Respiratory Therapy Cave

How to introduce yourself to a patient?

2012-01-27T00:17:00.000-05:00

Your humble question: What is the best way to introduce yourself to a patient and to identify the patient without breaking confidentiality rules?

My humble answer: There really is no rule how to introduce yourself. However, due to confidentiality laws (like HIPPA) I find it's best never to say the name of the patient. My technique is to get the patient to say his or her name so I don't have to. I usually do the following:

I pick up the written (printed) order and take it with me to the room
I always introduce myself as I enter the room: "Hi, I'm Rick from respiratory therapy."
Then I say something like, "Will you please say your last name?"
I confirm the last name with the order and I say the first name of the patient. Or, if I'm in a humorous mood, I'll say something like, "Yeah, you're right?" Or I say something like, "Yep, you're the right patient." You can get creative once you know you have the right patient.
Or... if the patient is unable to communicate you can always check the wrist band, or follow the above procedure with the family member or guardian.

Obviously there's more than one best way to introduce yourself to the patient. As with anything, every person has his own best practice.

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It's good that we are here

2012-01-26T10:02:00.000-05:00

I've seen death for what it really is. I've seen the road to death. Yet what impresses me more than anything is when a person who is closing in on the pearly gates is okay by it. I was reminded of this the other day as I entered the room of a 100-year-old man and he smiled.

He was among the most pleasant patients I've ever had. His smile was bright and cheery as my 2-year-olds. His vision of death perhaps the same. He's obviously seen much, and most of those he has spent his time with are now gone.

Yet here he is sitting in this recliner, most of his teeth dark, his skin cracked and wrinkled, his hair white and barely visible along the sides of his head, yet in the moment he is happy he is here. He has been humbled like no other man in the hospital. He has seen more misery. He has seen more happiness. He has seen more than the 22-year-old man in the room next to him who was crying and agitated because he had to spend "one more night in this dump."

He spoke little. He closed his eyes when you weren't speaking to him, and when you spoke he opened his eyes and listened. I was most impressed by this, considering his old ears could still hear, and his eyes could still see, so long as he had his glasses on.

What more did he have to say. Most people try to accomplish their goals in life, and to share their stories, by the time the predict they will die (some think they will live forever). I notice COPD patients are often quite willing to talk and to share their life stories. I've decided they've come to terms that they will die some day, that they will not escape the grim reaper's grip.

Yet when one is 100 years old, they have accomplished any goals they have set for their life, perhaps several years earlier. They have shared all their stories. I've rarely met an 80 year old who believes he has nothing else to offer in this world, yet I believe most of us don't expect to be around at 100. Few of us will be on the journey this long. It's a rare feet.

Yet he was happy in the moment. He was happy he was here. It sort of reminded me of the story that Matthew told in the Bible about how Peter, James and John see Jesus transfigured, his face white as the sun, as he is talking with Moses and Elijah. They saw Jesus transfigured on Mount Tabor in all his glory, as he truly is.

So Peter says, "It's good that we are here." He says this about the moment. He knows he's going to have many trials and trivializations the rest of his life. He does, as the Bible tells, reject Jesus three times before Jesus dies. Yet he is happy in the moment. He, in essence, has stopped to smell the roses.

Seeing the 100 year old man made me want to stop and re-evaluate my life. Am I truly happy where I am at? Or am I like the majority of people who spend their entire lives trying to obtain some goal, perhaps something trivial for material gain, and who fails to enjoy what life offers in every moment?

I do think of this often, and perhaps it's a gift because I have asthma and have been close to death's door a time or two as a kid. I think often that my 12-year-old will only be living with us five more years, and my parents won't life forever. And that, perhaps, is why I make sure to go to Florida every winter to visit my parents and go to Disney, even though I'm otherwise frugal with my money.

So in the moment I am happy. I think of this even as I worked my ass off at work the past two days, perhaps doing the work of two or three RTs, and yet when I arrived at work on Tuesday my boss lectured me about how I need to start picking up after myself, and stop leaving my coffee and water cups lying around. I believe he is not happy he is here.

And after a miserable day at work like that, I go home and hug my kids and roll around the floor with them. I am happy in the moment. I am happy I am here.

Do you ever have a moment where you think to yourself, "It's good that we are here?"

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Doctor Lexicon

2012-01-25T06:37:00.008-05:00

The Doctor Lexicon:

1. Stupid doctor orders: Doctor Orders written based on habit and with no scientifically proven value; doctor orders that are based on antediluvian theories.

2. Normal doctor orders: Doctor Orders written based on scientific evidence

3. Antediluvian theories: Theories that are old and outdated yet are still worshipped by doctors like the hypoxic drive theory.

4. Regular theories: Based on a rational guess

5. Scientific fact: Proven by science

6. Unfettered Doctor Power: Power doctors were given by people who refuse to question them. Power derived by patients who think doctors know everything. Power obtained because respiratory therapists find it easier to just do what the doctor said as opposed to questioning orders. Power obtained by RT Bosses who choose to place doctors on a higher eschelon than the respiratory therapists they represent. This is how we end up with bronchodilator abuse and stupid doctor orders.

5. Doctor Enabling: 1) Often results from Unfettered Doctor Power. Lack of questioning one person's authority results in that person abusing his power. It results in unnecessary breathing treatments, unnecessary nursing home stays, and other stupid doctor orders, etc. 2) Both patients and medical staff enable doctors to get away with anything they want. This breeds ego.

6. Doctor Ego: When a doctor's head swells to the size of a watermellon because he thinks he knows all and is never questioned by anyone because he has a nasty temper and is feared.

7. Bronchodilator abuse: When doctors order breathing treatments nonscientific reasons; ordering treatments just to cover their bases; ordering treatments just to make sure reimbursement criteria is met; treating all annoying lung sounds and all dyspnea with bronchodilator breathing treatments

8. Elitist Doctors: Doctors who think they are above and beyond every other person. They believe they know it all; Doctor ego; Unfettered Doctor power; Enabling. They have become totalitarian. They are able to do without being questioned. Doctors that haven't been questioned for so long they start to treat people like truck engines on an assembly line instead of as people.

9. Bronchodilator abuse: When doctors order breathing treatments nonscientific reasons; ordering treatments just to cover their bases; ordering treatments just to make sure reimbursement criteria is met; treating all annoying lung sounds and all dyspnea with bronchodilator breathing treatments

10. Covering your bases: 1) The silly idea that simply ordering a breathing treatment so the family thinks you're doing something, you're in the right. That ordering an $80 a pop treatment every four hours you're in the right. 2) Obviously if you throw everything at every patient you're going to hit on something and the patient will eventually get better.

11. Hoaxanex: The belief that Xopenex is somehow stronger and better than Albuterol

12. Hypoxic Drive Hoax: A theory postulated back in the 1930s when RTs were desperate to prove to doctors they were a useful profession. Now that the theory has been debunked we can't get doctors to quit believing in it. It's the belief you need to decrease oxygen when the PO2 is 86% or above. It's an excuse to make doctors not liable for keeping patients in a hypoxic environment. See Faux Confidence.

13. Hypoxic Drive Theory: A theory which states COPD retainers use oxygen as their drive to breathe and not CO2. It's debunked on a daily basis but most doctors don't care. See hypoxic drive hoax.

14. Respiratory Therapists: The people doctors call when they don't feel like thinking.

15. Albuterol: 1) Something doctors order when they don't know what else to do; It's what's ordered instead of using science. See covering your bases, bronchodilator. 2) The cheapest and most common bronchodilator. A medicine doctors think is the Tylenol for lungs. Holy water. Scrubbin-bubbles.

16. Real Doctor's Creed: A document doctors vow to uphold in leu of using science in order to make their job easier, cover their bases, and piss off RTs.

17. Bronchodilator idealists: Doctors and nurses who believe bronchodilators will lead to world peace and perfect health despite science to the contrary. They will say they have the truth on their side, yet when you tell them to "prove it!" they get all upset and start to quiver in their pants. They do this because they know there is no proof to what they are proposing. There is the history of stupid bronchodilator orders that's for sure, but there is no evidence to back up the reason for all these orders. You'll even see insurance companies allowing breathing treatments to meet admission criteria because some doctor said this is what will help them get better quicker, but there is no real proof to back up that bronchodilators do any good for anything other than (ahem) bronchospasm.

18. Idealist Doctor: they believe that a perfect healthcare system where everyone receives equal health care at equal costs, and that all patients will a particular DRG can be treated the same. They incorporate order sets. They shun individual thought. They throw temper tantrums when you question them. They believe bronchodilators work for all wheezes and dyspnea. Idealists will tell you bronchodilators work for all that wheezes, or for all annoying lung sounds, or for all lung diseases

19. Realist Doctor: They understand a perfect healthcare system isn't possible. They understand you can't treat all patients the same. They understand they don't know everything. They yearn for teamwork and are willing to give up autonomy for the benefit of the patient. They write orders based on science and create policies to encourage individual choice such as protocols that allow RTs to made point of care decisions to the benefit of the patient, RT, doctor and hospital. They understand bronchodilators dilate bronchioles and don't order them on all patients unless the hospital makes them by initiating idealist doctor driven order sets. The realist at the bedside giving the treatment sees the truth, that the treatment did nothing.

20. Science: It's proven to work. It's based on fact. Bronchodilators dilate bronchioles is a fact.

21. Fallacy: It's not based on science. It's not a fact. Bronchodilators will cure all lung ailments and annoying lung sounds is a fallacy.

22. Malady: A disease

23. Myth: See fallacy.

24. Bronchodilators: 1) Broncho - lung air passages. Dilator = opens up the airway to make air flow through them better. They relax smooth muscles that are squeezing the bronchiole passages and thus cause these muscles to relax. Bronchodilators treat bronchospasm. They relax the air passages. They dilate the air passages. 2) The cure for all lung dyspnea and annoying lung sounds.

25. Tylenol: Analgesic. Pain reliever. Fever reducer. Doctors think it treats every other ailment too. When all else fails order Tylenol. It's the worlds most euphoric medicine. Ideal medicine. Cure all. Holy pill.

26. Scrubbin Bubbles: The belief Albuterol will turn into suds and wash all the shit out of the lungs and cure them of all ailments like in that commercial for scrubbin bubbles foaming action.

27. Annoying Lung Sounds: Sounds doctors and nurses don't like. Sounds that cause fear and make nurses and doctors worry about the patient. Any lung noise audible or silent that causes the doctor to require thought.

28. Thought: Call RT

29. Autonomy: The yearning for total control.

30. Team work: Giving up autonomy. Understanding you don't know everything and can't do everything on your own. It's working together to solve a problem.

31. Ignorance: It's what you don't know. It's not a bad thing so long as you admit what you don't know.

32. Bronchodilator lies: Convincing yourself that bronchodilators treat everything, and every theory that disproves your belief is ignored.

33. Fake Diagnosis: So you're scheduled for a pulmonary function test (PFT), yet your diagnosis is diabetes. The doctor knows most insurance companies only cover PFTs if the diagnosis is COPD, cystic fibrosis, or asthma. Even though your doctor obviously thinks you need a PFT, your insurance won't cover it unless he lies. This should explain why on the PFT order form he gave you to take to the hospital it has "asthma" on the line next to diagnosis instead of diabetes.

34. To cover their asses: Doctors don't want to be sued, so they order whatever they think is needed so it looks like they did their best. Much of what we do in the hospital has no medical benefit whatsoever, and the only reason we do it is becasue the doctor wanted to cover his own butt from potential litigation.

35. Habit: orders: Doctors have a set list of things they order for each diagnosis. After a while he simply writes orders based on habit and may not even know what he wrote. For example, we have one doctor who orders breathing treatments for all his post operative patients. I asked him why he writes this order once and he said, "What's a breathing treatment?" Yet he continues to write the order. It's for this same reason many foley catheters are inserted into patients and other invasive procedures performed. Since no one questions the doctor, he has no incentive to update his ordering habits.

Types of Doctors:

Two basic Types:

1. Gallant Doctor: Gallant Doctor: This doctor knows how to take care of your asthma the right way. He keeps up to date on asthma wisdom, and goes out of his way to make sure you are well educated and on all the best medicines for you. He also works with you on a good Asthma Action Plan, and makes sure you feel comfortable knowing you can call him at any time. He also makes sure you schedule an appointment to see him every six months. Asthmatics who see Gallant doctors have the best chance of having well-controlled asthma. Thankfully, a majority of asthma doctors are this type.

2. Goofus Doctor: Whatever he learned in school umpteen years ago is exactly what he uses to care for you today. He's either too busy, lazy or sometimes simply too arrogant to stay up-to-date on the latest asthma wisdom. He will allow you to walk out of his office with only a rescue inhaler. Asthmatics who have Goofus doctors are Poor Patient Asthmatics who have a tendency to make unscheduled office visits, or trips to the ER, and are often mistaken as Goofus Asthmatics.

Generally, all doctors are either a Goofus or Gallant, but there are sub types of each Asthma doctor personality. Below are all subtypes of the Gallant Asthma Doctor:

1. The Gallants: Strong, Silent Type: She never gets excited, and has a ho hum or gloomy disposition. She often has a finger on her forehead and says, "Hmmm, I wonder..." She is well kempt, organized, jots a lot of notes and knows her stuff. She is very quiet and doesn't like to participate in small talk, but when it comes to asthma or your health she'll talk fluently. She'll assess you thoroughly while remaining taciturn. You might be intimidated by the silence, but she doesn't mean for you to feel uncomfortable. She's very friendly and polite, but also straightforward. She may also ask for your opinion, which may have you wondering if she knows what she's talking about. However, her intention is to involve you in the decision making. She will make sure you are well prepared and cared for upon leaving her office, but once she finishes the job, she will up and leave without shaking your hand or saying good-bye. While she's socially gauche with poor bedside manners, if you like a knowledgeable doc, she's the one for you.

2. Big Hearted Bully: Although he has the bedside manner of a rock and refuses to participate in small talk, he might simply be the best doctor in the world. He is focused and the key for you is to put up with his bluntness and his seeming arrogance. He does not go into detail as he expects you to do your own homework. He usually answers questions with one or two words and, sometimes, he simply grunts. If you annoy him with your petty questions, he'll grimace and moan. If you try to make suggestions, he'll intimidate you with his stare. Yes, you will get a thorough workup and he will take good care of you. If you call him with an asthma concern, he will go out of his way to meet you at the office. He's the only doctor type who will never write a prescription without seeing you first. His decisiveness and stubbornness may impress you, or it may vex you. Overall, if you are the kind of patient who likes a doctor to take control, he's your doc.

3. Columbo: She has a very friendly, nonchalant disposition and quite often has ruffled hair, with an overall disheveled disposition like the 1970s TV detective Columbo (collars up, tie crooked, spot of jelly on white lab coat). When things go wrong she scratches her head with an unreadable expression. She'll slouch in her chair with her legs crossed. She's been known to say things like, "Well, what do you suggest we do today?" Or, "What medicines would you like to try?" When you call her, she's the doc who asks, "Do you think you should come in to see me?" Or, if she meets you in the ER, she may ask, "Do you think you should be admitted?" After a while, you wonder if you are the doctor or if she is. On the other hand, if you are the kind of patient who likes to have more control, this might be the ideal doctor for you.

4. The Buddy: He's the doctor who is often late for your appointments. Even though your irritation level reaches its peak, when he finally does arrive, he cracks a joke you can't help laughing at. He's an amazingly happy person and has a knack for telling stories, especially when you are in an inconvenient position (like on the colonoscopy table, or with your mouth stuffed in the dentist chair). He has a positive disposition and can get you excited even about diseases you might have -- like asthma. He often downplays severity by saying things like, "Oh, you'll be fine," or, "I wouldn't worry about it if I were you." You might catch him saying something goofy like, "Well, today we're going to come up with the perfect concoction to fix you." Yet, if you can tolerate his sunny disposition, you'll participate in an awesome discussion unrelated to asthma. You may actually leave the office feeling like you learned more about his life than about asthma. Despite his quirks, you know he's taking great care of your asthma. So, if you like a friendly, upbeat person, he's your doc.

Along with being a Goofus or a Gallant, each doctor will have one of the following traits:

5.Totolitarian doctors: These are physicians who believe they know what's best for the patient and no one else's opinion matters. They do not like protocols because these allow other members of the care team to make decisions that might not be best for the patient. They do like order sets. These doctors have a tendency to get angry when things don't go their way.

6. Capitalist doctors: These are physicians who know they don't know everything and like to work with a team approach to benefit the patient. They encourage nurses and RTs to make individual decisions at the bedside, and respect the individual opinions and choices of other members of the patient care team. They like guidelines and protocols. These doctors are less likely to get angry because they are more open minded.

7. Order set doctor: A doctor who orders everything he can possibly think of. He fills out every order set possible with the hope that something -- anything -- will work. He covers all his bases by ordering as many procedures as possible. Yes there will be duplicate orders and even triplicate orders. Yes the unit secretary will go bonkers trying to sort it all out, and the nurses and respiratory therapists will snivel about doing all the "useless" stuff. But that doesn't matter because the theory is that if you throw everything at the patient, something is bound to work.

Should I worry if I take too much Ventolin at once?

2012-01-24T17:12:00.001-05:00

Your question: I accidentally mixed two amps of albuterol and one amp of duoneb into my nebulizer. I didnt' realize what I did until I finished the treatment. Should I be worried?

My humble answer: You'll be fine. Albuterol and Duoneb are both safe medicines, even when doubled up like that. If it makes you feel any better, during my hardluck asthma days I went through an entire albuterol inhaler in a day, more than once. When patients are sick we often give back to back to back albuterol or duoneb or both treatments. They are much safer than older bronchodilators, and are very specific to the lungs. They also work great to end stubborn asthma attacks.

However, now that I admitted to all that... I have to say that if you need that much Ventolin your asthma is probably out of control and you should seek medical advice. Surely it's safe to double up on your meds once in a while, or by accident, but if it becomes a regular occurrence there's a greater problem going on.

10 tips to gain control of your asthma

2012-01-23T12:41:00.000-05:00

The following is from healthcentral.com/asthma.

"How to gain good control of your asthma." (Originally published 6/20/11)

So you're tired of your asthma controlling you and now you've decided to gain control of your athma. The question lingering is: How do I gain control of my asthma?

You'll want to do all of the following:

1. Call your doctor. Let him know your concerns.

I'm unable to exercise
I'm unable to even walk across a room
I've been missing too much work
I've been using my rescue inhaler every day
I feel chest tightness every spring

2. Work with your doctor and set goals you want to achieve:

I want to be able to exercise
I want to be able to walk without getting short of breath
I don't want to miss any work days/ school days
I want to cut back on my rescue inhaler usage
I want to make it through a spring without having asthma sypmptoms

3. Your doctor will tweak your medicine regime. What medicine works best for you may be based on trial and error. Usually after 40 days on a new medicine you should notice if it's working.

4. Meet with your doctor again. Until you and your doctor decide your asthma is controlled, you should meet with him at least every six months. He may tweak your medicine regime until control is met.

5. Listen to your doctor: Part of gaining control will be dependent on you trusting and listening to your doctor. He's the expert. If he recommends a new asthma medicine, don't be afraid to try it.

6. Try new medicine: Give new medicines time to work. Don't be afraid to give it some time, even if you have some minor side effects. When I started taking Advair this caused me to tremble. However, after a few weeks my rescue inhaler use greatly diminished, and the trembling subsided.

7. Take all your medicine exactly as prescribed: You will never gain control of your asthma if you're a bad patient. Be a good boy or girl and take your medicine as your doctor orders. It may not be easy at first, but soon you'll reap the rewards as your asthma gets better and better.

8. Take your asthma controller medicine every day, even when you're feeling good: Medicines like Advair, Symbicort, Singulair, Flovent, and Pulmicort take two to three weeks to get into your system, and work to keep your lungs open. If you don't take them every day, your asthma may not get better. If you quit taking them, your asthma may get worse.

9. Learn your asthma triggers and try to avoid them. If dust triggers your asthma, let someone else do the dusty jobs. Dust proof your home. If cigarette smoke triggers your asthma, try to avoid it. If molds trigger your asthma, get rid of standing water, or paint moldy walls.

10. If your asthma gets worse, let your doctor know right away. Even if you think your asthma is getting worse, let your doctor know. He may make a tweak here or a tweak there that may make all the difference.

You and your doctor will become an asthma control team, and working with him you should be able to gain good control of your asthma. It may take some time, yet it can happen.

It's a democracy, so why are they taking away our asthma choices

2012-01-22T17:47:00.000-05:00

Warning!!!! There are people who want to decide for you what is good for you. They will say that you have a choice. Yet what they will not tell you is it will be a choice between fewer options. It will be a sort of control over you, yet you won't even see it, or feel it, or even know it's coming.

These people, many of whom already exist all over the world -- including right here in the good old United States of America -- think most people are not capable of making the right decision for themselves. They believe the American Experiment has failed.

So what is this American Experiment anyway? Well, allow me to define it:

American Experiment: Can man rule himself?

The American Dream: Everyone has a chance to succeed no matter color, creed or station in life. We are all smart enough to make our own decisions. We are all smart enough to weigh the rewards against the risks. We all have an equal opportunity to improve our lot in life.

Then there are two different types of people in this country:

1. Equal justice: These are those who believe in the American Dream, and believe the answer to the American experiment is YES. They believe you are smart enough to rule yourself. That you, asthmatics, are smart enough to make the right choices no matter how tough. You are equally smart. You are intelligent.

2. Social Justice: These are those who believe in the American Dream, yet believe the answer to the American Experiment is NO. They believe you are not smart enough to rule yourself, and therefore not smart enough to make the right choices. Their experts, therefore, must nudge you in the right direction. One of the ways to do this is to limit your choices. You are stupid.

They both call their system of government a democracy (they say this even though we are a republic, not a democracy). The main difference is in equal justice you are allowed to weigh all your asthma medicines and decide what ones work best for you, and in social justice your choices are limited so you don't make the wrong one.

For the first 160 years of this Nation we were a democracy (republic actually) run under equal justice, yet ever since about 1895 there have been people by insidious means who have been working hard to change this. They believe that the Industrial Revolution brought about change in society that would require change in the way society was run.

Today, those who believe in social justice have gained much power not just in America but around the rest of the world. Hitler ruled by the extreme measures of social justice, and so did Stalin and Mussolini. Yet what few people know is that the term was coined right her in America during the term of President Woodrow Wilson.

It has been a slow process. After early failures they decided it was best to take baby steps. They slowly worked to change the minds of Americans and those of the rest of the world. After Wilson, FDR was their next great leader. While Wilson planted the seeds, FDR created the regulations that allowed those seeds to grow into full, flourishing trees.

They are trying to create a healthcare system that limits your choices, yet they will tell you otherwise. They will trick you into believing that you have many choices, yet they know the choices are limited. You will have fewer doctors to choose from, and fewer health insurance companies. And you might even have fewer options of how you die and when you die. Yet you won't know it until it's too late. They'll just kind of slip by unnoticed.

They have already limited our asthma medicinal choices. Remember when I wrote this: Seven Classic Asthma Medicines To Be Discontinued. The medicines you no longer get to choose from are: Tilade, Intal, Alupent, Azmacort, Aerobid, Combivent, and Maxair. You did not decide, they did for you.

These are all your CFC inhalers. CFC destroys the ozone they say. The ozone is more important than human life. You aren't smart enough make and purchase medicines that don't destroy the ozone, so they had to "nudge" you in that direction. The market did not make this choice. You did not make this choice.

I know you didn't because I read your cries that HFA inhalers don't work as well, or that you want to continue taking Intal and Combivent, medicines that have worked so well to control your asthma, or your COPD, or your cystic fibrosis for years. You want control. You want to decide what medicines you take. Or you want your doctor to decide.

Yet in the new America, the new world, the one where social justice supersedes equal justice, and where you are "nudged" to make the "right" decision, you no longer get to decide. It doesn't matter what works best for your disease, because the planet is more important than you.

It doesn't matter whether you agree or disagree with theories that say man is causing global warming and destroying the ozone. I'm in no way saying I don't respect these theories. What I'm saying here is the government shouldn't be deciding what's best for you, YOU should be deciding what's best for you. You are SMART. Yet they think you are not smart enough to make the right decision.

A few years ago they tried to take away Serevent. They even tried to take away -- or thought about it -- Advair and Symbicort. They were scared about these drugs based on the belief that Serevent and Foracort were believed to make asthma worse, or kill asthmatics.

Yet even the FDA says Advair and Symbicort are safe for use, and that the benefits outweigh the risks. Basically what this means is that your risk of dying of an asthma attack are far greater if you do nothing than if you take Advair and Singulair. Yet YOU decide.

While I think Primitine Mist is a bad asthma choice, it has been available over the counter for years. Many ashtmatics live by it. It's their choice. Yet recently the FDA banned all CFC over the counter asthma medicines, and any chance these will ever be available OTC again.

I say they will never be OTC again because Primitine Mist has been on the market so long it was grandfathered in as an OTC medicine. Yet any new HFA Primitine Mist will have to be prescribed, something no doctor will do. Therefore it's not worth the investment to make an HFA Primitine Mist.

The market didn't decide this -- they decided it for us. They had to because they believe we aren't smart enough to make the right decision. They nudged you so now you have to see your doctor to get the best care. You SHOULD in my opinion see your doctor and have a Ventolin in my opinion and the opinion of most asthma experts -- yet in a world of equal justice I wouldn't get to decide what's right for you.

More recently some wanted the FDA to ban Singulair (also check these links). It didn't matter what you thought. They decided if you took it you were at an increased risk of suicide. It didnt' matter there were no scientific studies to show this.

The FDA did an extensive study on the Sinulair suicide risk, and decided there was no evidence. They even reported this: FDA concludes there is no Singulair suicide risk. Yet those who believe in social justice didn't care about the evidence, and there is a big black box warning on Singulair to scare people away from it, and perhaps from getting their asthma under control.

That's what black box warning do, you know, they scare people away from getting their asthma under control.

Another example is more recent. As of March 2, 2011 the FDA is ordering companies to stop making and shipping over 500 allergy and cold medicines. Obviously since these are on the market they were being purchased by people like you, and I never heard one drop of a cry that these medicines were linked to any problems. So why all of a sudden limit our choices? Fishy, hey? At least I think so.

In fact, according to Web MD, Doctor Harold Nelson of National Jewish Health had this to say about this recent effort by the FDA:

"These are well-recognized drugs that have been used for decades and there is no reason to suspect that there is a risk involved. If there were risks such as hypertension or stroke with oral decongestants, it would be more appropriately addressed by eliminating the ingredient from all products whether those that are grandfathered in, available OTC, or FDA-approved. These drugs haven’t cleared certain safety hurdles yet, but that doesn’t mean they are unsafe."

New medicines are studied intensely. The FDA has such a rigorous screening process for approving new medicines that the chance of an unsafe medicine being approved is near zero. I'm not implying mistakes can't be made. That doesn't matter to those who believe in social justice: YOU MUST BE NUDGED.

I'm not implying we shouldn't be careful when taking new medicines -- or old medicines for that matter. Yet what I am implying is we need to make smart decisions, do our own research, and weigh the advantages with the disadvantages on our own, and not be pushed, bullied or forced into making a "choice" that is not truly democratic.

Yet that seems to be the direction we are going in. It's scary to me. I see it. I hope other asthmatics do too, asthmatics with good, strong voices and pens that are willing to stand up and fight.

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How to deal with anger and public lashings

2012-01-21T20:04:00.000-05:00

Anger is something I beleive has no part in any business, with a few exceptions. For the most part, every member of the team, even people who make mistakes (which is all of us if we're human), should be treated with respect at all times.

Personally I've never received a lashing. By no means does that mean I haven't made mistakes, because Lord knows I've made every one in the book at least once. Yet I've been lucky in that way. Yet many times I've seen my coworkers get a public lashing.

In fact, just yeasterday I watched as a doctor lashed at a nurse because the nurse made a decision the doctor disaproved of. The doctor was right in what she was lashing the nurse about, yet the doctor was wrong in the manner to which she dealt with the situation.

Later in the day I pulled said doctor aside. I wanted to do this in private. I said, "Dr. Mashing, I don't mean to be disrespectful, but if you treat all your nurses like that no one's going to want to work here."

"I'm sorry, yet I can't have doctors disrespecting my orders like that," she said. "I need my patients..."

"Look, I think you are in the right there. My point is that by lashing at a nurse like that, humiliating her in front of all her coworkers, is not a good idea. If you have a problem you really should deal with it in a more professional manner. Again, you are right. I agree with you 100 percent, yet getting angry at that nurse the way you did is not productive at all."

I hated doing that, yet I had to. Too many times where I work people are afraid to talk to doctors about innapropriate behavior, and nothing ever gets done. If I could count the times I left this job to the powers that be and nothing was ever done -- no waves made -- I'd be retired and rich by now.

So how about a couple definitions:

1. Anger: Solves no problems. Anger means you are assuming you know what's best and accept no other reasoning.

2. Lashing: Pointing out someones flaws or errors in an angry and inappropriate and nonprofessional fashion; intentional public humiliation

So, how do you deal with an angry person:

Don't let the person crawl under your skin
Stay silent (keep your lips shut)
Walk away
You can say, "And you have a good day too, and walk away."
Keep your head held high and take it like a professional
Say yes sir or yes ma'am (if you're not to ticked to speak)

My favorite is #4 because you're letting the person know he's being unprofessional and it gets you out of the room. I think if someone is humiliating you the best thing to do is walk away. I don't think anyone has to stay in the room and be humiliated like that.

There are exceptions. If the person lashing you is your boss, and you're not sure that person will come to his or her senses, then you will have no choice to stand there with your mouth shut.

After the lashing, make sure you stay away from that person if possible. Do not think you can discuss anything with that person later thinking you can fix things. If you have a discussion with her, do it the next day with cooler heads.

Yet if you don't think you can solve the problem by dealing with that person, go to another person, like that person's boss. Yet more often or not the situation will blow over and you'll never need to mention it except for in a blog post like this.

Bottom line, anger solves nothing. It's an absolute waste of time and results in nothing in people losing respect for the person delivering the lashing. Understand that people make mistakes, and someday you will err too. Hopefully when you do err you won't get a lashing by one of your peers in a public place.

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Farting a crime? Smoking not?

2012-01-21T05:17:00.000-05:00

So I've confessed before on this blog that breaking wind is something fun to do in the hospital (such as in this post). You fart and the nurse thinks the patient pooped. You fart and the patient's family thinks it's the normal smell of a hospital.

We have a little fun like this. It's fun to silently fart in an elevator. Or, better yet, it's fun to fart in a crowded room and see how long it takes for you to be standing all alone. Farting is perhaps the best way to create space for yourself.

Yet in one country farting might become illegal soon -- like this African country. As the article contends: "The government of Malawi plan to punish persistent offenders 'who foul the air' in a bid to 'mould responsible and disciplined citizens.'"

Obviously there's public outcry. How do you prove who did it? Me and all my brothers would be in jail faster than you could... well, fart.

So someone farts in an elevator. How do you prove what person did it? Would it be worth the time, effort and money to find out. NO! Farting is a natural part of life. For some of us it's even fun.

Plus it would be kind of ironic if farting were to be a crime and smoking not, when second hand smoke has been proven to be harmful and second hand farting merely stinks.

Can a respiratory therapist cure all dyspnea

2012-01-20T10:09:00.000-05:00

Today we tackle your humble questions:

Your humble question: Can a respiratory therapist cure all dyspnea?

My humble answer: Contrary to popular wisdom, a respiratory therapist cannot treat all dyspnea. What is dyspnea? It's the feeling of air hunger. It's the feeling you can't catch your breath. If it's not caused by bronchospasm, then the respiratory therapist cannot treat it with his magic potion called Albuterol. If it's CHF dyspnea, or renal failure dyspnea, or metabolic dyspnea or emphysema dyspnea or any dyspnea other than asthma, then a respiratory therapist cannot cure it. In the case of non bronchospasm, the only remedy is either rest or a call to the physician to resolve the underlying condition.

The cure for RT apathy is the ABSOLUTE TRUTH

2012-01-20T06:35:00.000-05:00

One of the things we have gotten away from in this country is telling people about absolute truths because we are afraid of offending people. We've gotten away from this in church, courts, school, politics and, you guessed it, the medical field. The result has lead to many of the problems we face today.

There are two things we are told never to discuss with strangers, and these are religion and politics. The reason is because we don't want to offend them. Yet in church, in court, in school, and in politics we should be exploring the truth and teaching about absolute truths.

Yet out of fear of offending someone, we don't do this anymore. Today we are more interested in keeping the peace than telling the truth. The reason for this is because the truth can hurt. And by golly in today's world of political correctness, we are more interested in keeping the peace than teaching truths.

To make matters worse, since we have quit talking about absolute truths, we have become lazy intellectually. Instead of continuously looking for answers, we settle for what we already know. And I think there are no better examples of this than right here in the medical field.

For years evidence has been coming out -- and reported right here at the RT Cave -- that the hypoxic drive is real but the hypoxic drive theory is not real. Evidence supports the idea of giving patients the oxygen they need, and yet doctors continue to underoxygenate COPD patients out of fear they will cause the patent's carbon dioxide to rise and their drive to breathe to become diminished.

Yet in all my years as an RT, I have only seen this happen once. I've seen CO2 rise slightly, yet that's it. I have only seen a COPD patient have a syncopal episode following oxygen therapy once. And he was put on a ventilator and his breathing supported, and he lived on another two years.

Yet because we RTs are enablers, in that we are more concerned to keep the peace than to risk offending a doctor and stating the truth, this theory continues to be worshiped by many physicians. Because we are afraid to tell the absolute truth, patients are needlessly suffering. Because we are afraid to tell the truth, the science world has become lazy in their research because doctors are not pushing for the absolute truth.

Instead, doctors in this country continue to teach and practice based on theories that are older than dirt. Patients suffer, respiratory therapists and nurses are overworked and burned out (resulting in burnout and apathy), and the entire medical field suffers as a result. And we RTs and RNs know about the problem and solutions, yet we don't tell the truth because we are afraid of offending physicians.

We need to step up and rise above the fear to educate doctors that bronchodilators treat only a select number of disease processes that result in bronchospasm and not the list of nearly 30 disease process that they order them for. I'm sorry if this makes you made, but Ventolin does not benefit all that wheezes and all that causes shortness of breath.

Ventolin does not treat inflammation (pneumonia), it does not get into the alveoli (pneumonia and CHF), it does not reduce fluid in your lungs (CHF), it does not treat processes outside the bronchioles (lung cancer, pleural effusion, pulmonary embolus) and it does not treat processes of the upper airway (croup, dry throat), it is not a cure for aging, and it won't prevent death (death rattle).

Yet speaking these truths may hurt the person you're telling it to. You Will insult their intelligence. You may even risk losing respect, and even your job. You will be called lazy and trying to get out of work. Yet this is what's needed in the medical field.

I don't know if you guys know about this, but when Moses escaped Israel, only 20 percent of the Israelites left with him out of fear of the absolute truths that lay out there. They weren't sure they wanted to make the sacrifice, take the risk of going where no one has gone before. They were afraid to face the absolute truth. So for this reason only 20 percent of Israelites stood by Mt. Sinai when Moses introduced them to the Ten Commandments.

Yet that's all it took was a small 20 percent to stand up and tell the truth. All it takes is for a small group to peaceably assemble and say that the medical field is broke and we need to fix it, that we need to find the absolute truths and teach. We need to put a kingdom of light over the darkness caused by the power of deception.

Related posts:

Patient orientated versus task orientated

2012-01-18T22:28:00.000-05:00

Sometimes we medical caregivers become so involved in the task that we forget the patient is a real person. In a way, it's almost as though we are running an assembly line and each patient is simply a part that needs fixing.

Yet patients are real people. So this means that we have to focus extra hard on getting the task done without compromising the personal experience. We must always put the patient first and the task second.

Allow for a few definitions:

1. Patient orientated: You put the patient first. You consider the religious and emotional needs of the patient prior to performing any task.

2. Task orientated: You put your task first.

We're often asked to do so much that it's easy to become task orientated. This is most common in busy patient areas, like the ER. It's easy to just walk into a room and poke a patient without clearly explaining what you're doing. You're goal here is to get the task done and quickly move on to the next task.

Yet most patients hate this. It makes the RN or RT or doctor appear to lack a personality. You become ruthless, condescending and arrogant. You may not mean to be this way, but you will by default as a task orientated person.

Surely there are times when being task orientated is necessary, such as when the life of the person is at stake and some swift action is necessary. Yet more often than not the task must take a back seat to the patient.

Task orientated people tend to get angry when the patient isn't compliant, or when the patient refuses therapy. I've seen many doctors get mad at such patients.

A good example is the nurse who comes into the room of a 3 YO little girl and says, "Well, I have a shot. Will you help me hold her down so we can give it." Yep. That's not good. That's a task orientated person for you.

A people orientated person has more empathy than that. A good example of a people orientated action was when my reserved 3 YO daughter needed a chest x-ray. Instead of just expecting my daughter to comply and shooting the x-ray, the lady had my daughter sit upright and she said, "Now look into the little tube. You'll see the bubble guppies. All you have to do is hold your breath and..."

Voila. She got my daughter to sit still while she took the x-ray.

RT Rule #57: The best caregivers are people orientated first, task orientated second.

Turn it off at the door

2012-01-17T08:17:00.000-05:00

So it's Monday morning and you woke up on the wrong side of the bed. Or perhaps you're grumpy every Monday morning. Or perhaps you're always grumpy because it's your personality. Or perhaps your grumpy because you're sick and tired of people calling you for stupid reasons.

Well it's not my problem. Don't be grumpy to me because of something that has nothing to do with me. This brings us to RT Cave Rule # 54:

RT Cave Rule #55: If you're grumpy, turn it off at the door of the patient's room.

Everybody has days when they are grumpy. There are days when I'm grumpy. Yet 99.567% of the time I turn it off at the door to the patient's room. It's not the patients fault that I'm having a bad day.

I think in any profession you work with people you're going to get sick and tired of people. I know that in the ER you get so many people who don't need to be there. You get stupid people taking their kids to the ER for a common cold, and then you have people with truly sick kids who don't follow directions and end up with a kid that's even sicker.

So you get people burn out. You get stupid people burn out. Yet it's not my fault. When my wife calls the doctors office on Monday morning, it' s not her fault you let yourself become grumpy. So don't take it out on her. Don't take it out on me. Don't take it out on the patient.

This brings us to RT Cave Rule #56:

RT Cave Rule #56: Smile when you're talking on the phone, it will make it easier to be pleasant.

Dog, cat exposure good for asthmatics?

2012-01-16T12:48:00.000-05:00

The following is from healthcentral.com/asthma.

"Having dog or cat may prevent asthma." (Originally published

Some people think that if you have a family history of cat or dog allergies you should not expose your kids to cats or dogs. The belief is this will prevent cat and dog allergies.

Yet that theory may soon -- if it hasn't been already -- be thown into the large, heaping pile of asthma myths, along with the myth that you grow out of asthma or that asthma is a disease of the mind.

In a recent study researchers followed 565 kids from the ages of birth through age 18, and learned that those kids who were exposed to cats had a 50 percent less chance of developing a cat allergy. Boys exposed to dogs in the first year of life were likewise 50 percent less likely to develop a dog allergy.

Yet exposure to dogs the first year of life by girls caused no significant change in their risk of developing allergies. The reason for this remians a mystery.

According to the Washington Post "Study shows early exposure to cats and dogs does not make children allergy-prone," it's not the dog per se that causes allergies, but the dander, and flakes of skin the animal sheds, that cause the allergy response.

These allergens "get on the skin when the animal licks itself, the substance dries and eventually the skin flakes off. Common symptoms of a pet allergy are sneezing and a runny nose, although some people also have trouble breathing."

Healthcay Reporter Serena Gordon, in "Early Exposure to Pets Won't Up Kids' Allergy Risk: Study," made another important connection, and I have to say I was thinking the same thing when I first read this study

She wrote that this kind of goes along with the hygiene hypothesis which surmises many cases of allergies and asthma are caused because we are overprotective of our kids -- we are too clean. That exposure to germs while the immune system is developing -- in the first year of life -- makes our immune systems stronger.

Thus, a stronger immune system will be less likely to create antibodies to identify and destroy things that are considered normal -- like cat and dog dander.

Surely this is only one study, yet I have seen other studies that came to the same conclusion. This might be proof positive that early exposure to cats and dogs will allow our kids to be among the 70 percent of Americans who own a cat or a dog.

Early exposure may allow our kids the opportunity to enjoy these fun animals later in life without being zo zduffy and mizzable.

God and success

2012-01-15T12:18:00.000-05:00

You can disagree with any opinion, yet you cannot disagree with statistics. And every statistic regarding God and success shows that those who believe in God have more successful lives, and have more overall satisfying lives than those who do not believe.

Yes I believe in God. Yet it is also been my belief that even if I did not believe in God I would still raise my children in the world of God; I'd still go to church and have my kids learn about God and Jesus and Christianity. History shows, as the founding fathers new, that individuals function better when they believe in God.

Sure, if you believe in some other God or maybe even the Peanut Butter Ferry or Judas Priest that's fine too. What's important is that kids believe if they are good they will be rewarded in the end of life, and if they are naughty they will be disciplined at the end of their lives.

Likewise, people who are generally good, who live a frugal life and have their priorities in the right place are happier themselves, and they are seen in a more positive light by other people.

I believe this is why the Soviet Union failed, because they tried to get rid of God and religion and churches. The belief here was that in a socialist society, the state is supposed to be the true religion. To benefit all of society, the people are supposed to worship the state. The state knows what's best. The experts in the state know what's best.

It's also why the French Revolution failed, because the french revolution didn't favor the individual, as God would. God believes all individuals are valuable to a society, including those who disagree with you. That strong opposing opinions are good for a functioning society.

The French Revolution lead to the bloody slaughter of hundreds because they didn't value the individual. Those who didn't believe in the revolutionary cause were killed. It also resulted in the dictator Napoleon. So as you can see, revolutions don't always result freedom.

The American Revolution lead to freedom because the founding fathers believed in God, and they believed that the rights of men come from God, and can only be taken away by a government.

Yet if there's religion, then people will worship the religion. Christianity especially preaches personal freedom, or individual freedom, or individual rights. The Bible preaches that to get to Heaven we must be good on this earth.

People who believe in God live happier lives. And patients that believe in God are happier patients. It is my observation that if you have a patient with a life threatening illness, and he or she is in good spirits, chances are that patient is a believer.

I'm sure that's not always the case, yet as a rule of thumb the most pleasant patients are the ones who believe in God, because just knowing your life will not end when your body expires is somewhat soothing to the mind.

B2 Buterol

2012-01-14T10:35:00.000-05:00

Symptom: Rapid onset dyspnea

Diagnosis: Emphysema, pneumothorax

Frequency: Continuous for one hour

Effect: If you give the treatment long enough you'll assure there are at least two beta adrenergics sitting on each beta adrenergic receptor. The goal is that once the chest tube is inserted the air will come out twice as fast (b2 = beta *2 or twice the effect)

History of the fifth vital sign

2012-01-13T13:18:00.000-05:00

Back in 1991 I visited the emergency room because my asthma was acting up. It was my first visit to the ER since I was discharged from my six months stay at the asthma hospital (NJH/NAC) in 1985. An RT came into my room to give me a breathing treatment and he slipped this thing over my finger. That was my first exposure to pulse oximetry -- the fifth vital sign.

I had been to emergency rooms many, many times for asthma in my life, and never had I seen such an object. A temperature, blood pressure, and heart rate check were common, but to slip something that glows red, and causes a red number to appear on this little box the RT held, was something new.

"What is that?" I asked back then.

The RT attempted an explanation that zoomed over my head. "It's called a pulse oximeter. It tells me how well you're oxygenating and gives me your heart rate."

I wasn't satisfied with that answer. I wanted to know more. What was it? How did it work? What significance was it? What did the number 98 mean anyway? I asked these questions and, once again, the answer wafted over me like a cool breeze.

In the summer of 1993 I was a journalist for a small weekly newspaper. The local fire department received funding to get a new piece of equipment that was supposed to help them help sick people. The objects were quite bulky, pretty heavy, and covered by a large, black case.

A cord loomed from both, and the EMT I was interviewing slipped the probe over my finger. "This is what we call a pulse oximeter," he said. He attempted an explanation, yet again the answer flew over my head. I ended up taking a picture of the EMT holding the new pulse oximeters. On the caption under I wrote: "EMT Josh Paramedic is holding two new pulse oximeters purchased with money from a Grant by..."

My next exposure to the 5th vital sign came as an RT student.

What is pulse oximetry?

Simply put, pulse oximetry is basically sends two lights through your finger (or ear lobe or toe), through your artery, and then the light is collected by a sensor on the other side of your finger. The red light you can see, and the infared light you cannot see.

By calculating the amount of infrared light returning to the sensor, the pulse oximeter will tell you what percentage of hemoglobin is carrying oxygen. Since it's measurement is made by the pulse of arterial blood, it can also give you a heart rate.

A normal pulse oximeter reading is 98%, however, anything greater than 90% is deemed acceptable. In this way, supplemental oxygen can be administered and adjusted accordingly to maintain an adequate hemoglobin saturation. The reading is measured as SpO2 (S = saturation, p = pulse oximetry, O2 = oxygen).

How did the pulse oximeter come to be?

When I was a kid and was having an asthma attack, the respiratory therapist would place a nasal cannula over my face, and I'd promptly proceed to peel it off. He'd get mad at me saying, "You really need to keep this on. We need you to get oxygen."

Yet was my oxygen level really low? The only way to tell would be to either do an invasive arterial blood gas, something that was rarely done on a kid. I don't recall an ABG being drawn on me until I was at least in my upper teens.

Other than an ABG, the only way to know if a patient was oxygenating well was to use objective measurements such as skin color. Usually if a person isn't oxygenating well blood will be shunted from fingertips and lips, and these areas will appear grayish or blue. This is referred to as acrocyanosis, and is not life threatening. Usually a low dose of oxygen -- say 2lpm -- will be all that's needed to resolve the problem.

If the core of the the body is blue or gray in color, this is referred to as central cyanosis. Central cyanosis is critical, meaning oxygen isn't getting into that person's body at all, and oxygenated blood -- what little there is -- is shunted directly to vital organs such as the heart, kidneys and lungs. In these situations, usually large amounts of oxygen are needed to remedy the problem, and perhaps even some form of positive pressure breathing such as from an Ambu-Bag, BiPAP or ventilator.

Obviously if you see cyanosis you know oxygen is needed. Still, how much oxygen do you give? When do you taper it off? And what if the patient isn't oxygenating well yet doesn't show any cyanosis? What do you do then? Chances are, in the days prior to pulse oximetry, you winged it. Some patients got too much oxygen, and some didn't get enough. Outside of doing an invasive ABG, you really didn't have any means of monitoring and adjusting oxygen.

This was pretty much how it was even up to the early 2000s at some institutions. Yet then came along the 5th vital sign. This vital sign -- pulse oximetry -- made the job of respiratory therapists "much easier," notes Gennie Ridlen in her rtmagazine.com article Pulse Oximetry: A Historical Perspective.

She notes the history of the pulse oximetry can be traced back to 1862:

In 1862 Hoppe-Seyler disovered that oxygen was transported by hemoglobin, and he and he referred to the oxygen-hemoglobin compound as oxyhemoglobin
In 1864 Stokes proved that oxygen was transported in the blood by hemoglobin
In 1862 von Vierodt invented the first pulse oximeter. He measured oxygen consumption using transmitted light by wrapping a rubber band around his wrist to cut off circulation and shining a light on his hand, he saw the two bands of oxyhemoglobin disappeared and a band of deoxyhemoglobin appeared. Using reflected light from a spectrometer, he measured the oxygen consumption of the living tissues by noting the time that elapsed as oxyhemoblogin changed into deoxyhemoglobin."

Between 1862 and 1977 the pulse oximeter was improved upon to the point that the first pulse oximeter was marketed in the U.S. in 1977. The oximeter used a finger probe with fibre optic cables that were very sensitive to motion.

By the late 1970s new probes were invented to solve the problem with motion, and a heart rate tracker was added and the device was precalibrated to make it more accurate.

As with any new discovery in medicine, it took another 10 years for the pulse oximeter to make any real impact in the medical industry. Interest finally started growing in the early 1980s as the device was determined useful when a patient was sedated to monitor oxygen saturation, and by 1987 it became standard practice on sedated patient, operating rooms, critical care units and emergency rooms.

The devices continued to improve, and by 1995 you had a choice between bulky bedside monitors and finger probes that could fit into your pocket.

Opiates good therapy for air hunger

2012-01-12T22:45:00.000-05:00

There's nothing worse than the feeling you can't catch your breath, or dyspnea, or air hunger. I can attest that the worst pain you acn endure is worse than not being able to breathe. And when dyspnea becomes severe and chronic, one of the best remedies available are opiates (a.k.a. narcotics).

This was a remedy that was first applied to asthmatics back in the 19th century. It relieved the anxiety and the feeling of air hunger. Asthma was beleived to be a nervous disorder back then, so many experts believed opiates worked by easing the mind and, thus, easing the breathing.

However, morphine was also known to slow down the respiratory rate. Giving too much of the substance would run the risk of knocking out one's respiratory drive and, perhaps, even cause death.

These doctors were correct that morphine worked for asthma and dyspnea, yet wrong in their explanation.  According to medscapes.com "(opiates) decrease brainstem responsiveness to carbon dioxide (the primary mechanism of opioid induced respiratory depression) and lessen the reflex vasoconstriction caused by increased blood PCO2 levels so that the perception of dyspnea is reduced."

Opiates, thus, reduce dyspnea by vasodilation and decreased peripheral vascular resistance (blood pressure). This may cause hypotension and increased hystamine release. It also may decrease gastrointestinal motility (another thing to watch out for).

Opiates are also good mild bronchodilators, so they are another option when everything else is failing. Mainly, opiates are an option for your end stage lung disease patients who are chronically and severely dyspneic. The medicine can be given systemically, yet another option is to nebulizer the medicine to get an immediate response in the lungs with minimal systemic effect.

When nebulized -- yes opiates can be nebulized -- medical professionals must wear appropriate masks to prevent inhalation of opoids. They can be given as needed or continuous infusion. As needed is probably better because it allows you to prevent over sedation.

The following are your opoid options:

1. Morphine: The therapeutic dose of nebulized morphine is 5 mg of the 0.1% solution every 4 hours as needed. Studies have shown (click here) that opiates (nebulized or other) decrease shortness of breath, allow for a greater feeling of relaxation, and increase exercise tolerance. No significant difference was reported with doses higher than 5 mg. However, since morphine can cause bronchoconstriction, promote histamine release, and depress respirations, it should be used with caution. It also can cause hypotension, so it's ideal for anxious patients in respiratory disterss with high blood pressure.

It can also be provided orally, under the tongue (sublingually), injection into an IV, or even given by continuous infusion (although this option is generally reserved for post operative pain).   Here's a scientific article about Morphine for dyspnea, and here's a post from asthmatic Breathin Stephen who uses Morphine for his dyspnea.

2. Hydromophone (Dilaudid):  A dose of 4mg every four hours may be mixed with normal saline and given via nebulizer in patients who are allergic or intollerent to Morphine sulfate to treat dyspnea. Some patients have benefited from 1 mg nebulized dilaudid every four hours, and some required as much as 20mg to receive benefits. Symptom relief was generally felt within 15 minutes and most patients suffered no adverse effects.
Nebulized dilaudid sometimes works better for those suffering from dyspnea due to fewer side effects than the pill form of opiates. One common side effect is headaches.

3. Fenatanyl (Dublimaze):  Can also be nebulized and given for dyspnea relief. A dose of 25 micrograms in 2cc normal saline is the usual dose. Eighty one percent of patients in one study noted relief within 5 minutes, and relief lasted up to an hour. Oxygen saturations and respiratory rate also improved. So it can be used as an alternate for those patients allergic to or intollerent to morphine sulfate. Optimum dose and duration of benefits are unknown at this time. Unlike Morphine, it does not have the side effect of histamine release. It is expensive however.

4. Codeine:  A dose of 15 mg nebulized codeine can be given to patients for dyspnea relief is they have an allergy or intollerence to morphine sulphate (source medscapes.com).

5. Meperedine (Demerol): Not a very good analgesic. It's highly addictive, may cause hallucinations, and buildup can lead to ceizures.

6. Hydrocodone: No information available for treating dyspnea.

7. Oxycodone (Oxycontin): No information available for treating dyspnea.

8. Anileridine (Leritine): New analgesic no longer available in the United States. Is available in Europe. Similar to Demerol but chemicals are altered slightly to give it a stronger analgesic effect. It's available as a tablet or injection, yet 25mg can be aerosolized in a nebulizer for treating dyspnea.
For more information about respiratory medicine check out my medicine lexicon.

Is asthma contagious?

2012-01-10T12:59:00.000-05:00

The following is from healthcentral.com/asthma.

Your question: Is asthma contagious?

My humble answer: Asthma is not contagious. However, a virus (or the common cold) is the most common asthma triggers, and colds are contagious. You cannot catch asthma, but you can catch a cold.

2012-01-10T12:53:00.000-05:00

The following is from healthcentral.com/asthma.

Your humble question: Can asthma lead to COPD/ cancer?

My humble answer: Good question. I have no knowledge of asthma leading to cancer. However, in some instances asthma can lead to COPD. Usually severe, persistent asthma is considered COPD. This happens when asthma gets so bad that it causes airway changes, such as airway scarring. This will result in chronic airway obstruction that would be considered a COPD condition.

How can this happen? One way it can happen is poorly controlled asthma. This can result in airway changes. Yet another way is if you smoke. I'm not sure what the statistics are, yet I believe asthmatics who smoke are at an increased risk for developing chronic airway changes.

To prevent this, you will want to make sure asthma is diagnosed promptly and treated aggressively. You must be a gallant asthmatic, see your doctor regularly and take all your medicine as prescribed.

Can pulmicort be mixed with albuterol?

2012-01-10T02:04:00.000-05:00

Your humble question: Is a prescription for a nebulizer needed?

My humble answer: Yes. You will have to discuss with your doctor whether you need one or not, and he'll have to write a prescription.

Your humble answer: Can pulmicort be mixed with albuterol?

My humble answer:

It can be given with Albuterol. Where I work we mix it with Albuterol most of the time. However, some hospital policies recommend the medicines not be mixed for whatever reason. I do know that if you mix it with Atrovent (or Duoneb) the medicine suds up, however it still works. If during the course of your research you learn anything new let us know. Thanks.

Relaxation exercises may benefit asthmatics

2012-01-09T14:55:00.000-05:00

I can personally attest that knowing how to relax is very beneficial to asthmatics. The following is a post I wrote on this topic for Healthcentral.com.

"Relaxation exercises for asthmatics may benefit you," originally published April 14, 2011

I mentioned in my post about breathing exercises that I should write a post about my experience with asthma, anxiety, and relaxation exercises. That time has arrived.

Studies have linked asthma with anxiety disorders, and as a lifelong asthmatic I can tell you I've had my share of anxiety. This was especially true when I was a kid. Something what really helped me to control my anxiety was a method called Progressive Muscle Relaxation.

The stress of an asthma attack in itself can cause anxiety. Yet new wisdom confirms that anxiety may exists even while asthma is controlled, or even if asthma goes into hibernation. In fact, anxiety is up to six times more likely in asthmatics than non-asthmatics.

The reason the link remains a mystery. Likewise, it's not known if asthma came first or if the anxiety came first.

Regardless, I remember my first bout with anxiety/ depression. It came in November of 1976. I was a six year old kid and my great grandpa passed away. I remember pacing the living room for hours mulling this over in my head while the rest of my siblings went about their normal playful routine.

I also remember this effecting me in school. I remember in music class while the other kids were singing I couldn't get death out of my head. This was a recurring theme that repeated itself at least once a year. It wasn't always death that triggered an episode.

My mom even reminded me recently about how I'd worry "so much as a kid." She said she'd worry about me because I'd worry so much. Once my mom even grounded me from watching the news because I'd worry about the bad news. I'd be afraid that killer would find his way to our house, or sneak in my bedroom window.

I also remember being nervous and anxious especially around other people. Unfortunately, I was never diagnosed with anxiety until I was admitted to National Jewish Hospital in 1985 for my asthma. It was there that doctors were aware of the asthma-anxiety link.

While helping me get my asthma under control, they also helped me with my anxiety. This was key because not only is anxiety an asthma trigger, anxiety can also effect the way you take care of youself. If you're anxious, you may not be taking your medicines properly; you may not be compliant; you may not be a gallant asthmatic.

In retrospect, I know this is true. However, I was in a major state of denial back then. Tell a 15-year-old who knows everything he has an anxiety disorder and it's only natural he will deny it. Yet most of us wise up eventually.

To help me with my anxiety my doctors back then put me on an anti-anxiety medicine called Xanax, had me work with a counselor, see a psychologist, and encouraged me to participate in a relaxation classes held by one of the nurses once a week.

She took us young asthmatics to a calm, quiet location. In the spring of '85 she took us outside to a cool, shady area. She'd have us lie in the grass and close our eyes and concentrate on our breathing. She had us breathe slowly through our noses while doing diaphragmatic breathing.

She'd say something like, "Imagine an object, a tiny sun perhaps, in the air above you. Now picture this sun moving to your right foot. Curl your toes until you feel tension in your ankles, and hold it there. Hold it! Hold it! Concentrate on your breathing. Your stomach goes out when you inhale... and in when you exhale.... Now relax your foot.

"Now the sun moves over to your left foot..." She continued this process through the rest of the body all the way to the head. By the time she was finished I'd feel the weight of my body, completely relaxed.

Then she would continue talking, her voice alone soothing, "Now picture yourself at some happy place. Perhaps you're walking along a beach. Now you can hear the waves." Here she might turn on a tape so we could hear the waves. "You can feel your body melting away, blending to the soft sand behind your back."

Eventually she would stop talking, and almost always I hoped she would continue. I never once fell asleep during these classes, yet many times I could hear snoring or heavy breathing by the other kids.

I wanted the relaxation to last a long time, and I wanted to appreciate every moment, so I didn't let myself fall asleep like some of the kids did.

Sometimes we'd lie there like that, all relaxed, all concentrating on our breathing (or sleeping), for up to a half hour. And when she finally said the class was over, we'd all pick ourselves awkwardly off the ground feeling like wet noodles.

To this day I still use this method, sometimes several times during the day. Sure I still have anxiety, yet I control it instead of the other way around. I haven't used anxiety medicine since 1985, and if you met me today you'd never guess I had this history (at least I'd hope not).

Being a well-educated adult helps a great deal, and admitting I have this anxiety helps too. Yet when needed, the methods I learned from the good people at National Jewish have come in use many times.

It's helped me many times to get a grip on those tense, stressful moments. It also helps when my asthma is acting up. Relaxation exercises, along with breathing exercises, are proven to help control asthma, reduce symptoms, and help you with your overall wellbeing.

National Jewish Health provides a good picture of what Progressive Muscle Relaxation is all about. To learn more click here.

What is the microflora hypothesis of asthma?

2012-01-09T12:50:00.000-05:00

The following post is from healthcentral/asthma.

"The microflora hypothesis of asthma and allergies." (Originally published

It's a proven fact asthma rates are on the rise in Western nations like the U.S. and U.K. In the past pollution was blamed. Yet with pollution on the decline and asthma rates still rising, many experts are looking at other theories.

Two theories gaining acceptance are the hygiene hypothesis and the microflora hypothesis.

The hygiene hypothesis pretty much proposes allergies and allergic are caused because we're too clean.  In the absence of bacteria our immune system gets bored and attacks things we consider normal -- like allergens.

I simplified the hygiene hypothesis in a previous post. If you're not familiar with it I recommend you click here. In this post I'd like to introduce you to the microflora hypothesis.

First a few definitions:

Normal Flora:  According to the Online Textbook of Bacteriology these are tiny little microbes that cover the surface areas of your body, including your skin and mucus membranes. This consists of some fungi, but mostly bacteria. Their main job is to prevent the growth of bad bacteria.

Microflora: According to thefreedictionary.com these are normal flora of a specific location, such as the intestines.

Probiotics: This is simply a synonym for normal flora.

So what is the microflora hypothesis?

It's actually similar to the hygiene hypothesis only it goes a step further. It states microbes in your intestinal tract (microflora) work together with your immune system to keep your immune system working right.

An imbalance of these microbes any time in your life can cause your immune system to develop an inappropriate response.  This may best explain why asthma can be developed at any time in your life.

So what causes microflora to become imbalanced?

Two things in our modern, industrialized way of life are suspected to cause such an imbalance:

1. Antibiotics
2. Dietary changes

So, how might antibiotics cause an imbalance of microflora?

Antibiotics: These were considered to be a godsend to the medical field when they hit the market in 1944, as they allowed doctors to treat and prevent infection. While these are good, there are consequences to antibiotic abuse:

Some bacteria are smart: They catch on and develop resistance to antibiotics and this forces us to invent more powerful antibiotics.
Some antibiotics kill too much: Instead of killing just the infecting bacteria we were also killing the good bacteria we need to maintain balance
Antibiotics only kill bacteria: Actually we knew this all along, but I just thought I'd add it here to make a point.

While antibiotics are only able to treat bacterial infections, they were -- and often still are -- prescribed to treat any infection, even viral. Often they are ordered just so you think the doctor is doing something. You have asthma symptoms; you have a cold, so you expect antibiotics.

In fact, this study shows that way too many asthmatic kids are being prescribed antibiotics to treat asthma even though doctors know they aren't recommended in the treatment of asthma. It's expected many doctors order them just to "cover their bases."

Yet it's a common fact the most common asthma triggers are viral infections. So treating your sickness with an antibiotic is useless unless you really have a bacterial infection.

The most common antibiotic prescribed would be broad spectrum antibiotics. These kill more than one type of bacteria, yet the hope is they'd kill the culprit. The problem with these is they kill the good along with the bad.

Narrow spectrum antibiotics can also be prescribed. These are antibiotics that only kill the desired bacteria. Yet to prescribe them in the office without further testing would be a crap shoot. To pick the right one you're sputum must be tested to identify the bacteria. If no bacteria are identified, antibiotics will be useless.

If bacteria are identified further testing can be done to see what antibiotic kills it. In this case, a broad spectrum antibiotic can be selected. The problem with all this is it takes time and money.

So most often your doctor will skip all this testing and just give you the antibiotics you want. You're happy, he's covered all his bases, and you eventually get better.

The solution to this problem might be simple:

Avoid antibiotics use.
If antibiotics are needed,narrow spectrum antibiotics should be used.

Modern diet: According to The Probiotic Revolution, "people in industrialized countries eat significantly more fast food and refined foods, and much less fiber. They're also less likely than people in the developing world to rely on fermentation to preserve goods -- thus depriving themselves of a ready source of probiotics."

The solution to this problem might also be simple. Eat more of the following:

Whole grains
Nuts
Fruits
Vegetables
Probiotic supplementation

Probiotic supplementation: As far as a cure for asthma and allergies, some studies have been ongoing to determine certain therapies can be done to restore the imbalance of probiotics in the gut. Studies are ongoing to see if this prevents or treats allergies.

Since 75 percent of asthmatics also have allergies, the hope is probiotic supplementation will also prevent and treat asthma as well. Studies are ongoing, and we'll have to wait and see how they turn out.

So there you have it: the microflora hypothesis. It's one of several theories of what might cause one to develop asthma. What do you think?

Click here for a more in depth discussion of this hypothesis.

If you're a fool with your money, don't come crying to me when it runs out

2012-01-08T10:54:00.000-05:00

Fools get caught in the money trap!

Last summer it was slow at the RT Cave. In fact, it was so slow we were losing about half our hours each week. It didn't bother me so much because my wife and I were prepared for such a lull. I was actually enjoying the extra time off. Yet my coworker Paul wasn't prepared.

When he approached me I could tell right away he was distraught. He said, "You know, Rick, it's unfair that we have to have so many days off lately. If they complain about me getting a second job I'm going to blow up."

"I don't mean to sound rude," I said, "but you're barking up the wrong tree."

"What? Why do you say that? I only worked 24 hours last week. I could work another job and make up for the lack of hours."

"Well, if you didn't spend all your money on everything you wanted when the going is good and the money is flowing in, you wouldn't have to worry about losing hours, and you would need a third job."

His eyebrows seemed to cross and his lips curled, yet he didn't say anything.

"Look, I said, you wanted to hunt, and you spent a thousand dollars on all that hunting gear that sits in your garage. You took up fishing and now you have a boat and fishing gear sitting in that storage facility you pay a hundred bucks a month to rent. If I remember right, that's also where you story your $250 a month camper you bought on a lease. You have two leased cars in your garage, and you also have two jet skiis, two snowmobiles, two motorcycles and then there's that brand new car you bought for your daughter. Add that stuff up and add them to all the other toys you have in your brand new home and it's easy to see why you have to work three jobs."

Of course this discussion didn't really happen, yet if I were completely honest with some of my coworkers, friends and family members I'd be having this discussion with many of them. They complain about not being able to pay their bills, and yet they spend money like it were never going to stop coming in. They never prepare for the inevitable recession or slow time. And in the hospital, business has its normal cycles of up and down, just like the economy.

Our politicians want you to spend your money unwisely, and that is why -- I think -- it isn't taught in school how to wisely spend your money. This is also the reason for bubbles when the economy is good (Internet Bubble, Housing Bubble, etc.) and it's also the reason people panic when the bubbles inevitably burst.

The same can be said of governments. If those in Washington were as wise with their money as the frugal citizen, America would not be billions of dollars in debt. If state governments wouldn't have been unwise with our money in the 1990s, they wouldn't be fearing bankruptcy. Industries who plan and prepare and spend frugally wouldn't need bailouts.

If your work hard and spend your money wisely and go into hard times, then I'll feel sorry for you and maybe even help you out. Yet if you are a fool with your money, don't come crawling to me with your sob stories.

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I like physician's assistants (PAs)

2012-01-07T02:26:00.000-05:00

I love physician's assistants (PA). They practice medicine under a licenced physician, yet often times they seem to be wiser than doctors. Not always is this true, but quite often. I think the reason is because they worked as nurses and RTs.

PAs don't seem to order useless breathing treatments because they've worked at the bedside long enough, and with RTs, to know they don't do anything for all that wheezes and all dyspnea.

Many doctors are completely oblivious to what really works for patients, at least when it comes to respiratory stuff, and so they tend to order whatever they were taught to order. Sometimes they even order out of habit.

PAs tend to assess and order therapies based on that assessment, and doctors tend to go down the list of procedures in their head and treat all patients with a given disease the same, kind of like an order set.

Doctors tend to be more autocratic, and don't like to give autonomy to RTs. PAs love to ask RTs what they think, and tend to be more a part of the team.

What I write here is not always the case, yet it tend to be often enough. PAs tend to be happier and nicer on the phone and in person. They tend to be more open minded and friendlier in general. Again, not always, yet quite often.

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Wishes and prayers

2012-01-06T19:05:00.000-05:00

Kings 3: 5-12
Romans 8: 28-30
Matthew 3: 44-52

The three brothers were excited to throw their pennies into the wishing well. The eldest wished for a new bike. The middle brother wished for a new shotgun. The youngest -- the one who was in Kindergarten, wished to be allowed to go to church each Sunday and for his family to be kept together.

The eldest brother said, "Oh come on! Why would you waste your wish on something so stupid. You're supposed to ask for something useful."

Ironically, the only wish that was granted was the wish of the youngest brother. The point of this tale is that we often wish for things that we really don't need, and those wishes aren't granted.

If you had one wish what would you wish for. What do you pray for?

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Ativan Nebs: A treatment whose time has come

2012-01-05T05:17:00.000-05:00

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Ativan NebulizersA treatment whose time has come

Yes it's true! The time has finally arrived for respiratory therapists to dole out Ativan nebs instead of Albuterol. The evidence for this change is abundant, as you probably already know.

Albuterol is often ordered to treat all annoying lung sounds, dyspnea, and lung diseases. Yet studies show only 10 percent of these aerosols benefit the patient.

The result here -- as you well know -- is exuberant waste that results in RTs being lowered to the level of neb jockeys. The end result is respiratory therapy apathy syndrome, or RATS.

We here at RATS Pharmaceuticals recommend you skip the Albuterol -- unless true bronchospasm is present -- and give Ativan nebs instead. Not only does Ativan have a greater benefit to the patient, it improves morale of patient caregivers

Ativan* (scientifically referred to as lorazepam) is an anxiolitic good for relaxing any dyspneic patient, allowing them to get a good nights sleep. The forced audible expiratory wheezes caused by over hydration, dehydration and exaggeration will all be gone.

Your confused and demanding patient will now sit in a recliner with a smile firmly implanted on his face instead of persistently pressing on his call button. Patient anxiety, nervous tension, depression, and restlessness will all be gone.

Sundowners often take night shifters away from their fun and games, yet not anymore that Ativan is in the air. Now patients are calm and tranquil and all snug under blankets. Your patients and their nurses will delve into la-la land instead of calling for a therapist.

Irritable family members smile and drool instead of taking up your time. Doctors benefit too as Ativan aerosols waft in the air for up to six hours following a thorough 10 minute treatment of 1-2 mg of Ativan solution.

Aerosolizing Ativan will create a peaceful and tranquil milieu throughout the entire hospital. Respiratory Therapists will find joy in doling out nebulziers, and Respiratory Therapy Apathy Syndrome, burnout, and Monday Morning Blues will be disorders long forgotten.

Ativan is one member of a group of benzodiazepines that work by enhancing the effect of gamma-aminobutyric acid (GABA), a brain chemical that is naturally calming. GABA can slow down or stop certain nerve signals in the brain. As a result, Ativan has several effects on the body, including:

Reducing anxiety (treats your restless patient)
Causing sleepiness (takes care of sundowners)
Relaxing muscles (for that calming effect)
Stopping seizures (to quelch those fits of anger)
Impairing short-term memory loss (so the annoying ones don't remember your name)

Ativan Nebs: A treatment whose time has come. To start an Ativan Neb program at your hospital, please call your local RATS representative.

*Side effects to Ativan are generally mild and rare. Ativan can cause confusion and delirium, especially in the elderly. High doses, especially for patients with lung diseases, may cause a patient to forget to breath, resulting in respiratory failure and death. Ativan is not a remedy for any disease condition, including bronchospasm, and -- like Albuterol -- it only treats symptoms. It may induce dizziness and unsteadiness, so it's greatly recommended workers inhaling it avoid staircases, cooking, or excessive thought. Any persons exposed to Ativan aerosols should avoid driving motorized vehicles for up to 24 hours and should arrange for rides. For future reference, please note again that Ativan Nebs do not cause bronchodilation. May also cause urge to want to nap at work, and this urge should not be resisted. May also cause hair loss, fun and orgasms.

RATS NEST formed

2012-01-04T19:54:00.034-05:00

We're infested with rats. I'm not talking about those little, nasty critters, but Respiratory Therapy Apathy Syndrome (RATS). It's a disorder recently diagnosed by the newly formed Respiratory Therapy Apathy Syndrome Nebulizer Society (RATS NEST).

RATS NEST was formed by Mike Olin, a recently retired respiratory therapist out of Los Angeles California. Olin informed the RT Cave that "I started feeling awkward, apathetic and passive in a way, toward my profession. I loved my job, yet something was amiss."

Yet, he continued, "After a long discussion with my psychologist, I realized I wasn't burned out, and I wasn't depressed, what I had was RATS. I was beyond burnout. I had grown so tired of running around the hospital doing senseless procedures that even when I was doing something I loved about the job I was apathetic and passive."

He explained that before he retired he hired a research company with his own money to interview over 10,000 respiratory therapists around the world, and he learned that 80 percent of respiratory therapists with greater than 10 years experience had described RATS symptoms, such as sudden outbursts of anger, sore feet, grumbling loss of interest in working

A few days after he retired he formed the RATS NEST, a society of respiratory therapists infested with RATS. The goal of the society is to "provide a place where respiratory therapists with like concerns can share their experiences and concerns and come up with a plan to improving RATS."

The main technique is to form committees, write articles, and hold seminars to help RTs cope with RATS and create techniques for improving conditions for RTs in hospitals, such as techniques and strategies to convince doctors and RT bosses and other RTs for the need for RT driven protocols.

Olin said that so far he's the only member of the society to not remain anonymous and that's because he's retired and doesn't have to fear losing his job. He said the main problem with RATS is "even infamous respiratory magazines like the RT Times refuse to acknowledge the existence of RATS. We're on our own here. We tend to lack the respect of other groups because most of our members choose to remain anonymous for fear of losing their jobs."

He says one of the next goals of the society is to create a blog and an online community for RTS infested with RATS and other RTS who love being an RT and want to create a better environment for RTS, improve patient care, reduce hospital costs and improve the inexplicable condition called RATS.

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The key to a healthy lifestyle

2012-01-03T17:43:00.000-05:00

When doling out food, it is my belief that you should not go by the serving size that's on the package of the product. This serving size was made up by the manufacturer to make their product look good.

I'm not sure what all the rules are, but if you have less than half a gram of fat in a serving, then you can call your product fat free. Thus, if half a cup of corn flakes has 0.499 grams of fat in it, then corn flakes is considered fat free.

Well, corn flakes doesn't have 0.499 grams of fat in a serving, I was just using that as an example. A better example is butter spray. You know butter is bad for you. If you smear a tablespoon of butter on a piece of toast you're getting 5 grams of fat.

Yet if you take the spray version of that butter, one squirt is considered a serving. If you're normal like me, one squirt is never enough. Because the product says fat free, you think you're not putting fat on your bread. Yet you are, because that 0.499 times however many squirts you are using adds up.

Now I don't think one gram of fat is going to hurt anyone, but if you put 10 squirts of butter on your toast thinking there is no fat in it, that comes to 5 grams of fat. Now make that 20 squirts, and you're really delving into the fat with 10 grams.

If you're on a diet thinking you're eating a fat free product, you could be in a world of hurt come Saturday weight in time. You might have been good all week, and you barely lost a pound.

So serving sizes on products are meant to make the company look good. Let's go back to our bowl of cereal example. One serving is half a cup. If you're a little grandma perhaps half a cup of cereal fills you up. Yet if you're a grown man like me, half a cup of cereal is like eating a cracker.

Therefore, a serving size should be based on something other than what's on the side of the box.

That said, what is the best way to determine serving size? First, you have to do your homework. You have to decide what is healthy for you, and what you can eat on whatever diet you're on. Then you have to do a Google search to find out how much fat is in that product.

Or, if you're like me, I simply eat the foods in the Body For Life diet. Yet sometimes there's food not mentioned on this diet, and then I have to use another method of determining if it's a product I can eat.

So that brings us to the: how-to-determine-the-best-serving-size-for-you method. First, you Google your product to learn how much fat is in it. Don't go by serving size, I'm talking: is there fat in it? Or whatever content you're looking for: calories, carbohydrates, etc.

If it's cereal, for example, you pour a bowl so you have enough cereal to cover your fist. And if it's a steak, a portion size (one serving size) would be whatever fills covers your flat palm. If you have a large hand, then you're aloud to eat a little more. If you have a small palm, then you will be eating a little less.

Ideally, if you're eating the appropriate foods, a serving of two or more products should fill you up just nice. The BFL diet allows me to eat a protein and a carb with each meal, plus as many vegetables as I want. You can adjust the diet in other ways depending on how serious you are, yet I usually take the easiest route because I only have one goal: lose weight and/or don't gain.

You can adjust the diet however you want. I mean, if you're really serious, you can only purchase lean meats. You can only eat low glycogen carbs, which would be those that are basically not white, such as no white bread and no baked potato. I believe most fruits are low glycogen, yet you still have to do your homework.

Me, however, I take the easy route. I eat pretty much whatever I want, I simply make sure I get the correct serving size, not the one doled out in a restaurant, and not the miniscule amount noted on the package. As a rule, if I eat a sandwich at a restaurant, I usually cut it in half. Steaks are cut in half too. Burgers, well, it depends on how big it is.

So pretty much on my diet I am allowed to eat steak and hambergers every two hours throughout the day if I want. Of course you have to use common sense here too. How serious are you? Plus, is the meat you're eating lean or not? Usually, I limit myself to one such luxury per day. But you can do what you want.

Farmers back in time would eat when they had the chance. That's where we get our standard three meals a day: breakfast, lunch and dinner. If you really want to be a serioius dieter, you will want to forget about the three meal plan. You should start your own.

The problem with the three meal plan, to make it simple, is by the time it's meal time, you are starving. And what happens when you're starving? You pig out. You eat too much. Plus, by the time you're body is saying it's hungry, it's going into emergency mode and slowing it's metabolism and storing fat -- the exact opposite you want.

You want your body metabolizm to be continuously going. You want your body burning fat all day. You want your body to be a lean mean fat burning machine. To do that you will want to eat a small meal (for example, one protein and one carb with a veggie and glass of water) every 2-3 hours. This will keep your metabolism going.

Usually what I do is I plan on eating two really nice sized meals a day, and I consider these lunch and dinner. Here I will have my steak, potato, hamberger, pork, and vegetable with a bun, bread, or whatever. I want to really be full when I'm done.

Then two hours later I'll have what I call a snack. Stuff I consider snack food is: cereal, cottage cheese, oat meal, yogurt, small sandwich, etc. You might consider these meals, but these things don't satiate my hunger enough to last long.

Thus, after my "meals" I wait three hours before I eat a snack. After my snacks I wait two hours before I eat a meal. That way, I keep myself satisfied. I never go hungry. This is my own tweak of the BFL diet. Whatever diet you do, you can do your own tweaking to satisfy your own body.

I think that's one of the reasons so many poeple fail at diets, becasue they think they can read a diet and do what the diet says. Well, that would basically entail every person in the world eating the same diet, and having the same results. In the real world, that won't work. Every body is different. Every body needs a different serving size.

One more thing here. Another key to not getting hungry is fiber. If you eat a steak or a burger, chances are you will be filled up. Yet if you eat a bowl of cereal, you will probably be hungry in an hour and risk the urge of binging. So, when eating something like cereal, you need to only eat cereal that are high in fiber.

So Special K is out. Sure they say it's a good diet cereal, but you can't eat it becaue it has no fiber in it. You'll just be hungry an hour later. You'll be wanting to eat. You'll be craving that cake your spouse made the night before, or that candy Butterfinger you have in the cupboard.

A couple other rules I have is that if someone offers me something I'm allowed to eat it, or drink it. I don't want to be anti-social. If I'm at my neighbor's house and he offers me a Bud, then I drink up and enjoy. If I take the kids to my aunt's pool and she has cake and hot dogs, then I endulge.

Of course you don't want to do this kind of stuff every day, yet you can. You're body's metabolism needs to be fooled once in a while anyway.

Another rule is when you start your diet, or lifestyle, or whatever you want to call it, don't expect to feel good the first week if you eat small portion sizes. Eat big the first too weeks. Cheat the first two weeks if you need to. Do whatever you need to do to make it through.

Then in wees three or four, when you're stomach has shrunk, you can get more satisfaction from the smaller meal sizes. Then you can tinker with size. When you start you're diet your stomach is going to be full of all the junk you normally eat, and it will probably be large.

Another rule is I take one day off a week and eat anything I want. I try to make this day the one I might be tempted to otherwise eat bad, such as if I plan on going to a party, or aunt Mary's pool, or the neighbors for drinks, I try to make that my day off. Yet things don't always go as planned.

I certainly don't want to be the boring person who says, "No, I'm dieting." You'll never hear me say that. Ever. Nobody knows I diet. In fact, when I go to work, I carry with me a big bag full of food to last the 12 hour shift. I actually take more food with me to work when I'm "dieting" than when I'm not.

The fact is, if you're eating healthy, you can actually eat more and more often. The key is you want to eat several small meals through the day to keep your metabolism going. That's it.

You don't even have to exercise. Exercise helps, as it can get your metabolism going even faster, and muscle burns fat a gazilion times faster than fat, which barely burns anything. So aerobic activity, getting your heart rate over 100 for 20 minutes three times a week is important, but not necessary.

Some form of weight training helps too. Yet, if you hate to exercise, studies have been done, and common sense says this too, if you put into your body less than what goes out, you will lose weight. If you put in 2,000 calories a day and you burn up 3,000, you will lose. It may be gradual, yet if you stick to it you'll lose, or at least not gain.

I guess it all depends on what you want. It all depends on what your goals are It all depends on what kind of food you like. But to sit on the couch all day eating potato chips is not going to get you feeling better about yourself. To get results, you'll need to take some form of action.

Lungers: Here's your incentive to get in shape

2012-01-02T01:24:00.001-05:00

Asthmatics! Here's your incentive to get in shape this year. Read my latest post from MyAsthmaCentral.com

Alright Asthmatics! Here's Your Incentive to Get in Shape This Year

Happy New Year, fellow asthmatics. If you're like me you focus on getting in better shape all year, but continue to fail. I'm going to provide you with some added incentives to never quit trying to get into shape.

It's a simple fact that many of us tend to, well, gain a little weight as we age. It's normal actually. Yet, if you have asthma like me, you need to be a little more careful, because obesity and asthma do not bode well together. It's a fact.

Quite often I'm asked this question: "Am I short-of-breath because I have asthma or because I'm overweight?" To be honest, the answer might be both.

I actually asked myself that question once, and I got my answer after I started doing the Body-for-Life Program and lost 40 pounds. Not only was I no longer winded, I was able to cut way back on my rescue inhaler usage. It was awesome.

For one thing, if you are overweight your heart is already working extra hard to pump blood through all your extra weight. So even minimal exertion may make you winded even if you don't have asthma.

Plus a full stomach, and stomach fat, may push up on your diaphragm, which may give your lungs less room to expand, which may also make you feel winded.

Eating McDonalds and other Fatty foods is fun and quite convenient, yet many studies show fatty foods may cause asthma.

A study completed by the Center for Disease Control showed that obese adults were 66% more likely than normal weight adults to have asthma. Experts at the University of South California did a study that showed obese children were 1.5 times more likely to be diagnosed with new onset asthma.

Results from the National Health and Nutrition Examination Survey 2005-2006 (as you can see here) showed that "Obese children were about 26 percent more likely to have allergies than children of normal weight".

According to researchers from Kaiser Permanente, Massachusetts General Hospital and Harvard Medical School, people with asthma are five times more likely to be hospitalized for asthma, have a lower quality of life, and have worse asthma control as compared to those with asthma at a normal weight.

Likewise, according to a study released in 2007 by researchers at Emory Crawford Long Hospital, obese asthmatics are more likely to have persistent or severe asthma.
This 2005 study by experts at the Harvard School of Public Health notes that 75% of emergency room visits are among asthmatics that are obese.

The study also notes that many people are obese before they become asthmatics. There are two theories why obesity may lead to asthma:

Shallow breathing
Hormones released from fat tissue

Breaths are shallower than normal due to fat tissue making less room for the lungs to expand. Full stomachs also puts added pressure on the diaghragm, which further restricts the ability of the lungs to expand.
This shallow breathing increases the probability inflammation will exist in the air passages of the lungs, and this causes the airways to narrow.

Inflammation in of air passages is also believed to be caused by hormones, such as leptin, released from fat tissue. Leptin is present in all asthmatics, but it is elevated in the obese.

Likewise, people that are obese are less likely to have a hormone called adiponectin, which is an anti-inflammatory hormone.

Researchers at Kings College in London, according to study performed at York University in Toronto shows that asthmatics who exercise "might" have better asthma control. Basically, this pretty much proves what we already know, although it's neat to have a little proof.

However, it must also be noted that inactivity due to asthma itself may lead to weight gain. This is why it is especially important to maintain good asthma control so you don't have an excuse to miss out on exercise.

Another study showed that while obesity may not worsen asthma, it may make asthma medicine work less well. Experts here recommend that if you're overweight you may need a higher dose of controller meds as compared to those of normal weight.

Still, it should also be noted that many asthmatics are not overweight. In fact, many children are skinny as I was as a child.

Regardless, getting in shape and staying in shape is hard. Yet because asthma and being out of shape do not bode well together, you must never quit trying. More so than people with normal lungs, we asthmatics have an even greater incentive to get in shape this year.
So come on and join me. I'm doing the Body-For-Life Program because it works for me. I challenge you to find a diet and exercise program that works for you, and then stick with it for the full year.

The world revolves around social people (extroverts)

2011-12-31T02:16:00.000-05:00

There's this old saying that the squeaky wheel gets the grease. I think it's common wisdom that extroverts tend to be squeaky wheels more so than introverts. Therefore, I've concluded that the world revolves around extroverts.

Consider singing in school. Many extroverts love singing, so they think everyone should sing. Yet you have the introvert or shy kid who doesn't feel comfortable, yet he's still pressured into singing. You can see him way in the back, if you look close, and he's probably lip sinking. His face might be red.

The introvert may have allergies and asthma, and this coupled with his shyness has other kids picking on him, maybe pounding him in the chest or something like that. This happens because he's not talkative, and not social as the extroverts are.

You have TV shows like iCarly and all the actors are extroverts. They make fun of people who have allergies and might be, well, shy.

Looking at our history we only had one president who was an introvert, and he only became president because he was vice president when Warren G. Harding was killed (or committed suicide). The president I'm referring to was Calvin Coolidge, or silent Cal.

Extroverts in Washington don't have time to read their history or their economics 101 courses, so they make laws without really knowing what their doing.

You have doctors who do things they were taught (like not oxygenating COPD patients) based on theories from the 1930s, and even though we know better now the old methods are still worshipped. We introverts try to stop this, yet it continues to go on.

The world is run by extroverts, I surmise, and introverts are just along for the ride, forced to live in an extrovert world. You dance, we watch. You talk, we read and learn. We know, yet you feel and believe.

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The human aspect of working in a hospital

2011-12-30T17:30:00.000-05:00

I'll be honest that I'm not the best respiratory therapist. Obviously there's a lot of respiratory wisdom and experience stuffed in my cranium, yet sometimes it takes a moment to sort through it all and come to a decision. That's why I never would make a good doctor.

Yet, I suppose, it takes all kinds to make an institution run smoothly. I'm usually silent when there's a lot of people around, and my voice is soft. Yet one on one with my patients and the patient's family is where I excel. I also have a knack for fine tuning machines so they work well for patients and keeping them comfortable. I often go out of my way and use my soft skills keep people happy.

So I'm good at PR. I think that's a good asset because many RTs and RNs and most doctors tend to lose the human aspect after so many years of doing this job. I've had many patients and family members thank me wholeheartedly for taking the time explaining things, or taking the time to give a patient on a BiPAP a break from the mask even though the doctor didn't order it. One time I even brought a patient a burger, and another patient one of my books because she looked bored and said she loved to read.

Just recently we had a patient who needed the BiPAP to take a deep enough breath to blow off CO2 and to oxygenate. The doctor ordered not to take mask off no matter what. Yet that doctor isn't sitting by the side of the bed with the crying patient whose face is aching and sweaty under the mask.

So I gave her a break. The doctor later told me I wouldn't have done it if I had seen the x-ray. Yet I said I did see the x-ray and I wasn't taking her off with the intention of keeping her off. I did it for three reasons:

1. To give her a rest
2. To prove to her she needed it, because she quickly got short of breath.
3. To allow her to rest her face, take a drink of water, blow her nose

You see, that's where I excel. Then I explain to the patient the BiPAP is not long term, and while it's uncomfortable, it's much better than a tube in your throat. If you had a tube in your throat you wouldn't get any breaks.

I think some folks become apathetic and lose sight of the human element. Doctors order for Q4 breathing treatments without considering the patient also needs to sleep to get better. They order for no breaks of the BiPAP mask, and they put catheters in patients who can just as easily pee in a can.

They rip the patient's gown down right in front of the family, and they say what's going on without making sure the patient and the family understands what's happening, or they blow up at you right in plain view of the patient.

The family and the patient are stressed, and then I come into the room and explain everything in a simple method that boosts my ego a bit and has everyone in the patient's room feeling better -- a little better anyway.

You can shut the door, or pull the curtain, or explain things. You can listen to the patient's stories or you can watch a ball game with the patient. You can ask the patient if he needs anything and actually go out of your way to get it or do what they want. You can fetch a nurse and reassure the patient. You can make sure the patient's not in pain or the patient is breathing fine. Yet you can't be assured anything will get done unless you do it yourself.

You can check on a COPD patient every two hours instead of every 4-6 just to assure the patient that you're right there and available -- that you're keeping an eye on him. Family likes this too. You can be proactive by assessing the patient and preventing the patient from crashing.

When you're at a code for a patient in bed one you can talk to the patient in bed two. You can assure her that her room mate is a little sick but will be okay. And then you can do a follow up with the patient in bed two to let her know what happened. A little reassurance goes a long way.

All it takes to make someone happy sometimes is just a little notice of the human element. Sure you have a job to do. Sure that patient becomes just another part on the human assembly line, yet a person is still a person no matter how small as Horton the Elephant would say. People get scared and anxious. Hospitals are scary. And I have the ability to take some of that edge off -- all of us can take that edge off.

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Don't blow up at your RT

2011-12-29T23:22:00.000-05:00

Noting the nurses in the ER were busy, and noting the patient had a CPAP and a bunch of other stuff than needed to go to his room, I inquired to the nurse what room the patient was going to be admitted to.

She said, snarly, "Look! If we knew what room he was in he'd be admitted already. We don't know any more now what room he's going to as we did a half hour ago when you asked!"

Surely my natural instincts were setting in and I wanted to blow up at the nurse, yet I humble gained control, set my hand on her arm, and said, calmly, and with the most realistic smile I could muster, "Relax, I was just trying to help you guys out."

She mumbled a few things and was on her way. I decided never to offer my services in such a fashion again., at least when she's working.

RT Cave Rule # 54: If you want your RT to help you out in the future, don't tick him off today.

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The true meaning of Christmas

2011-12-25T11:58:00.001-05:00

I remember going to Grandma and Grandpa Frea's house on Christmas Eve and seeing a million presents scattered from the Christmas tree to the fireplace mantle, alongside the fireplace and lined up all the way along the wall and up the staircase. I remember the excitement as we kids looked over all the boxes looking for something that was ours.

Of course in the end, after a long, long wait, there was only one box sitting alongside me when the gifts were handed out. Then Santa would show up and bring another small gift. I remember opening the package and receiving a great big firetruck with ladders and all. The excitement was real.

Then we'd ride home. It was dark and the stars were abounding. On the way home we listened to Christmas tunes on the radio, and listen as dad talked about how neat it was to see all the stars, "A great night to see Santa Clause," he said. And we kids were rushing to get as close to the window as we could to see the sleigh.

"I see it right there," dad said.

"I don't see it," I said with my face plastered against the cold glass, my brother David half way on my lap with his face pressed on the glass too.

Then we'd rush into the house, through squishy snow, pull our snow pants and boots off, and rush to get our pajama's on. The goal was to fall asleep as fast as we could so we could get up and see how many presents we had.

Of course then I wouldn't be able to sleep. I lay there looking on my dresser at the firetruck. I lay there past midnight. "What was that!" I'd jump up and look out the window. "Was it Santa?"

Then finally, after the longest night ever, waking up and rushing to the living room. Bobby and David were already up and sitting under the Christmas tree. Mom had said last night not to touch anything until she got up, yet Bobby and David already had the presents sorted by person.

There were a ton of presents, and this time instead of the entire Frea family, there was only THIS frea family of a mom and a dad and five boys. So the chances of many of these toys belonging to me was pretty good.

There were big toys. There was a wagon and a tricycle that more than likely belonged to Dan and Tony. And there were big boxes and little boxes. Then we looked at the fireplace mantle and there were five big stocks stuffed full of stuff. And Bobby handed each one of us ours.

I sat on the couch with mine next to me, salivating at the candy cane sticking out of the top. Little Danny already had his open and sticky white saliva dribbling down his chin. Finally mom came out carrying little Tony, and she said, "I guess I wasn't sleeping past 7 a.m. today with all this commotion.

Before I knew it all my presents were open, and I wasn't completely satisfied. I wanted to get Star Wars figures and what I got was a stiff statue of a Star Wars figure. I wanted little Hot Wheels, and I did, but I was upset that my brother David got better ones. He got a big Hot Wheels truck. In fact he got two.

Later mom said she made a mistake, because I was supposed to get one. Yet David would not give me what was mine. He claimed them both for himself.

As I got older the presents became fewer. I would get one box and that was it. David and Bobby would also get one. Dan and Tony would also get one or two little things. Grandma and Grandpa went to Florida. So the Christmas of 1978 seemed to be one of my best Christmas memories ever.

Until 2010. Now I have my own family, and I woke up and saw all the Christmas presents under the tree and was the happiest man in the world because I knew not one of the gifts was for me. They were all from me, but not for me. I learned that the gifts themselves was not the purpose of Christmas, but the happy looks on the people who received them.

The greatest gift was not material possessions, but humility and family. And I also realized for the first time since 1978 why there seemed to be so many presents under the tree that year and not so many later on. I realized that it was not the gift but the age of the kids.

As kids grow older they prefer electronics and games and even clothing, and this results in fewer gifts. Likewise, as kids get older they realize the true meaning of Christmas, and don't expect as much (well, sorta). When kids are little we parents find joy in giving the first Tricycle to the little ones, and the first Wagon.

It was those BIG toys that made this year seem like there were so many gifts. Yet the same amount was spent on the BIG toys for my two little kids 2 and under, as on the really tiny boxes for the bigger kids of seven and 12.

And then my kids put two little boxes in front of me, and I understood why it was that my parents always said not to give them presents. And why it was that they always waited until last to open their gifts.

This was because I didn't need any gifts. In fact, it mattered not that I even opened mine, except I knew it would make my kids happy and my wife happy. They bought me a radio because they knew that would make me happy. And it did.

Yet what really made me happy was that every one in this room was here today and was happy because of me. It was because of my hard work as an RT and my dedication to my wife and kids. It was because of humility and Jesus.

I made a video of my seven year old opening up her package, and when she found out Santa gave her a DSI her joy was unquestionable. She was ecstatic. My 2 year old was excited about a simple sucker she got in her stocking, even though she had several other larger packages yet to open.

My 12 year old was upset that my daughter got a DSI and he didn't, even though he already had one. He was unhappy. Truly, he had yet to realize the purpose of Christmas. To him, Christmas was getting stuff. Yet I said nothing, because I remember how happy I was when I was his age to get stuff and I still grew up to realize the true meaning of Christmas.

This year, at 40, I realized the true meaning of Christmas. It's not materialism: it's family. (This was written on Christmas Day 2010).

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Faux priorities of RTs and how I prioritize

2011-12-24T02:01:00.000-05:00

The following are the priorities in most hospitals:

Charting
Doing EKGs in ER whether they're needed or not
Doing order set EKGs on the floor
Donig STAT EKGs so the doctor can go home (or so patient can go to surgery)
Making patient happy so hospital gets a good review
Doing scheduled treatments on time and as ordered (not necessarily when needed)
Taking care of the patients who actually need your services

Here's how I prioritize therapies

Respiratory and cardiopulmonary arrest
Patient doesn't look right
Shortness of breath (treatment) and chest pain (EKG)
Making patient happy
Doing non emergent, non chest pain EKGs
Doing STAT orders so doctor can go home or patient can go to surgery
Doing scheduled therapies (Q4, Q6)
Doing QID and TID and BID therapies
Charting

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RT Idealists versus RT Realists

2011-12-23T07:15:00.000-05:00

Some of my coworkers get annoyed that I'm always questioning need. I'm always asking patients if they're really short of breath, and I'm always asking if they feel better after a bronchodilator. And when a patient says he feels the same after a treatment and has never been short of breath, I chart as much. I chart: No difference with bronchodilator therapy.

When I have a patient with an SpO2 of 86 percent and the doctor orders for me to decrease that patients oxygen based on the hypoxic drive hoax, I ask why? When I proposed a breathing treatment protocol to the staff and they cast it aside based on fear it would result in loss of work, I asked why they came up with that belief? I asked if they have any proof protocols result in loss of work?

One of my coworkers said a protocol would just result in more paperwork, and I asked why he thought that? Another said doctors would never go for it anyway, and I asked why not? Why do you think that?

My coworkers seem to know everything? They know what will pass and what will fail before we even propose it. They should be our public leaders, because then the world would be perfect. We would just do things because... why? Well they happen to know all the answers.

The truth is they don't have all the answers. The truth is they are idealists, and the reason they are annoyed with me is because I'm a realist. Idealists do things based on feelings and emotion, and
realists ask questions and do things based on the truth and proven facts. Idealists throw everything at every problem and hope something sticks -- order sets. Realists solve problems with protocols that encourage point of care critical thinking.

Idealist doctors solve problems by covering their bases by ordering everything -- cook book medicine. Realists don't waste their time doing things that aren't proven to work for that patient, or that don't make sense; or at least they get annoyed when forced to do something they know isn't useful or scientifically proven to work.

Idealists are your political people who say things just to make people happy, and they do things that they know don't make sense just to keep a smile on a doctor's face -- and to boost that doctor's ego.

Realists questions doctors. Realists question stupid orders. Realists are hated because they are always asking questions instead of keeping their mouths shut and doing their job the way idealists
do.

Idealists solve problems based on feelings and emotion which results in doing things that aren't proven and are often useless, such as creating order sets where every patient is given Albuterol. Realists don't waste their time doing things that are needless because they take the time to think.

Instead of thinking, idealists call respiratory or order breathing treatments. This results in useless procedures and causes the RT to run around ragged all day to get all this work done. It results in burnout and apathy or RATS. Since Idealists control the world right now because their ideas sound good on the surface, the healthcare system is in trouble.

I would consider myself a realists. It's why people get annoyed with me. We grumble and gripe at new breathing treatment orders because we know Idealist in the healthcare system order things for no other reason than ignorance.

Idealist: See idealism. A person who believes perfection is possible. They believe 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 what they want to do won't work. They believe if there is a problem something must be done, even if that means taking away personal rights and discouraging individual thought and choice. 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 that resulted in the boom in the diagnosis of asthma and pneumonia. They are the
ones 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 (yes, the truth hurts). If you go to them with the truth they will get angry and toss vitriol at you and make you out to be the enemy. They say that when you question their realist ideals you are cconfrontational. You are causing confrontation. Yet if you're afraid of confrontation you're an enabler. The idealist at the bedside sees a patient who's short of breath with an audible wheeze and thinks bronchodilator before even assessing the cause. Their goal is euphoria in the healthcare industry; an ideal system by their definition of ideal. A scientist will not take this route. Perfection.

Realist: See realism. 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. If it's moronic and doesn't make sense, we try to find a better solution such as protocols. They are the ones at the bedside doing the clinical assessments and critical thinking to determine the cause the the best solutions. They base their solutions on science and proven facts as opposed to feelings and "it sounds good." They are often feared and hated because the truth hurts before it makes you better.

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Heart Attacks increase during Christmas season

2011-12-21T15:16:00.000-05:00

By far I am behind in my blog reading, yet I happened to check out COPD News of the Day to learn what I had already suspected, that the risk of heart attacks are up by 5% around the Christmas season.

She sites this article from Health.com which states that while ERs tend to be relatively slow on Christmas day, and patients opening presents don't even know they are at high risk for a heart attack. Yet many are.

The article notes that December 26 is one of the most hazardous days of the year for people "vulnerable" to cardiac problems such as heart attacks, arrythmias and heart failure (CHF).

The article also sites a 2004 study that showed heart related deaths increased about 5% around the Christmas season, the article notes, " perhaps because patients delay seeking treatment for heart problems or because hospital staffing patterns change."

I personally don't think it has anything to do with hospital staffing patterns. I think it has to do with modest patients thinking they are impervious and humble and delay seeking treatment for their seemingly life threatening condition.

I have written on my blog before how people simply don't want to be inconvenienced by doctors and medical stuff. It's not abnormal at all.

I've also noticed how the hospital tends to be ironically slow during the Christmas season. And while I'm working the days following the Christmas until after the New Year's Celebrations I expect there to be one or more cardiac patients being wheeled through the ER doors.

It's just a fact of life.

The resolution to this problem is the same as any other, and involves education. The more people are educated the more likely they will seek treatment.

Yet sometimes even us well educated delay seeking help, and in this case a good supporting cast of family members is essential to getting the good health care you need.

Just remember it's your life. It is up to you to take care of yourself. When you notice any of the following signs of heart problems call your doctor immediately, or have yourself taken to an emergency room ASAP:

Signs of heart problems include:

Chest discomfort. It can stay or go away and come back. Generally it goes away and comes back.
Uncomfortable pain in chest
Dull pain in chest
Squeezing pain in chest
Full feeling in chest
Jaw pain
Left arm pain (most common)
New onset back pain
Stomach pain
Right arm pain
Nausea
Heart Palpitations
Shortness of breath
Breaking out in a cold sweat
Light headedness
No symptoms at all

If you even notice one or a few of these symptoms you best be getting your heart to the emergency room. It's best to come in and be told you are fine than to stay home and hope you are fine.

We will not make fun of you for coming into the ER. In fact, just the opposite: we will respect you for taking the proper action when your body is feeling or acting funny.

I believe it is very rare for someone simply to drop dead of a heart attack without that person first showing and then perhaps ignoring the signs and symptoms. Take care of your body and your heart, and know the signs above.

Do this even if you are in good health. If you don't save your own life, perhaps you can use this information to save the life of a friend or loved one.

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Can I take albuterol orally if my neb is broke?

2011-12-20T12:51:00.000-05:00

The following question is from healthcentral.com/asthma.

Your humble question: My nebulizer just stopped working. Can I take albuterol neb solution orally for an emergency until I get a new nebulizer?

My humble answer: No. If swallowed the medicine will simply be broken down by stomach acid and will have no effect. I would recommend recommend using your albuterol inhaler, or calling your doctor and asking for an inhaler so you can use that until your nebulizer if fixed. Most studies show that using an inhaler with a spacer works just as well as a nebulizer.

Santa working on new medicine

2011-12-19T01:21:00.000-05:00

Santa is trying to help us asthmatics out. Learn what he's up to by reading my latest post from MyAsthmaCentral.com

Santa's Elves Working on New Asthma Medicines

Last year we wrote santa a letter which included A pragmatic Asthmatics Christmas List. Over the past year Santa and his little elves have been working hard, mixing molecules and liquids in search of the ideal asthma medicines.

"Experimenting with Albuterol and Levalbuterol molecules in this was was fun for my elves," said Santa in a recent email to me. "And knowing we might provide humor for asthmatics is very rewarding for us all."

The following are some of the fake medicines he's presently working on:

All-Bettero-ol: Makes lungs "all better." Oh, what the heck, no matter what is ailing you these days, this medicine makes it "all better."

Preventolin: One puff and it miraculously prevents asthma from happening.

Soapenex: This inhaler suds up in your lungs in cures all ailments in there.

Openex: It opens the airways and keeps them open for 365 days. Take one puff on January 1 and you're good for the year.

Bronchodilitator: Just by spelling bronchodilator wrong means it must work better than what's currently on the market. Oh, and it must have fewer side effects too.

Scrubbing Bubbles: Works similar to Scrubbing Bubbles bathroom cleaner in that it suds up in the lungs and gives them a good scrubbing, and therefore cleans out any ailments that might be in there. It cures asthma, but is also cures pneumonia, pulmonary edema, lung cancer, COPD, cystic fibrosis, and a whole lot more.

No-side-effex-onex: It has all the powers of Albuterol and Levalbuterol with no side effects at all (no risk of increased heart rate and no increased shakiness).

Happinessolin: Has magic ability to cross the blood brain barrier so not only does it make breathing better it eases stress and anxiety

Faitholin: It seems to enhance the effect of prayers, meditation and faith. Exact methodology is mystical. It seems to have greatest effect on happy, religious people. Squirting an amp on nurses may cause laughter.

Do-all-olin: It has omnicient powers like Faitholin, yet cures anything from COPD, asthma, heartfailure and even hangnails. And yes, it has been proven that if you sprinkle a little of this on your nose it will remove unwanted nose hairs.

Feel free to add any of the above to your Christmas Wish List. Also, if you can think of any other fake (or real) medicines you'd like to receive for Christmas, let us know in the comments below and we'll be sure to tell Santa.

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Theory: Nice patients are those who believe

2011-12-18T14:08:00.000-05:00

I wrote a while back that good patients are the best patients and good patients go to be with the angels. If you have a patient who is downright miserable upon learning of his fate, or extremely depressed, those are the patients who believe they are going to die and just be gone.

Those patients who are happy even up to the moment their heart stops the flow of blood through the bodies pipes are, more often than not, those who believe in the afterlife. And I would surmise these same patients had a very good life they are leaving behind, and a better world because of it.

Of course this is just my theory, yet I do believe it to be true just based upon my own observations. One of the things I do upon reviewing charts is check to see if the patient has a religion, or I simply ask, or I simply observe the Bible or other such elements, and determine the patient is a believer.

Then I get to know the patient by default. If I find the patient is grumpy, or demanding, or cantankerous, I notch this up as another bit of evidence my theory is in fact true.

I recently stumbled upon another blog called Christian with a view. I have my own view on religion as all people do, yet I found this blog very thought provoking, and intelligent discussion provoking, which is something I love.

I'm one of those people who simply love an intelligent discussion. I don't care if it's with someone I agree with or other. Actually, I find that no two people have the same opinion, which I suppose explains why even conservative christian republicans even disagree among themselves.

Anyway, this blogger reminded me of my theory of the good patient. And I'm not implying that all people who don't believe in God are crabby either. I just think all people have a tendency to be good. Yet, as a rule of thumb, I've observed most happy patients are religions to some degree, and believers.

Your thoughts.

Q4ever Treatments

2011-12-17T01:55:00.000-05:00

There's a saying that company and fish stink after three days. The same may be true of breathing treatments.

Q4ever is a term to describe patients on Q4 hour breathing treatments until discharge. Some hospitals have a policy that treatment orders expire after three days, yet hospitals that need extra money don't allow such a policy. Thus the result is Q4ever treatments.

The patient's been in the hospital a month and the patient's still on treatments. The doctor doesn't even know they're ordered half the time, yet they also don't want us questioning their judgement. Therefore therapy never gets adjusted as patient progresses.

Eeeks. This policy reeks.

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A BiPAP case study-ethics case

2011-12-16T23:18:00.000-05:00

I just want you to know that if a doctor ever orders me on a BiPAP or Ventilator and refuses to give me anything to relax me -- like Ativan, I'll kill him if I get off.

So here's the patient's ABGs on 40% vm:

pH 7.2
CO2 77
PO2 82
HCO3 29

The patient's wob is labored. He has a history of end stage COPD, possible CHF. The BiPAP is working well for the patient. His VT is approximately 700-1000 and respiratory rate 39 on settings of IPAP 12 and EPAP 5. I now have his FiO2 down to 30% and his SpO2 is holding at 98% and so I could actually decrease his FiO2 even further.

Yet the patient tells me he feels panicky, like he's not getting any air, and feels like he wants to pull the mask off. I give him the speal that the BiPAP is working well and that it's preventing him from needing a tube in his throat so we can breathe for him that way.

So after my speil he says he can tolerate the BiPAP. Yet I get on the phone and call the doctor and ask for something to relax this guy. The doctor says, "Do you know what you're asking me to do?"

"Yes, " I said, "And you have to understand that I think if we can keep him on this BiPAP we can also keep him off the ventilator. Even if we suppress his respiratory rate by 10, he's still getting twice the tidal volume he was getting before the BiPAP, so he'll still be blowing off CO2."

He said, "I'm sorry, but I just can't do it."

My only thought at this point is, "I'm glad this guy's not my doctor. Because this could be me some day. The next day I came to work and learned about the dream doctor.

Your thoughts???

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The balance of sodium and potassium: part 2

2011-12-14T00:05:00.002-05:00

So when either sodium or potassium are our of whack a slew of problems can occur. So let's examine the conditions of high and low potassium and high and low sodium and what a doctor and nurse might do to remedy the situation.

Hyponatremia: This is when sodium is below 135.

Causes:

Profuse diaphoreses (sweating
Profuse wound drainage
Excessive diarrhea
Vomiting
Trauma (excessive blood loss)
Low sodium intake
Addison's disease (hormonal changes)
Hypothyroidism (hormonal changes)
Overuse of thiazide diuretics (lasix and bumex)

When sodium is low in extracellular fluid it is therefore high in intracellular fluid. Since water follows sodium, this causes cells to swell. When this happens in the brain it can cause central nervous system problems such as altered mental status. In the abdomin this can cuase nausea, vomiting and diarrhea.

When sodium is below 115 it's considered severe. This can result in muscle twitching, tremors, seizures, increasing intracraneal pressure, coma, and death.

The treatment is to eat. Those who can't eat must have an IV inserted and be given lactated ringers or 0.9 percent sodium chloride solution. Water restriction may also be essential.

Hypernatremia: This is when sodium is above 145.

Causes:

Low fluid volume (inadequate fluid intake)
Excess sodium ions (too much salt intake such as with tube feedings)
Diarrhea
Steroid use (cushing syndrome)
Hyperaldosteronism
Diabetes
Kidney failure
Excessive use of bicarbonate

This condition results in the following due to fluid leaving cells resulting in cellular dehydration:

Muscle weakness
Twitching
Personality changes
Agitation
Hallucinations
Decreased levels of consciousness
Low cardiac output (causes muscle weakness)
Heart failure
Dry mouth
Thirst
Tachycardia
Fever
Brain bleed (if severe due to fragile capillary membranes)

Treatment is to slowly give hypotonic solutions such as 0.45 percent sodium chloride to restore the balance. Rapid infusions of sodium may cause cerebral edema

Hypokalemia: This is when potassium is below 3.5

Causes:

Diahrrea
Vomiting
Diaphoresis (sweating)
Laxitive use
Diuretic use
NG tubes
Alkalosis

Critical level is below 3. This can result in:

Cardiac arrythmias due to weak heart muscle (flat T wave, depressed ST segment, U waves)
Decreased neuromuscular function (muscle weakness)
Weakened respiratory drive due to muscle weakness
Absent bowel sounds due to weakened GI muscles
Depresses insulin release from pancreas
Cramps
Cardiac arrest
Respiratory arrest

Treatment is to treat underlying cause and give IV potassium or high potassium diet.

Hyperkalemia: This is when potassium is above 5

Causes:

Renal failure
Too much potassium intake (IV intake)
Salt substitutes containing potassium
Infections (cause potassium to move from intracellular to extracellular fluid)
Trauma (same as above note)
Burns (same as above note)

Critical levels may cause disturbances in cardiac function that result in peaked T waves, prolonged PR interval, and wide QRS complex that may result in arrythmias and cardiopulmonary arrest.

Treatment is to fix underlying cause and by either restricting potassium intake or giving sodium polystyrene sulfonate or something similar to it or IV diuretics to make he patient pee out extra sodium ions. IV calcium chloride or calcium gluconate may also be sued in emergent situations.

Bicarb, dextrose or insulin administration may shift bicarb into cells and are considered temporary treatment. Dialysis may also be considered.

Source for the above material:
*Crawford, Ann, "Balancing Act: Sodium and Potassium," Nursing 2011, July, pages 44-50

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Is asthma curable?

2011-12-13T12:49:00.000-05:00

The following questions I've answered from healthcentral.com/asthma

Your humble question: Is asthma curable?

My humble answer: There is no cure for asthma. However, with proper treatment you can control and prevent asthma symptoms so you can live a relatively normal life. Here are some tips

Your humble quesiton: Is there a cheaper substitute to spiriva?

My humble answer: Not at this time. Spiriva is a relatively new medicine and it is patented, which means no other company can use the same formula. I'm not sure how long the patent is good for

Your humble question: Is it safe to use singulair and prednisone at the same time?

My humble answer: Yes it is safe to use prednisone with singulair. Just make sure you follow your doctor's instructions to a tee.

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The balance of sodium and potassium

2011-12-12T23:08:00.000-05:00

It's neat how the body works to maintain homeostasis (balance) within the body. When things get out of whack all sorts of bad things can happen to a person. A good example of this is the body's effort to keep potassium and sodium balanced within the body.

Sodium and potassium are both cations, which is an ion with a net positive charge. An ion is a group of atoms that have an electrical charge. Sodium is the main cation of extracellular fluid and potassium the major cation of intracellular fluid.

The Sodium Potassium Pump is what keeps maintains the balance. It's constantly working to maintain a normal potassium level of 3.5 to 5 mEq/L in extracellular fluid and to maintain a normal sodium level of 135 to 145 mEq/L in intracellular fluid.

Ann Crawford in her article "Balancing act: Sodium and Potassium" in the July issue of Nursing (pp. 44-50) describes the pump as the main mechanism of moving sodium "from inside cells to the extracellular compartments, and returns potassium from the extracellular compartments into cells using adenosine triphosphate (ATP) as an energy source."

She likewise explains that electrolytes tend to move from areas of high concentrations to lower concentrations. So the body naturally works to maintain potassium inside cells 35 times greater than outside cells so potassium has a tendency to want to get out of cells. Likewise, sodium outside cells is kept 14 times greater than insidee cells so sodium has a natural tendency to want to go into cells.

Sodium attracts water. So if sodium levels inside the cell were to get too high the cells would absorb water and would swell and ultimately explode. Obviously this wouldn't be good.

Rene Fester Kratz in his book "Molecular & Cell Biology for Dummies" explains the pump as a protein in cellular walls and "for every round of action, the sodium potassium pump moves three sodium ions out of the cell and two potassium ions into the cell. Thus the pump creates a higher concentration of sodium outside the cell, a higher concentration of potassium inside the cell, and a greater positive charge outside the cell. These differences in ion concentration and electrical charge are important in the functioning or nerve and muscle cells in animals."

Sodium is controlled by a hormone called aldosterone secreted by the adrenal cortex, write By Michael Roberts, Michael Reiss, Grace Monger in their book "Advanced Biology" (2000, U.K, page 290). Aldosterone increases the absorption of sodium ions by the gut, and this causes the sodium concentration in the blood to rise.

When sodium in the blood is high the adrenal cortex is sent a signal to decrease aldosterone production. If sodium in the blood is low the adrenal cortex is sent a signal to increase aldosterone production. When sodium levels in the blood falls less fluid is absorbed into the blood and the blood pressure falls.

When this happens renin is released into the blood stream where "it catalyses the conversion of one of the plasma proteins into a substance called angiotensin. This then stimulate the adrenal cortex to secrete aldosterone," according to Advanced Biology.

A rise in sodium has the reverse effect, where less renin and angiotensin are produced and less aldosterone is produced.

It should likewise be noted here that as the concentration of sodium in the blood rises the potassium concentration in the cell falls. The sodium potassium pump then works hard to maintain a balance of sodium and potassium inside and outside cells and a positive charge outside cells. This is important for normal body function.

Sodium works to maintain acid base balance by combining with an anion such as chloride to form sodium chloride or bicarbonate to form sodium bicarbonate. These act as buffers to absorbed hydrogen ions to help maintain a normal cellular and blood pH of 7.35 to 7.45.

Crawford further explains that sodium also functions to:

Promote transmission of nerve impulses
Maintain intracellular osmality
Activate several enzymatic reactions
Assist with regulation of acid base balance
Promote mycardial, skeletal, and smooth muscle contractility

One neat thing about sodium is you don't have to worry about taking in extra sodium because your body is very efficient at preserving it, and plus your body gets all the sodium it needs from small amounts of just your basic foods.

Potassium, along with working with sodium to maintain electrical neutrality, plays a major rol in cellular metabolism, "especially in protein and glycogen synthesis and in the enzymatic processes necessary for cellular energy, according to Crawford.

It's critical to maintain many body functions, such as:

Acid base balance
Nerve impulse conduction
Maintenance of normal cardiac rhythm
Skeletal smooth muscle contraction

While little sodium is needed from food, potassium is not stored efficiently by the body, so you need to supply your body with an adequate amount daily.

Other than the sodium potassium pump, potassium levels are regulated by the kidneys and the adrenal cortex, and any excess potassium is excreted by the feces and sweat.

Chris O'Callaghan in his book "The Renal System at a Glance" (2006, UK, page 53) writes that other than the sodium potassium pump, potassium levels are regulated by the kidneys and the adrenal cortex, so abnormally high or low potassium is a sign of adrenal cortex or kidney abnormalities.

Callaghan writes that a rise in potassium ions in extracellular fluid of the adrenal cortex directly stimulates aldosterone release which ultimately leads to an increase in sodium re absorption by the kidneys and potassium excretion into the bloodstream by the kidneys.

Crawford explains that there is no mechanism to notify your kidneys of a potassium deficit, so it may continue to excrete potassium even when levels are low.

Crawford also explains that sodium is exchangeable with hydrogen ions, and therefore changes in acide base balance will effect potassium levels. "Acidosis causes an increase in hydrogen ions in extracellular fluid; to maintain pH, some hydrogen ions shift to intracellular fluid. To maintain intracellular electrical neutrality, some potassium ions shift to the extracellular fluid, which may cause hyperkalemia.

"Conversely, in alkalosis, more hydrogen ions are present in teh intracellular fluid, so some hydrogen ions move to the extracellular fluid to buffer and maintain pH. This again produces inequities in teh intracellular ion electrical charges; potassium ions compensate by moving from the extracellular fluid to the intracellular fluid, causing hypokalemia.

Next Wednesday I will explain what happens an imbalance of sodium and potassium occurs. I will delve further into hypokalemia, hyperkalemia, hyponatremia, and hypernatemia.

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Admit you're wrong and set things right

2011-12-11T12:50:00.001-05:00

Genesis
Romans 5: 12-19
Matthew 4: 1-11

We are all tempted to sin, and often we give into these temptations due to pride and selfishness. Then we have a tendency to blame other people for our sins like Adam blamed the woman, and Eve blamed the Serpent. The only one in the story of Adam and Eve who was honest was the Serpent. He connived Adam and Eve to commit a sin, and he was proud of his act.

When we do evil things our lives are not as we would like them. In Matthew (4: 1-11) Jesus is tempted by Satan to do evil things, and he does not give into the temptation. After fasting for 40 days and 40 nights he is starving, and Satan tries to convince him to create a miracle and make bread, and Jesus tells the Devil to go away.

Paul tells the Romans (Romans 5:12-19) that the sins of one man, or the selfish decisions made by one man, can effect the entire world in a negative way. One man's decisions can cause havoc on all the rest of society, yet all it takes is one man making an unselfish and honorable decision to set things right.

He writes, "Sin came into the world through one man, and his sin brought death with it. As a result, death has spread to the whole human race because everyone has sinned. There was sin in the world before the Law was given; but where there is no law, no account is kept of sins."

He further describes that many people have sinned due to pride and selfish behavior, yet the benefits or gifts or rewards that come from all these sins is never greater than the rewards of the one person who puts himself after other people. He writes that "one righteous act sets all mankind free and gives them life. And just as all people were made sinners as the result of the disobedience of one man, in the same way they will all be put right with God as the result of the obedience of the one man."

Of course he was talking about Jesus, yet what he is writing can be symbolic of all mankind. While we are suffering in this world due to the poor and selfish decisions of only a few men, all it takes is the unselfish works of one man to set things right again.

Likewise, Matthew tells the story (Matthew 4: 1-11) tells how after fasting for 40 days and 40 nights Jesus was starving. He was tempted by the Devil, who said, "If you are God's Son, order these stones to turn into bread."

Jesus answers, "The Scripture says, 'Man cannot live on bread alone, but needs every word that God speaks." What he is saying is that good things in life do not come from any material possession including food, good things in life come from virtues.

One of the most simplest of all virtues is to take responsibility for our actions. We must admit when we sin, and not place blame on other people. The things that happen to us are not by chance, but the result of our individual choice. We either choose to have our priorities in the right order, or we do not..

When we have our priorities in the right order, things work right. When we don't have things in the right order things may work right for a while, yet then they fall apart and getting them back in order can only be accomplished by accepting blame, returning to God (or virtues), and prioritising responsibility.

Lent is a time that we look at our lives and admit that we are sinners, and that we are the cause of our sins. It is not your wife or your husband that causes you to sin, and it is not Satan, and it is not your mom or dad, it is yourself. You

Lent is a time when you look at yourself and find what is wrong with your life, and decide to take the wrong out. Yet to truly accomplish this takes the courage to admit our mistakes, and then to ask God for guidance, nurturing direction and courage.

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My discussion with a quality assurance analyzer

2011-12-10T01:43:00.000-05:00

Quality Assurance Analyzer: "This patient doesn't meet criteria."

Me: "So what do you have to do to get him to meet criteria, order breathing treatments?"

QA Analyzer: "Yes."

Just another example of why RTs get so burned out.

Here's another discussion;

QA Analyzer: "Did you do any breathing treatments on that kid today?"

Me: "No."

QA Analyzer: "Oh! If you did I could note him as meeting criteria. Yet otherwise I don't think we can justify the visit."

Me: "So do you want me to lie and chart that I did one?"

QA Analyzer: "Yes." She smiled.

Of course I was joking and I didn't. Yet this is yet another example of why the government setting criteria is ridiculous.

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Things that make our job easier/ harder

2011-12-09T07:50:00.001-05:00

It seems to be my first 8 years as an RT saw many new things that made our job better. I'll list some examples here:

1. Microprocessor ventilators: work with patient instead of other way around
2. Microprocessor BiPAPs: easy to use, pts tolerate them, and they keep people off vents)
3. Computer charting: no longer have to hunt for charts, easy access
4.

However, in the past five years every thing added has made our job harder:

1. Order sets: RT procedures automatically ordered even so all bases are covered, increases workload
2. Protocols called order sets: increases workload
3. Medicine locked up: Inconvenient to get to medicine
4. Obamacare: Increased need for QA analyzers and order sets
5. QA analyzers: who constantly double check our charting (nit pickers, that's what I call them)
6.

Can you name any more things that have made our jobs easier or harder????

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The two types of pulmonary edema

2011-12-08T06:39:00.000-05:00

Fluid can sometimes build up in the lungs, and we generally refer to this as pulmonary edema. There are two types of pulmonary edema:

1. Caradiogenic: Fluid backs up from a weakened heart. Pulmonary pressure increases, and this fluid is forced into the parychemal tissue lining the bronchi and alveoi.

2. Noncardiogenic: The heart did not cause the pulmonary edema. There is a simple pneumonic to remember all the disorders that fit into this category: NOT CARDIAC. As noted:

Near drowning
Oxygen therapy
Transfusion or Trauma
CNS disorder
ARDS, aspiration or altitude sickness
Renal disorder or resuscitation
Drugs
Inhaled toxins
Allergic alveolitis
Contrast or contusion

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No more mist tents

2011-12-07T17:51:00.001-05:00

An old mist tent

About five years the infamous RT boss took all the mist tents and put them in the basement of the hospital because there was no room in the RT storage room. This marked the end of the era of the mist tent for infants.

As a matter of fact, when oxygen was first introduced as a method of inhaling supplemental oxygen in the mid 19th century, the main technique was having the patient sit in a tent. This was the main technique until the oxygen tank was invented.

During the 1920s oxygen masks and nasal cannulas became the best method of giving oxygen to adults, so tents were left to only a few adults but mainly kids.

Ultimately the tents were cooled by packing ice and water in the back of the device and a cool mist was added to the circulating air inside the tent. This was one of the main methods of treating kids with inflamed upper air passages, or croup.

When I was 11 in 1981 my doctor wanted to put me in a tent once because I refused to wear a nasal cannula. The RT was dilly-dallied for hours before complying with the order, yet eventually he talked me into sitting in it. I remember watching TV through the blurry plastic. After a few hours in was dinner time and I was allowed out. I refused to get back in.

Yet even by 1981 using such tents on adults was rare as the grumbling RT implied. By the time I became an RT in 1995 mist tents, or oxygen tents, were used for this purpose or simply to supply oxygen to kids.

It was to the point that doctors wouldn't even try allowing us to place a nasal cannula on a kid, it was just automatic a mist tent (or oxygen tent) be ordered. It was our discretion whether we turned on the mist or left it off. It was on for croup and off for asthma and RSV. If the doctor had a preference he'd order either mist tent or oxygen tent.

Yet we RTs preferred to use a nasal cannula. I have rarely met a kid who couldn't tolerate a nasal cannula. Surely they might fight initially, yet once it's on they forget about it and tolerate it just fine.

The tents posed problems of their own. For one thing, few kids wanted to stay in one. Usually to get a kid to stay in the parent would cuddle in the tent-surrounded crib. This made getting access to the kid difficult. Plus toys were limited because some could spark and cause fires.

The reason I brought this up was because Advanced for RTs has reported that the CDC no longer recommends mist tents be used because they the mist enhances the spread of droplets in the air. So this should mark the final farewell to the old and infamous mist tent.

Ironically the CDC has yet to outlaw nebulizers which equally spread droplets into rooms. I'd like to see the CDC come out and recommend that one way valves or filters be used on all nebulizers, and, if possible, that nebulizers not be used at all unless indicated.

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Principles

2011-12-04T05:24:00.001-05:00

We here a lot in this life that if we as humans live by the principles we set for ourselves that we will grow to be respected people living noble lives. In this sense we as humans relate principles with good.

It is true that those among us who live under "good" principles tend to lead "good" lives, it is not necessarily true that all principles are all good. For example, Stalin, Hitler and Mussolini all had certain principles that they followed, and with history as our testament that the principles these evil men followed were not all good.

Although it is true that when a child is born, that child is inherently good. During the coarse of life he is often faced with prodigious forks in the road where he either can choose the "good" path to nobility and respectability, or he can choose the path to evil.

If you have ever read the Bible, you can look there for many examples. One is the temptation of Adam and Eve, and another is the temptation of Jesus as described in Matthew (4:1-2): "Then Jesus was led by the Spirit into the desert to be tempted by the devil. He fasted for forty days and forty nights, and afterwords he was hungry."

He was starving, and that was when Satan tempted Jesus to turn rock into bread. And Jesus resisted the temptation, stating that the word of God is more valuable than anything on earth, including bread. So he chose to take the path of goodness.

Yet the first temptation may not even be mentioned in the Bible. As is described by Catholic doctrine, Satan was initially created by God as a good angel. Yet he was faced with a choice, and by his own choice he became evil. And it is in this same way that many people since that day have decided to take the path of evil. Although evil for a majority of us may be in a subtle way, it is still evil.

So what is it then is it that drives one to choose one route or the other: evil or good? The answer is the principles that we follow for ourselves. Usually these are laid out for us by our parents, or those who raise us when we are children. Yet it's actually simpler than that, as the basic principles of life are those of which we are born with: we are all born inherently good, with the intent of being good. We become "bad" only by choice.

Thus, the foundation of life is based on the principles we live by. A principles, as defined by Dictionary.com, is "an accepted or professed rule of action or conduct." Born as inherently good people with the inalienable right to make free and individual decisions, we, at some point during the early course of our lives, get to decide what principles we will live by.

The principles of good are generally based on virtues such as those that were written by Ben Franklin in his Autobiography: Temperance (eat not to dullness), Silence (speak not what might benefit you or others), Order (let all you things have their place), Resolution (finish what you start), etc.

It is my firm belief that most of us yearn to be good, because by being good people we are able to fit into society better. However, some of us believe the opposite, and Hitler, Stalin and Mussolini are extreme examples of that, and so too is Satan if you be live in that beast.

So the principles most of us follow allow us to keep our natural course in life, and if you're a follower of a Faith, allow you to maintain your purpose in life as directed by God. Or, by following the basic principles of life, allow you to maximize your ability to use the gifts you were given.

Examples of principles may include:

I will not speak too much, for my words can trap me
I will not take advantage of a drunken woman
I will not sleep with someone until I get married
I will not chart a breathing treatment I did not actually do
I will not let money control my life
I will not eat and drink to fullness or dullness
I will not waste my day away lying around, and instead accomplish something
I will control my anger
I will not complain
I will not disrespect my parents or other people
I will not hold grudges
I will smile as often as I can
I will use only positive words
I will pray often
I will be generous
I will be forgiving
I will treat other people with respect
I will keep my priorities in the right order

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Things you don't want to hear in a hospital

2011-12-03T01:37:00.002-05:00

The following are things you don't want to hear in a hospital:

How do you do that again
Where do I poke
Oh Shit!!!
I can't find a pulse
Oops
I could swear I could feel a pulse when the patient arrived
Ooops! I didn't know you were on the pot
I can't get a blood pressure
His blood pressure is dropping
Well I've never done that before
Well that ain't good

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You can smoke, eat and drink and still be a good RT

2011-12-02T00:59:00.001-05:00

I notice a lot of hospitals are going smoke free. The idea is that hospital administrators believe medical professionals should be setting a positive example for the community. This is fine. I don't have a problem with it.

What I do have a problem with is hospitals not hiring working because they smoke. I think what a person does on his own time is no one else's business. However, hospitals do have a right to hire and fire at will so long as they don't violate race and sex codes.

On a similar note, some people say that respiratory therapists shouldn't smoke just because they are respiratory therapists. I read one column recently where the columnists -- a young RT -- was shown by her preceptor a very effective means of encouraging patients how to quit smoking.

Yet the columnist later saw that same preceptor smoking. He smiled and said, "I never said it was easy to quit." She wrote that this was hypocritical. Here he was encouraging people to quit when he himself had a problem. He should quit.

I disagree. Say you have a baseball player who never hits over .100 his entire career. Do you think that person will never make a good manager. If that were the case Sparky Anderson and Jim Leyland never would have amounted to anything.

My point is that what you do in your life does not correlate to how good of a teacher you are. You can lead a life of misery, you can smoke, you can eat terribly, you could be 500 pounds overweight, yet that doesn't effect your ability to teach. In fact, it might make you an even better teacher.

You can use yourself as an example of why it's important to quit, or never to start in the first place.

In the same way that many in the medical field have learned from the bad choices of patients who are obese and smoke and are now suffering the consequences of their bad habits, our own patients can learn from our experiences.

Just because you're an RT or an RN or a doctor doesn't mean you have to be perfect. Just because you're an RT doesn't mean you have to eat a boring diet, do exercises you hate, and never smoke or drink anything fun. This is America for God sake.

Being responsible is a choice. Being stupid is a choice too. You are free to choose no matter if you are a teacher or not.

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Functions of the lungs

2011-12-01T20:31:00.000-05:00

The lungs serve three functions. Can you name them? If not don't worry because I will name them here.

1. Respiration: Oxygen inhaled and carbon dioxide exhaled
2. Reservoir for the left ventricle: Pulmonary circulation is a blood reservoir for the left ventricle. Even when cardiac output changes this reservoir volume remains constant (about 600 ml)
3. Filter for systemic circulation: Pulmonary circulation filters particles and prevents them from getting to the systemic circulation and causing blockages, particularly blockages in capillaries in the heart and brain. Filtered particles include:

Fibrin
Blood clots
Fat cells
Platelet aggregates
Debris found stored blood
Debris found in IV fluids

4. Metabolism: Mainly of bioactive substances

5. Storage and synthezising: Of Heparin, histamine, bradykinin, serotonin and certain prostaglandins

6. Conversion: Angiotensin converted to its active form by the lungs

7. Inactivation: Adenosine Triphosphate (ATP) adn norepinephrine are partially removed from blood and inactivated by the lungs.

The later two functions are particularly important to maintaining homeostasis.

Source: Egan: Fundamentals of Respiratory Care

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What is short of breath?

2011-11-30T15:58:00.000-05:00

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.

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Satan

2011-11-27T06:16:00.003-05:00

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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Things only an RT would say

2011-11-26T01:22:00.042-05:00

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:

I have the ABGies
That breathing treatment's not needed
Now that the patient has allbetterol in his system he's good to go
The hypoxic drive theory is a hoax
Xopenex is the same as Albuterol
Bronchodilator abuse
All that wheezes is not asthma
All shortness (dyspnea) of breath is not asthma
The only reason the treatment helped that patient with dyspnea was the oxygen boost
I only work so I can have days off
I'm not smart enough to be an RT (or maybe I'm smart enough not to be an RN)
I love being an RT
I hate being an RT
That patient does not need suctioning
Suctioning an awake and alert patient is unethical
Most of what we do is a waste of time or delays time
You don't intubate a number
Q4ever treatments
Doctors don't wean on weekends or after office hours
Oxygen does not treat anemia
Breathing treatments do not cure rickets
Ventolin is like scrubbin bubble therapy. Doctors think it gets deep into the lung and scrubs them clear of all lung ailments.
Doctors think Ventolin prevents everything from asthma to rickets, from atelectasis to pneumonia
Ventolin does not even get deep enough in the lungs to treat pneumonia
There's no smooth muscle and no beta receptors in the alveoli
Are you short of breath?
Let me listen to your lungsounds
Let me get you a stool, a fan and a table to lean on
I walked 20 miles at work today
You want a what...!!!
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
I can't find (feel) a pulse
Take in a deep breath... and blow, blow, blow, blow.....
This EKG will be quick and easy.... unless you're a hairy man, then it'll be painful
If you need me I'll be in the waiting room watching TV

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dnr vs full code

2011-11-25T09:05:00.000-05:00

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.

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Happy Thanksgiving

2011-11-24T20:42:00.001-05:00

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!

Should hyperventilating patients breathe into a bag?

2011-11-23T21:34:00.000-05:00

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."

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

2011-11-23T16:11:00.000-05:00

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.

More Asthma Terms

2011-11-21T17:47:00.001-05:00

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:

Acute: It's happening right now.

Chronic: It'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).

Inflammation: Swelling 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.

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Faux (pseudo) pneumonia

2011-11-19T01:16:00.001-05:00

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.

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How to deal with hotheads at work

2011-11-18T07:20:00.000-05:00

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.

The Natural Progression of COPD

2011-11-17T02:32:00.000-05:00

I saw this curve at my pulmonologist's office about 16 years ago yet I couldn't remember what it was called until I found it 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. Essentially, this curve shows that smoking essentially speeds up the aging process.

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.

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WHO spins facts about 2nd hand smoke

2011-11-16T15:01:00.000-05:00

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.

Facts about 2nd hand smoke

2011-11-15T12:11:00.002-05:00

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.

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.
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.
It causes 600,000 premature deaths each year
It causes hardening of arteries and heart disease (about 46,000 deaths annually)
It increases your risk for stroke and brain aneurysms (thinning arteries)
It increases your risk for getting chronic obstructive lung disease, especially if you have asthma
It increases your risk for getting pneumonia
It shortens your lifespan (yes, even if you inhale someone else's smoke)
Separate areas in a building to not decrease your risk for second hand smoke related exposure. This is why smoking sections have no effect.
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.
40% of children are exposed to smoke at home.
31% of smoking related deaths occur in children
2nd hand smoke greatly increases the risk of sudden infant death syndrome
2nd hand smoke increases risk your child will develop asthma
Kids exposed to 2nd hand smoke are 1.5 to 2 times more likely to smoke themselves
Results in increased sick days and lost wages
Increases economic costs to society by forcing all of us to pay for the care of smoking related diseases and smoking cessation programs
Decreases lifespans (each cigarette takes 7 minutes off your life)
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)
Other breathing problems in non-smokers, including coughing, mucus, chest discomfort, and reduced lung function
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
Increases in the number and severity of asthma attacks in about 200,000 to 1 million children who have asthma
More than 750,000 middle ear infections in children
Pregnant women exposed to secondhand smoke are also at increased risk of having low birth- weight babies.
It may be linked to breast cancer
Causes premature death and disease in children and in adults who do not smoke.
Smoking by parents causes breathing (respiratory) symptoms and slows lung growth in their children.
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.
The scientific evidence shows that there is no safe level of exposure to secondhand smoke.
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.
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.
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:

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
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
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.
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.
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.
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).
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.
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).
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.
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.
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.
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.
In 1929 a study was published in Germany linking cigarette smoke with lung cancer (see here).
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,

Why do humidity and cold air trigger asthma?

2011-11-14T18:05:00.001-05:00

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 MyAsthmaCentarl.com

Here's Why Humidity and Cold Air Trigger Asthma @ MyAsthmaCentral.com

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:

Humid air is heavier and harder to breathe
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 here, rapidly 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.
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Rise above evil to find good, and death to find life

2011-11-13T05:40:00.000-05:00

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

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A nebulizer is not a microphone

2011-11-12T01:10:00.004-05:00

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.

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

2011-11-11T02:47:00.000-05:00

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

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Protein in raw mild may prevent asthma/allergies

2011-11-10T13:20:00.000-05:00

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.

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RT apathy may be symptom of a greater problem

2011-11-09T19:30:00.000-05:00

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?

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Dave the Apathetic Respiratory Therapist

2011-11-08T20:18:00.000-05:00

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.

Dictionary.com 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.

Listen to the Wisdom of the living

2011-11-06T09:25:00.000-05:00

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.

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Second hand sitting linked to heart disease and diabetes

2011-11-05T10:17:00.000-04:00

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.

Dailymail.co.uk 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.

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What are the trendy topics in RT

2011-11-04T09:21:00.001-04:00

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 AARC.org, 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.

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

2011-11-03T09:26:00.000-04:00

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. He 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.

So I enter the patient's room and do the EKG and go to draw the blood gas. The patient said, "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 who think they know what's best for us, and they make rules for us to follow (like that we have to pay taxes), and then they force us to comply. 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 by 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.

Thoughts?

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Respiratory Therapy Apathy Syndrome (RATS)

2011-11-02T15:26:00.000-04:00

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:

I work hard to help people who refuse to take care of themselves.
We intubate and put on ventilators patients with terminal illnesses because their family members think they'll miraculously recover.
We get tired of doctors intubating based on a number in lieu of using common sense.
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.
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."
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.
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.
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.
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.
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.
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?

Grumbling and griping at any new RT order, even those that they deem as needed
New onset of swearing (swearing by someone who normally doesn't swear)
Exhaustion
Burnout
Sore feet
Lack of interest in job
Silence
Repeated absence or tardiness
Lack of empathy for patients
Refusal to go above and beyond the call duty
Refusal to recommend new ideas because they feel they won't be accepted anyway
Comments such as "I hate my job."
Complaining
Refusal to learn anything new because they have decided it's pointless
Constant talk of getting a new job but feeling trapped
Eye rolling

What are the signs and symptoms of worsening RATS?

Saying things that might jeopardize your job
Talking bad about your job even in front of doctors, nurses and your bosses
Uncontrollable outbursts
Not introducing yourself to patients
Not talking to coworkers (nurses, doctors) who annoy you
Contempt toward certain doctors and nurses
Contempt toward patients who refuse to refuse treatments
Lying in your charting
Skipping treatments and charting "refused"
Problems at home
Sexual dysfunction
Signs of depression
Signs of stress
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:

Stupid doctor orders (the most common)
Overbearing nurses
Abuse of the word STAT
Repeated pages for unnecessary procedures
Needless intubations
Ignoring common sense
Incessant complaints about senseless charting errors
When charting is inappropriately prioritized
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:

Days off work: Get away from the problem
Exercise: Proven to help you deal with stress
Good diet: Works in conjunction with exercise
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)
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)
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.
New job: Go to school and try to move up the ladder, or switch professions (simply switching to another RT job will not help).
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:

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).
Xanax: It helps, yet the last thing doctors want are a bunch of relaxed RTs running around causing havoc.
Alcohol: It’s legal and it does help
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.
Sex: Eases symptoms temporarily
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.
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.
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. This might explain why RTs and EMTs get along so well. You can also read about it at the Urban Dictionary.

You can only do so much

2011-11-01T20:22:00.002-04:00

You can lead a dog to water but you can't make it drink.

You can walk a kid to school but you can't make him learn.

You can teach a person how to live a healthy life, but you can't make him do it.

You can only do so much, at which point you have to know you did your best.

Character and life's lessons

2011-10-30T14:43:00.000-04:00

A couple definitions first:

Character: Do you learn from your mistakes? Do you have a voice in the back of your head that helps you make the right decisions and prevents you from making bad decisions? It's who we are even when no one is watching. It's doing what is right even when no one is around. Everyone has character, and it's either good or bad. It determines your response to life's choices.

Good Character traits: Usually they are virtues such as honesty, integrity, dependability, loyalty, enthusiasm and humility. click here for more on this

Conscience: The niche in the back of your mind with a voice (perhaps of your mom or dad or Jesus) that says, "STOP!" when you are about to do something stupid. (read more here)

Respect: Do people appreciate what you do? Do you appreciate other people?

So when as a kid we hate when our parents are modest and are vague when we ask them questions like, "So, what do you think I should do with my life." As a parent and teacher, I find that I'm now the modest and vague adult.

You see, I became what I am by making mistakes and learning from them. If my dad would have encouraged me to become what I did not choose, then perhaps my life wouldn't have turned out as good as it did. My life is what it is through the development of character.

It's using the Free will God gave us. We make decisions and we reap the rewards or the benefits of our choices. When we make choices that result in undesirable consequences, we then (while developing character hopefully) make better decisions, wiser, safer decisions as we go through life depending on our personalities.

Imagine, for example, Ben Franklin's dad advising him to become a doctor instead of a journalist. His entire life may have resulted in something completely different, and he'd be a no-name today. America wouldn't exist.

So, what I'm saying is I think, as a dad, as a teacher, as a humble human, we learn that it's best to let fate take its own course, and the best way to do that, the best way to teach, is by example, and by encouraging kids to make their own decisions.

Thus, it's best not to come home from work and say, "My, I had a miserable day at work today." Or, if a student says, "I hear RTs have little respect," it's best to say, "This is a good career," as opposed to, "

I've learned that what makes a person what he or she becomes is not so much what

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