and Cold Air Trigger Asthma @

Every asthmatic, and every asthmatic mom and dad, should be aware that both humidity and cold air are two very common asthma triggers. So why is this? What can you do about it?

It's been common wisdom for years that humidity and cold air helps with croup, or swelling of the voice box and trachea.   Put a croupy kid in the hot and steamy bathroom and the swelling gets better.

Another method that often works for croup is taking the child outside in the cold winter air.  This is why many times when a parent decides to take the child to the hospital, the child is fine by the time they arrive in the emergency room.

This is true for croup, so many doctors of old believed it must also be true for asthma. Yet it was a fallacy, and now -- thankfully -- most doctors are aware of this fallacy. In fact, now doctors are aware that both cold air and humidity can actually trigger an asthma attack.

When I was little boy way back in the 1970s my pediatrician recommended my parents have me sit in the hot steamy bathroom when I was having trouble breathing. It was also recommended I have a humidifier in my room.

Both of these made my asthma worse, not better. Yet I was a kid, so how was I to tell my parents that?  My doctor and parents thought they were doing something good, yet their wisdom was flawed.

I wrote a post before how low and high humidity can trigger asthma. Studies show that a humidity of 50 percent or greater may lead to a greater incidence of asthma trouble.

Two common theories for this are:
  1. Humid air is heavier and harder to breathe
  2. Humid air harbors fungus, molds and dust mites that trigger asthma
Humid air is most often a problem in the summer months, especially in August and September.

(On a side note here, when I was a kid there was also a fear that air conditioners were bad for asthma.  That was a fallacy that lead to many uncomfortable August car rides).

As I wrote before, I also remember having asthma trouble when my brothers and I would go sledding. I'd usually have to quit early and arduously walk home with my asthma symptoms raging.

Now we have research that shows air that is too dry can also trigger asthma. Air tends to be drier in the winter months. The reason for this is that the colder the air the less water it can hold.

When you inhale cold air that is dry this can dry the mucus membranes lining your lungs that are your bodies natural defense mechanisms against viruses and bacteria. So this can lead to increased infections too. And Lord knows viral infections are the most common asthma trigger.

Dry mucus membranes can also aggravate allergy symptoms. And considering 75 percent of asthmatics have allergies, this likewise is important.

Now that you understand that dry air can trigger asthma, consider the following:

1. Exercise can trigger asthma: As I write in more detail hererapidly breathing in air dries inspired air, which ultimately dries the airway, which then releases histamine that can increase inflammation of the air passages in your lungs. This then leads to bronchospasm. The fact runners tend to breathe through their mouths only exacerbates this problem because the nose is a better humidifier than the mouth.

2. Mouth breathing can trigger asthma: Your nose humidifies inspired air, so if you breathe through your mouth this air is not getting humidified enough. This is especially important during the winter months when the air is drier. Studies have linked nasal congestion with severe asthma, and I think this is one of the main reasons -- those with sinus trouble breathe through their mouths.

3. Cold air triggers asthma: Again, this is true because the colder the air the less humid the air is. This is why asthmatics, especially those with exercise induced asthma, have trouble exercising outside when the air is cold. Rapid breathing of cold, dry air triggers asthma as noted above.

To prevent asthma the The Center for Disease Control and Prevention recommends humidity be set between 35 percent and 50 percent. Humidifiers can be used in the winter months, and air conditioners and dehumidifiers in the summer months.

However, with good asthma control most asthmatics should still be able to exercise. Likewise, as I write here, many Olympians with asthma are still able to perform during the Winter Olympics.

It's good wisdom to know that cold air, dry air, and humid air can trigger asthma. It's also important to know that by working with your doctor to control your asthma you should still be able to continue doing the things you love most.

Sunday, November 13, 2011

Rise above evil to find good, and death to find life

Things often look bleak as we look at the world.  Yet we are reminded on Easter that life begins with one person.  You must start change if ever you want to change things.  You cannot simply let doom and gloom in the world take you down with it.  Life does not end with death.  If it did, the world would have ended long ago.

Jesus reminded us of this, as things looked bleak in his day, and he volunteered to die and he rose again.  Death may be what we see, yet we must rise above it all.  Rise above the evil.  Rise above the doom and gloom. 

Jesus did not promise that he would prevent evil and sickness.  He did not promise that times would not some day be bad again.  He never said the world would be free from war and evil people.  The reason he doesn't promise this is because what he did give us is free choice.  We have a right to make decisions, and then we also have a right to face the consequences of our decisions -- good or bad. 

When bad things happen it's of our own free doing, or someone else's. This can never be prevented, yet we can rise above it to stop these people.  We must look at the evil, we must look at what is bad, and find what is good in it.  This, in essence, was the miracle that Jesus provided.  He had the ability to look at the worst and find the best.  He could look at the worse situation, like the poorest of the poor, and find richness.

Think about it.  Jesus willfully put himself to the most repugnant and painful act possible, and he died on the cross.  Then he was able to find life out of it.  That's right, out of his own death he found goodness.  He taught us that we can look at any human situation and find life in it.  We can even look at death and find life in it, because through death life continues.

So when evil occurs it is of our own doing.  We are all in this world together, and it is together that we must rise above the bad and the evil to make things better.  It has been done before. 

We must keep optimism going like the flower that rises on a sunny day only to be snowed upon. Yes it may appear as though the flower may not come back up, yet it rises again. 

Man was put on earth thousands of years ago, and while there have been many things, and many people die, and while there have been periods where times were good and times where things appeared ominous and gloomy, new people always came along to make things better again. 

People die, yet new humans rise up.  In this way mankind always lives.  On Easter we are reminded o this.  by reading and celebrating about the resurrection of Jesus we remind ourselves that there is always life even when we don't see it.  Great times will rise again.  Happy Easter


Saturday, November 12, 2011

A nebulizer is not a microphone

Do you ever have a patient who starts talking as soon as you give her the nebulizer?  Sometimes they're so loquacious I have to leave the room just so they can get the treatment.  Yet other times the treatments not needed anyway, so I just stay in the room and enjoy the company.

I had a patient recently who truly did need the treatments when she's sick, although she'd been a patient a few weeks and was feeling great.  She's quite a loquacious lady, and as soon as I gave her the neb she started talking.  She made a neat observations:

"You ever notice how I use the neb as a microphone?" she said.  "As soon as I get it I start talking into it. It doesn't amplify my voice or anything, yet it does make me talk."

Gosh, could we call this loquacious-uterol or loquacious-olin. 

I suppose in reality a nebulizer is not a microphone, yet it's often used as one.  I guess in a way. considering 80 percent of treatments aren't needed anyway, it might as well be a microphone. 


Friday, November 11, 2011

They only call you when you don't want them to

As soon as you sit for lunch the emergency room will want you.  As soon as you "finally" sit down to take a break a patient will need a breathing treatment.  As soon as you click on the Internet they will call. Yes it's true:  they only call when you don't want them to.

This brings us to RT Cave rule #48:

RT cave #48:  If you want someone to page you they won't.  If you're in a room and the patient won't shut up, and you can't think of a way to escape, your pager won't go off.  It's just the way it is


Thursday, November 10, 2011

Protein in raw mild may prevent asthma/allergies

Reuters reports on a new study that shows that children who drink raw milk were less likely to get asthma as compared to children who drank pasteurized mild.   The theory is that certain proteins destroyed during the pasteurization process are useful in helping the immune system stay strong and fit.

Reuters quotes one experts as saying this may present scientists with a double edged sword.  While pasteurization kills unwanted bacteria from mild, it may also kill necessary proteins we need.

Another reason that pasteurized mild might do is prevent infants from getting exposure to certain bacteria necessary for a proper immune maturation process.  The Hygiene hypothesis states that infants not exposed to certain bacteria may develop asthma.  This study may be added proof of this hypothesis.

While raw milk tastes down right terrible in my humble opinion, many people believe pasteurization is not needed and raw milk has many health benefits, such as preventing asthma and allergies.

While further studies will be needed, this study may be further proof that the modern Western world is causing asthma.  Other theories suggest our modern diet, genes, pollution, Tylenol, c-sections, lack of breast feeding, premature birth, among others may have a negative impact on the immune system that results in lung inflammation that results in asthma and allergies.


Wednesday, November 9, 2011

RT apathy may be symptom of a greater problem

It is said that apathy is what destroys nations. After taxes were raised so high to support programs to help the needy, Ancient Roman workers felt they were working not to better their own lives but to support other people. There was no monetary incentive to do more than the minimum.

People thought things like, "What's the point of going out of my way to do anything when there's no incentive for me to do it?" I hear similar things said by RTs of today. Their wages are low, benefits are minimal, and their bosses simply tack on more jobs when you complain.

So, like Dave, you simply keep your mouth shut. You show up for work and the apathy sinks in deeper and deeper. It's attitudes like this that sink nations. It sank Ancient Greece and Ancient Rome and even Ancient Spain. Now it makes me wonder if RT apathy is a sign of a greater problem: Apathy of the American system.

Think about it. Your taxes are high, housing values low, bureaucrats abundant, people living off government programs abundant, national debt abundant. With the progressive tax system if you make more money the Federal government sifts it away, taking away the incentive to work harder.

The interesting thing about Ancient Rome, which I find eerily similar do what's occurring in America today, is that taxes are high and people try to find ways of skirting around paying them. This is a side effect of RT apathy.

Hence, RT Apathy may be a symptom of a greater problem.  What do you think?


Tuesday, November 8, 2011

Dave the Apathetic Respiratory Therapist

Dave is a respiratory therapist who constantly complains about useless breathing treatments. So I drew up an RT Driven protocol thinking he'd help me push it through.  Yet he hated it.  He said, "All this is gonna do is create more work for us."

Dave is a quintessential example of an apathetic respiratory therapist.  Apathy in the RT cave spreads faster than the plague.  It's caused by education and experience.  The wiser an RT becomes the more apathetic he tends to be. 

With 30 years experience that followed two years of intense RT schooling, Dave has a plethora of RT wisdom in his cranium.  Yet many doctors are afraid to give up autonomy.  Plus doctors and nurses still believe the old myth that bronchodilators treat everything from dyspnea to rickets.  To read about the 12 myths of respiratory therapy click here.

Yet when Dave tried to educate the doctors and nurses he was told to shut his mouth.   Either that or the doctor became so frustrated with Dave the doctor doubles the frequency of therapy and adds IPPB and mucomyst just to piss Dave off.  So then Dave grumbled about studies showing IPPB merely works to over inflate good alveoli, yet Dave was told to shut up again.

Dave wrote up an RT driven protocol in the past, and the RT cave boss said it was a good idea and even hailed it as brilliant, yet other than that this boss did nothing to push it through.  The boss, in other words, blew Dave's protocol off.  The boss didn't want to make waves and he also didn't want to risk losing procedures.

Dave decided that no matter what he did he was either told what he wanted to hear or ignored.  He became frustrated.  While he loved to learn, he decided there was no point.  So when I approached him with my idea of a RT protocol, he had already gone down that route and rejected my idea.

He often says, "The only reason I work is to get a paycheck."  He's bored of his job, he has a sense no matter what he does it won't get better, so he's just along for the ride.  Like many respiratory therapists, he's apathetic. defines apathy as absence of passion, emotion, excitement, or interest.  Apathetic people don't necessarily hate their work, they simply feel too much of what they are doing is irrelevant to the course of improving the world or benefiting the patient. Apathetic RTs, like Dave, feel their is no incentive to go above and beyond the call of the basic duty.

In the case of respiratory therapists, they feel doing breathing treatments on every patient admitted to the hospital is a waste of time, and does nothing to improve the health of most of the patient's they're ordered on. It's a feeling that you know how to improve the hospital setting, you know how to really help patients, yet no one cares to hear your story.

It's hard for teachers to teach Dave anything because he no longer cares. There's an old saying that once you become apathetic you no longer care.  Dave no longer cares.  He now refuses to read up on anything new unless he's forced to do so. He didn't used to be this way, yet he is now.  He's become apathetic.

When people try to teach Dave something new he learns with an attitude.  He grumbles and gripes.  He's apathetic.

Now that I've dug deeper into it I understand Dave's behavior. What Dave has is Respiratory Therapy Apathy Syndrome (RATS).  You can read more about Dave's conditions by clicking here.

Sunday, November 6, 2011

Listen to the Wisdom of the living

We medical professionals have the job of sharing our wisdom. It is our job to teach our patients about their disease process, what they can do to get better, or to stay healthy once they are better. We have the job of encouraging patients to quit smoking.

Yet once the discussion moves beyond the scope of our profession, once the discussion moves on to religion, or politics, or family, or life, I have learned it is better to seek the wisdom of the other person rather than to share my own wisdom.

I learned this the hard way. I learned it through death, twice.

Two weeks ago a 92 year old man asked me about my family. I ended up sitting with him for over an hour in a great discussion. It turned out that he was a Dentist and, believe it or not, he was good friends of my childhood Dentist.

As he was talking, or mostly as I was talking, I started thinking that he was the same age that my grandparents would have been. So I asked him if he knew my grandparents. He said that he did.

Yet I had to move on. I had to check on another patient. And he made me promise I would come back. I knew I'd be back, because I had him scheduled for another treatment four hours later. I wanted to ask him what he knew of my Grandparents.

However, two hours later his breathing was labored and he called for a treatment. He passed during the treatment. I closed his eyes and prayed for him.

This past weekend I had a similar situation I wrote about here. He and I had something in common in that we both read the Bible every day and try to understand it. I wanted to ask him what his favorite Bible story was. I wanted to ask him if he met a person who didnt' believe, what chapter of the Bible he'd recommend to that person.

The discussion never got that far. It didn't because, I believe, your Humble RT spent too much time talking about his opinion. That may not have been the case, yet that's how it felt. I never got my questions in. I felt I had more to learn from the patient.

When I returned the patient passed away, once again while I was in the room. I closed his eyes and prayed. Other than pray there was nothing else I could do for him.

In a sense, I felt this way when my grandma passed away. I felt I had many questions about her and her family that will never be answered. My wife felt the same way recently after her mom and grandma passed. Questions will never be answered.

So the moral here is that we must seek the wisdom we yearn for while a person is still alive, and this will mean taking the time to ask and then to listen.



Saturday, November 5, 2011

Second hand sitting linked to heart disease and diabetes

There was a study out a while back that showed that if you were fat and smoked that you were better off losing weight before you quit smoking.  The reason was because the study showed being overweight was worse for you than smoking. reported on a study that confirmed just that.  Going to work and sitting at a desk all day can be more dangerous than smoking. 

The Dailymail reports the research was conducted by the American College of Cardiology.  The study concluded that "prolonged sitting is linked to cardiac disease, obesity, diabetes, cancer and even death and could be just as dangerous, if not more so, than smoking."

It makes sense because diabetes, cancer cardiac disease and death are all secondary to obesity.  Other people can get those conditions, yet your risk is greatly increased if you are overweight.  A study doesn't really need to be done to prove that.  Yet it helps.

The researchers believe that the more you sit around the less your body does to fight off those diseases.  It's just like smoking increases your risk by inhaling chemicals. 

Another similar study showed that watching too much TV was linked with increased risk for heart disease and diabetes.  I really don't think we need to do a study to show these things.  It's common sense. 

Second hand smoke has been proven to be almost as dangerous as first hand smoke. So it probably won't be long before second hand sitting is proven to be as dangerous as first hand sitting. 


Friday, November 4, 2011

What are the trendy topics in RT

Your RT Question:  What is the main research base for respiratory therapy?What are the prominent peer reviewed journals, and what are the trendy topics getting articles published right now? 

I don't know that these are peer reviewed journals, yet the best place to find research is by going to, RT Magazine, Advance for rt.  The AARC times is, I think, one of the best magazines in RT, as well as chest, although the later is more research and analysis than what I think you're looking for. 

I think the main emphasis of respiratory therapy right now is meeting criteria for reimbursement, reducing costs, and improving patient outcomes.  The Keysone committee of Michigan is a big success and even the Obama administration is encouraging other states to adapt a similar program.  Since the program was adapted, pneumonia admission rates have decreasing in Michigan, deaths in the CCU have decreased, etc. 
Another area of big change is oxygenation of neonates.  Where it used to be recommended to give 100% oxygen to newborns, it's now recommended to give 21-40% due to studies showing giving newborns too much oxygen was linked to cancer later in life, among other consequences.


Thursday, November 3, 2011

At what point can we trump a patient's freedom?

I find that most patients are almost too willing to give up their freedom when they are in a hospital. They are too eager to allow us healthcare providers do whatever a doctor orders even when they don't want to do it and are scared.

Too me this is scary.  It shows that fear can drive a person to be eager to give up freedom.

I'll give a couple examples.

1.  You go into a patient's room to give a breathing treatment.  The patient is scared because he is short of breath.  You go to give the breathing treatment and the patient says, "I've had 20 of these already and they don't do any good.  Why am I getting them?"  You say, "Because it's part of an order set for pneumonia,"  Or, more likely, you'll say, "Because the doctor ordered it."  The patient says, "Oh, if the doctor ordered it, I must need it."  Actually what the patient is saying is I'm willing to give up my right to choose because my doctor knows what's best for me and couldn't possibly make me do something that's not needed.

The truth is, breathing treatments are useless for pneumonia, and that patient would be wise to use his freedom to choose to refuse that therapy.  Yet I find it rarely ever happens.

2.  You have a patient in the ER who's short of breath with a rising CO2.  You are ordered by the doctor to put the patient on a BiPAP.  The patient is scared of being short of breath, yet terrified of the BiPAP.  The patient refuses.  Yet the doctor comes in and says, "The patient is a full code and must be put on BiPAP!  Talk her into it and put it on!  It's for her own good.  Either we do this or she dies!"  So now you force it on the patient against her will.  You have intentionally trumped the freedom of that patient "for her own good."

Example #2 here might be replaced with an intubation.  A young 25 year old comes in and is afraid to be intubated, yet he can't breathe.  He is obviously a full code, and even if he refused we have to do what's best for that patient.  So do we respect the wishes of the patient, or do we sedate him and intubate him against his will?  In many cases, I think the doctor would trump the patient's wishes.

3.  You have a patient with kidney failure who is a regular patient of the hospital.  His heart rhythm and blood pressure are erratic and life threatening.  Just because his heart rate is high and blood pressure erratic he falls into a category that mandates the unit secretary ordering the sepsis order set.  As part of this order set is an EKG and a blood gas.  Surely the EKG is indicated regardless. However, the blood gas is an invasive and painful blood draw and there was no scientific need for it.  Surely you can get a pH from this blood draw, yet you can also get it from your normal venous blood draw too as I described here.

So I enter the patient's room and do the EKG and go to draw the blood gas.  The patient says, "I've had many of those and I don't want that again."  I make sure he's sure, and he says absolutely.  So I tell the doctor and the doctor goes belligerent and tells the patient if he's going to refuse everything he might as well go home and die.  The doctor makes the doctor get the blood gas against his will.  The patient is pissed and insists he's going to go over the doctors head to complain.  I tell the patient I wish him luck, but no matter what he says doctors are treated as gods around here.  The patient grows to love me for my humor and honesty.  Yet he's irate his right to refuse a procedure was trumped by the doctor.

I think these are ethical issues that would be interesting to debate.  You have most patients too willing to give up their freedom because they think an expert knows what's best for them, and you have the expert who forces his will on the people.

In an eerie way, this sounds Orwellian.  In an eerie way, it sounds too much like what is going on in Washington.  It seems we have experts in Washington (from both parties) who think they know what's best for us, and they make rules (laws) for us to follow (like that our tax money goes for things we don't approve), and then they force us to comply (strip another freedom).  And because many of us don't know any better, we "assume" these experts know what they're doing -- yet most of the time they don't.

So at what point are we too willing to give up freedom?  I think the answer to that is when we are ignorant. Ignorance breeds fear, and fear makes us eager to give up freedom.  The solution to this is education.  I think everyone should be taught about health care in school.  Everyone should know about what we do in the hospital.

Yet if we kept educated the masses, then politicians would lose control, and big businesses wouldn't sell so many products, and hospitals wouldn't be as busy, and they'd all lose profits.  Since this is a money driven world, perhaps money is what drives our ignorance and fear.  The powers that be -- the elites among us -- want us to remain ignorant.



Wednesday, November 2, 2011

Respiratory Therapy Apathy Syndrome (RATS)

When a respiratory therapist gets tired of doing BS procedures he develops what experts like to call Respiratory Therapy Apathy Syndrome (RATS). They start to suffer from uncharacteristic and unexpected mood swings and verbal outbursts even when they are asked to do something useful.

Respiratory Therapists (RTs), throughout history, have always been subjected to situations most people would fail to comprehend. While they are an essential part of the medical care team in hospitals, there's an old saying among RTs infested with RATS that much of what RTs do is either a waste of time or delays time.

RATS is a feeling that nothing you do matters. It's becoming passive when it comes to improving your profession. It's becoming submissive, or letting people you think -- or know -- are wrong win. It's being humble when you should be aggressive or assertive. It's being obedient and unresisting.

It's being numb to the presumed idiocy around you. It's being numb to everything and just not caring about the things you once cared about.

Actually, it's not so much not caring as much as feeling that your opinion doesn't matter. So numbness is a better description here. It's giving up and letting doctors win considering RTs know they can't beat the doctor clique.

At some point a respiratory therapist feels he is simply an observer, a peon whose job is to do what he is told to do rather than what he wants to do or what he thinks is right. He becomes an observer because he begins to think what he thinks doesn't matter.

How can an RTs take his profession seriously, when doctors, like actors, are trained to perform in a certain way in order to be accepted by other doctors. Likewise, doctors are trained to do what the government wishes in order to assure that the patient's admission is reimbursed by the Centers for Medicaid and Medicare Services (CMS).

RATs should not be confused for burnout. Burnout is the result of being overworked and under paid, and the cure may be rest and a raise. The remedy for burnout is as simple as changing a light bulb.

RATS, on the other hand, is lights out. It's permanent. Simply changing a light bulb won't affect it. Once you have it you hang onto it for dear life, unless dementia sets in (ah, dementia, the easy road).

It's insidious. It's ingrained. It grows roots like a cancer and digs itself deep into the respiratory thinkum which is attached to the medulla oblongata. The respiratory thinkum is invisible to x-ray, CT Scan and MRI.

What's the Etiology of RATS?

The etiology of RATS is suspected to be repeated exposure to the R-Isomer, a component of most bronchodilators from Epinephrine to Alupent to Albuterol to Xopenex.

Ventolin particles attaching to beta adrenergics aren’t' the problem. If the R-isomer is needed it’s needed. The problem is that once beta adrenergic receptors are full, the R-Isomers begin to pool in the blood. This is usually a result of continuous second hand bronchodilator mist exposure.

Once the accumulation of R-Isomers becomes abundant, these pooled R-isomers combine with Oxygen to form a new molecule we call VentoApothum. It crosses the blood brain barrier and attaches to the respiratory thinkum. This results in inflammation of the respiratory thinkum that usually leads to apathy.

 Another theory is that repeated exposure to the R-Isomer triggers an abnormal immune response similar to the allergic response. Inflammatory markers are released into the blood stream that attach to the respiratory thinkum, causing it to become inflamed.

 Scientists now believe that if you are exposed to something that causes inflammation, and you're repeatedly exposed to it, the inflammation will become permanent (kind of like occupational asthma). So with chronic inflammation of the respiratory thinkum, the patient now has RATS. It will never go away. It's chronic. There is no cure.

 The respiratory thinkum has now become sensitized.  Once the therapist is exposed to RATS triggers (see list below) the inflammation worsens than an exacerbation of RATS occurs.  This results in sudden and uncharacteristic outbursts and other signs and symptoms (see below). 

 More than likely the cause of RATS is a combination of the above.  Yet the illness may remain a conundrum for some time, especially considering most doctors don't give a hoot about it.

How is RATS diagnosed?

The only way RATS can be diagnosed is through keen observation and questioning, and looking for the signs and symptoms as noted below. 

What's it like to be infested with RATS?

To give you a better picture of what it's like to be infested with RATS, consider the following situations described by random victims:
  1. I work hard to help people who refuse to take care of themselves.
  2. We intubate and put on ventilators patients with terminal illnesses because their family members think they'll miraculously recover.
  3. We get tired of doctors intubating based on a number in lieu of using common sense. 
  4. We do breathing treatments on people because nurses and doctors believe bronchodilators are the cure for every annoying lung sound and all causes of dyspenea. Many more bronchodilators are ordered just to assure the hospital meets government set criteria for reimbursement.
  5. We RTs love our patients, yet we get annoyed at many of them because they know they don't need a bronchodilator, yet won't say anything because they think things like, "Well, since the doctor ordered it I must need it."
  6. RTs are often called to duty not because a patient needs a breathing treatment or an EKG or an ABG, but because the doctor doesn't know what's wrong with the patient, and doesn't know what else to do, so he orders something just so the patient thinks something is being done. And since patients don't know any better they just let this abuse go on.
  7. We RTs have read the studies doctors choose to ignore. You know the studies that prove inhalers work just as well as nebulizers. This might explain why doctors think nebulized bronchodilators (not inhalers) are akin to Tylenol as the world’s most perfect remedy for any ailment. RTs know this is BS, and most doctors don't care.
  8. Likewise, we RTs become irritatingly irate at RT bosses who care more about accurate charting and reimbursement assurance than the patient. A patient could die and nothing would be said, yet if an RT forgot to dot an i or cross a t all hell would break lose.
  9. We RTs become frustrated because the patient who truly needs RT services has to take a back seat to the patient who requires an RT service just so that patient meets criteria.
  10. RTs are the hospital's bitches. Our services are utilized by some nurses and doctors in lieu of using common sense and thinking. It's easier to call RT than it is to use your brain. These Nurses and doctors use us RTs to alleviate themselves of labor and responsibility.
  11. We RTs are well educated, trained and are experienced, yet when we make recommendations we're ignored and often punished. We are often discouraged from being team members, and this makes us angry, reticent, and apathetic.
Differentiating RATS from burnout:

This condition used to be referred to as burnout or even as the depression stage of grief. Yet a thorough examination of respiratory therapists from around the world has assured psychologists of the uniqueness of the respiratory therapist's plight.
It's become a condition where RTs have become the victims by abuse of their services. The end result is apathy toward the patients they love and want to help. The true victims are the patients who truly need respiratory care. The true victims are the respiratory therapists themselves.

This condition is known as Respiratory Therapy Apathy Syndrome (RATS)

Who gets RATS?

It's generally a condition that develops after repeated episodes of burnout due to BS procedures and nonsense calls for RT advice that randomly (and sometimes continuously) occur over the course of any given year. The older the RT becomes, and the more he learns, the more likely he is to realize the signs and symptoms of RATS.

RATS is also the result of the 12 biggest myths of respiratory therapy.

What are the signs and symptoms of RATS?
  1. Grumbling and griping at any new RT order, even those that they deem as needed
  2. New onset of swearing (swearing by someone who normally doesn't swear)
  3. Exhaustion
  4. Burnout
  5. Sore feet
  6. Lack of interest in job
  7. Silence
  8. Repeated absence or tardiness
  9. Lack of empathy for patients
  10. Refusal to go above and beyond the call duty
  11. Refusal to recommend new ideas because they feel they won't be accepted anyway
  12. Comments such as "I hate my job."
  13. Complaining
  14. Refusal to learn anything new because they have decided it's pointless
  15. Constant talk of getting a new job but feeling trapped
  16. Eye rolling
  17. Not caring
  18. Not getting stressed
  19. Not getting worked up
  20. Not having an adrenaline rush during emergencies
  21. Walking regardless of urgency
  22. Staying calm during emergent situations, even when everyone else is stressed out
  23. Staying calm and just doing your job
  24. Comments such as, "You should know me well enough by now to know that I don't care to take care of the patient first, lab, x-ray, or respiratory therapy.  We are all a team; we are all in this together. It's not a big deal that this CHF patient gets his albuterol neb before those procedures."
What are the signs and symptoms of worsening RATS?
  1. Saying things that might jeopardize your job
  2. Talking bad about your job even in front of doctors, nurses and your bosses
  3. Uncontrollable outbursts
  4. Not introducing yourself to patients
  5. Not talking to coworkers (nurses, doctors) who annoy you
  6. Contempt toward certain doctors and nurses
  7. Contempt toward patients who refuse to refuse treatments
  8. Lying in your charting
  9. Skipping treatments and charting "refused"
  10. Problems at home
  11. Sexual dysfunction
  12. Signs of depression
  13. Signs of stress
  14. Constant complaining or even the opposite, abnormal silence
What are RATS triggers?

Triggers are anything that causes an exacerbation of RATS your body becomes sensitized to things that don't bother normal RTS.  Triggers are things that increase inflammation of the respiratory thinkum.  It's often called a RATS flare up.

So, that in mind, the following are believed to be associated with sudden outburst, flares or exacerbations of RATS symptoms:

  1. Stupid doctor orders (the most common)
  2. Overbearing nurses
  3. Abuse of the word STAT
  4. Repeated pages for unnecessary procedures
  5. Needless intubations
  6. Ignoring common sense
  7. Incessant complaints about senseless charting errors
  8. When charting is inappropriately prioritized
  9. When RT wisdom is ignored
What is the treatment for RATS?

Currently there is no approved therapy for RATS mainly because most doctors refuse to acknowledge it as a condition. They think RTs are simply lazy and trying to get out of work.

Yet most experts to concur that RATS is a chronic condition and therapy is only palliative and temporary.

That said, Dr. Ven Tolin of PsyKologiscs Yippy College of Workers (PSYCOW) has listed the following recommendations for improving RATS: 
  1. Days off work: Get away from the problem
  2. Exercise: Proven to help you deal with stress
  3. Good diet: Works in conjunction with exercise
  4. Humor: Find ways to laugh off the problem or make fun of the situations that are the most frivolous (this blog is a good example)
  5. Sleep: The more you can get the better. Recommended 8 hours a night with a cat nap added in at some point during the day (or even your shift)
  6. Complaining: A good complaining session is a good way to learn you're not alone. While I don't necessarily recommend complaining, sometimes it does help get things off your chest.
  7. New job: Go to school and try to move up the ladder, or switch professions (simply switching to another RT job will not help).
  8. Hobby: Find something to do that you love, something that helps you feel needed, like volunteering, or writing a blog, or educating, reading, etc.
Controversial therapy for RATS:

Keep in mind that most doctors don’t want to acknowledge RATS as a condition and don’t want to ease RT pain and suffering. Therefore, while many of the following are proven to help, doctors usually ignore requests for the following therapies: 
  1. Ativan or Morphine: RTs often petition for this line of therapy and are flat out denied mainly because it helps with RATS.   (Warning: If an RT is ever ventilated most doctors recommend NOT using this line of medicine.  They like to see RT pain and suffering). 
  2. Xanax: It helps, yet the last thing doctors want are a bunch of relaxed RTs running around causing havoc.
  3. Alcohol: It’s legal and it does help
  4. Cigarette Smoke: Don’t call RTs hypocrites who smoke, because it’s proven to help ease many of the symptoms of RATS. However, some studies show cigarette smoke irritates the respiratory thinkum and causes random outbursts.
  5. Sex: Eases symptoms temporarily
  6. Long walks in the sun: Studies show sun rays absorb the R-Isomer into the atmosphere. However, the EPA is concerned about studies linking the R-Isomer to ozone depletion.
  7. The Absolute truth:  This would entail RTS to gain the courage to ask doctors for evidence and facts regarding the therapies they order, or to ask questions.  It's an extrapolation of the truth and questioning questionable behavior and seeking absolute truths.  It would be an end to doing things just because.  It would be placing the truth before keeping friends, the peace and happiness.  It would entail making waves.  It would entail a search for the truth.  It would entail honesty.
  8. Frontal Lobotomy:  Yep, this would take care of it all right. Yep, it sure would. 
Conclusion:  If you can't think of whether it's the S-isomer or R-isomer that causes RATS, just think R for RATS.  The R-Isomer is good for bronchospasm, yet if you're not having bronchospasm you don't need the R-Isomer.  When the R-isomer pools up in your blood it can cause you to become infested with RATS.  Yes, it's an incurable disease and there is no treatment. 

A disorder that is eerily similar is Responder Apathy Syndrome (RAS).  This might explain why RTs and EMTs get along so well. You can also read about it at the Urban Dictionary.