A world of bronchodilator lies!!!

So, have you guys ever wondered why doctors order so many breathing treatments for pneumonia? Slowly but surely we've been learning what doctors are really learning in medical schools. And, for the most part, it's based on a series of lies.

I hate to say it, but it's true. First of all, you've seen the surreptitious Physician's Creed I've been posting on my blog as I obtain pages from my secret sources. Yet recently one of my valued readers emailed me five online articles with the note: "It is hard not to expect doctors to use bronchodilators for pneumonia when articles like these are so easy to obtain."

The first one he sent to me was this one about bronchodilators at Yourtotalhealth about bronchodilators. The worst part about it is this article was approved by a doctor. I hate to say it, but he's either ignorant about bronchodilators, living on another planet, or he's an all out liar.

Here's what the article had to say: "Bronchodilators are medications taken to improve breathing. They help expand the airways and improve the breathing capacity of patients with bronchial asthma, chronic obstructive pulmonary disease (COPD), emphysema, pneumonia, bronchitis and other lung diseases."

So right off the bat this article lies. Bronchodilators improve breathing, but only in patients who have airway narrowing due to bronchospasm. This can be the case with bronchial asthma and chronic bronchitis, but is not true with emphysema and pneumonia.

Emphysema is a disease where the tissues in your lungs break apart. There is nothing that Ventolin does to increase lung tissue. Pneumonia, as I've written a million times on this blog, is a disease of inflammation of the alveoli. Not only are bronchodilator aerosols too large to make it to the Alveoli (Ventolin is 0.5 microns, a perfect size to fit into the bronchioles, but too large to fit into the 0.1-0.2 micron alveolar sacs).

Plus, there are no beta adrenergic receptor sites in the alveoli for the bronchodilator to attach to. And, even if there were, bronchodilators relax smooth muscles in the bronchioles. There are no smooth muscles to relax in the alveoli. Plus a bronchodilator will do nothing to treat inflamed alveoli.

Some doctors claim bronchodilators open up airways of pneumonia patients so they can cough up the junk, but this is a lie too, because pneumonia does not cause bronchospasm unless the patient is an asthma or COPD patient.

Of course the article only gets worse: "Bronchodilators also help clean mucus from the lungs to improve breathing. As air passageways are opened, mucus moves more freely because it becomes thin and can be coughed out more easily."

Where's the scientific proof to back this up? What study was ever done that proves bronchodilators clean mucus from the lungs. Of course, that is why we RTs joke that doctors think Ventolin works like scrubbing bubbles, in that it gets deep down in the lungs, suds up like soap, and gives the lungs a nice washing.

Of course, if air passages are not constricted, there is no need to open them (which is the case for most pulmonary patients). Likewise, MUCUS DOES NOT MOVE MORE FREELY BECAUSE IT BECOMES THIN AND CAN BE COUGHED OUT MORE EASILY. Who the hell thought that one up?

Ventolin is not a mucus thinner. In fact, Ventolin has absolutely nothing to do with secretions. If you want a mucus thinner, you have to go to a medicine called Mucomyst, which is a medicine made to reduce the viscosity of secretions. Ventolin does not.

The article states, "They work by relaxing the bands of muscle surrounding the airways." This is correct. By reading his own article this doctor should have realized what he said above was not true. And we wonder why Ventolin is the most abused medicine in the entire hospital.

Just reading this one article ticks me off so much I don't even want to waste my time with the rest. Here, I'll let you check them out though. Perhaps you can write the authors and ask them where they get their proof for their claims. Or is science not a part of medicine anymore?

This article from Allina Hospitals and Clinics describes Xanthines like Theophylline (Theodur) as a bronchodilator that treats pretty much any lung condition, including pneumonia. Of course we know it's a bronchodilator, meaning it dilates constricted bronchioles and that's it.

My anonymous source writes, "Then this study for antibiotic use for pneumonia suggested that more bronchodilator use may be needed especially in patients that have a prior history of bronchodilator use. I know that I don't have a medical background and probably don't truly understand this study, but how do we fight against this type of information?

Likewise, she writes, "I do agree with you about the bronchodilator fallacies, but there is a lot of literature that sure confuses the rest of us non-medical folks."

Let's consider that final study first. Here a study was performed to see if a bronchodilator breathing treatment would be as efficacious as using antibiotics to treat childhood pneumonia, which is often caused by a virus. The conclusion was this: "Treating children with non-severe pneumonia and wheeze with a placebo is not equivalent to treatment with oral amoxycillin."

First of all, antibiotics, like bronchodilators, are of no use when it comes to treating viruses. It's like pouring tap water on a wound and saying it's disinfected. Basically, this study is saying that 100 pneumonia patients were treated with a bronchodilator and they all eventually recovered. There's no scientific basis behind this study. It's poppycock.

It's studies like this that have us still using Chest Physiotherapy in hospitals. One study 50 years ago showed that 100 post operative patients were given CPT and they all recovered. So from then on it's ordered on all post operative patients. It's all based on poppycock studies, and it's given merit too.

So basically this study shows that bronchodilators are just as ineffective for childhood pneumonia as antibiotics. Although the results were interpreted otherwise.

Well, I understand how this can be confusing. Doctors, nurses and even RTs are confused about what bronchodilators do. It's not just a few, because I'd say about 80% of all bronchodilators given in the hospital are not indicated. I know, because I'm standing by the side of the bed before, during and after every single treatment a patient receives in the 12 hours I'm on duty.

Because I've been using bronchodilators for 40 years and have never once used it for anything other than for bronchospasm. And because I do my research and have studied bronchodilators ad nauseum. Something doctors don't do. And that's fine. But it would be nice if they would admit their ignorance instead of denying it and letting it go to their head. Instead of doing that, wise doctors and hospitals are going more and more to RT driven protocols so we RTs can use our experience, wisdom and education to the benefit of not just the patient, but the hospital too. Can you imagine how much money would be saved if stupid bronchodilator orders were even cut by 25%? It would be millions of dollars.

It seems to me that too often in this life we do things the opposite way we should in medicine. It seems to me that we'd be skeptical to give a medicine for a disease until it is proven to be effective. But, in medicine, we don't want to spend too much time or money on research when we can just give the medicine and CHOOSE to believe it is doing something. And then we have to deal with the consequences no matter how harsh those consequences are.

What's going in with healthcare reform is another perfect example. Here we pass all this healthcare reform while we have zero, zilch, nada evidence that it will actually work. Which is why it's sometimes better to do nothing than to do something we think is good but we don't really know. What we really should do is leave it to the experts. When it comes to bronchodilators, the people in the room assessing the patients are the true experts.

Yet that's not what happens. Those in Washington didn't vote for healthcare reform because there is proof it will work. They passed it because it makes them feel good. It makes them feel like they're helping people. It doesn't matter if there's evidence it won't work or not: it makes them feel good.

That's the case with bronchodilators. We give them for every respiratory disease, every patient who is short of breath, every irritating lung sound, and doctors and nurses and even some RTs simply feel good that we are doing something, and they CHOOSE to believe the medicine is doing something for them.

It's kind of like the lady who's given laxis and a bronchodilator because she had heart failure and was in pulmonary edema. Five hours later she says, "Wow! That breathing treatment really helped." See, this patient saw the bronchodilator so she gave it credit. The same is true for doctors and nurses. They give credit for what they CHOOSE to believe helped the patient. When the rest of us know it was not the bronchodilator that helped the patient. The bronchodilator did nothing but add more fluid into that patient's lungs. The real credit goes to the Lasix, which helped the patient pee out the excess fluid from her body and lungs.

Of course we intelligent folks know that cardiac asthma must not be confused for asthma. The patient can get them confused, but we medical workers never should -- yet there are those amongst us who do all the time.

Allow me to say here, folks, that the battle for bronchodilator reform is not going to be won over night. It's going to take no longer being enablers for doctors and nurses. We need to quit just giving the treatments, and we need to educate one doctor and nurse at a time.

Although, the only problem is we are merely humble RTs who want to keep our jobs. So quite often it's better to keep our mouths shut and do what we are asked rather than try to change ignorance we have no control over.

For more information on how doctors abuse bronchodilators, see my Physician's (Doctors) Creed in the links above, or click here. Click here to read more about bronchodilator reform. Click here to read about the benefits of RT Driven Protocols. Click here to read my apology for my tone in this post, and my apology to the websites and doctors above mentioned.

DR Creed: Bronchodilators treat inflammation too

The following might seem like nonsense to thinkers like you and me, but the Real Physician's Creed teaches doctors otherwise. Heed, what follows is suruptitious wisdom previously shared only with physicians.

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Page81

Section B6

While inflammation was mentioned in the previous section as an indication for bronchodilator, we decided to add this section due to questions ad nauseum regarding the use of bronchodilaotrs as such.

We educated folk know that bronchodilators are, well, bronchodilators. They, in essence, dilate bronchioles, which are the air passages in our lungs. Actually, what they do is relax spasming bronchiolar muscles when they are spasming.

Yet, while this is the scientifically proven use for bronchodilators such as Albuterol and Xopenex, we know that can't possibly be the only use for this great medicine. Therefore, since it sounds good and makes us feel good, bronchodilators just have to be indicated for inflammation too.

After all, inflammation is the cornerstone of many pulmonary ailments. We aren't quite sure how it works, but just know bronchodilators work along with inhaled and systemic corticosteroids to ease inflammation.

Likewise, it is not true that "If the bronchioles are not spasming, bronchodilators do not dilate bronchioles.

It is also not true that bronchodilators do not make it down to the alveoli, as we know this medicine has amazing shrinking abilities to reach the alveoli, and amazing enlarging abilities to stick to the large airways and nasal passages.

It is also not true that there are no beta adrenergic receptor cells in the alveoli and the throat, as we know they just have to be there. Also, there must be beta receptors in the nose and throat too.

Therefore, in case you were wondering, bronchodilators do work well for inflammation of the nose, throat, bronchioles, alveoli and anywhere else along the respiratory tract.

And this is why we recommend bronchodilator breathing treatments work for pneumonia (an inflammatory disease of the alveoli), bronchiectasis and bronchiolitis, as well as several others.

Note: Like the rest of this Real Physician's Creed, this information must never be mentioned verbally in front of RTs. They can wonder, but must never know.

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Doctor Lexicon

The Doctor Lexicon:

1. Stupid doctor orders:  ) Orders from a physician that lack common sense and have no purpose, and therefore having no benefit to the patient.  2) Orders that benefit the hospital by assuring the patient meets reimbursement criteria, although with no otherwise scientifically proven benefit to the patient. 3)  Doctor Orders written based on habit and with no scientifically proven value 4) doctor orders that are based on antediluvian theories.

2.  Normal doctor orders:  1) Doctor Orders written based on scientific evidence, or at least best practice medicine; 2) Orders form a doctor that benefit the patient

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, as opposed to proven by "oh, it sounds like a good idea."

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. 

9.  Impatient Doctor:  1)   Impatient must have everything done right now, and lacking such promptness he becomes particularly irritable.  (2) A doctor who shares his adrenaline rush in a negative fashion and has everyone up in arms and flustered.  The tasks his co-workers are doing appear to be completed with all thumbs, and this makes progress slow.  The milieu of the room is tense, and even while someone might have an idea to benefit the patient, no one wants to speak because Mr. Impatient is highly critical, easily angered, and constantly says, "Come on!  Come on!"

10.  Patient Doctor:  (1) Peaceful;  ;partially patient and ideologically indulgent.   (2)  A doctor who remains accommodating, calm and composed and he encourages his co-workers to do the best they can.  He's open to ideas and ideas are flowing from one mind to another.  He understands his demeanor of equanimity disseminates a calm and productive milieu.

Real Physician's Creed

1. Page 76: The Physicians Creed, how to take care of pesky RTs
2. Page 78: The Creed: Length of therapy and ABGs
3. Page 79: Creed updated to account for EKGs
4. Page 79: Real indications for EKGs
5. Page 80: Real indications for bronchodilators
6. Page 81: Bronchodilators treat inflammation too
7. Page 82: Real Dr's Creed: Bronchodilators treat CHF too
8. Page 82: Dr's Creed: Bronchodilators now lowers Fever
9. Page 83: Dr. Creed: Ventolin increases lung tissue
10. Page 84: Dr's Creed: Beta Blockers and pulmonary fibrosis
11. Page 85: Here's how bronchodilators treat hypercapnea
12. Page 86: Here's how bronchodilators treat lung cancer
13. Page 87: Dr's.Creed: Beta agonists & unrespiratory ailments
14. Page 88: Here's how bronchodilators treat pulmonary embolisms
15. Page 91:  The feel good policy of oxygenation
16. Page 98: The Ventolin Types
17. Page 99: The noninvasive ventilation (BiPAP) creed
18. Page 122: Treatment plan for man with lung cancer
19. Page 123: Croup now treated as asthma
20. Page 767: Discharge = Serevent, Admitted = Preventolin
21. Page 2,142: Real Physician's Creed Products
22. Page 9,435: The 17 Real Indications for Tylenol
23. Page 9,436 Politics and beta adrenergics
24. Page 304,403:  The three types of pneumonia
25. Appendix: New Scrubbin-family Black Box Warning
26. Appendix 2: The Bouncing Molecule Theory
27. Appendix 3: Why order SVNs over MDIs
28. Appendix 4:  The Kreb Cycle Theory of Oxygenation
29. Appendix 8: Hypoxic Drive Hoax Revisited
30. Appendix A: How to deal with Brovana
31. Appendix B: RTs Now Required to do gun cessation programs
32. Appendix Z: Section 982: Faux Study: One Budesonide Amp should cure stridor
33. Dr. Creed Updated for Obamacare

Here's what Albuterol really does, and does not do

Albuterol is the world's most abused medicine. Listed here are some of the medical conditions it is so often prescribed for in the hospital setting. This is followed by a pithy explanation of why it does or does not work for that particular diagnosis.

Asthma. Bronchial airways are chronically inflamed and hypersensitive (twitchy) to asthma triggers. Exposure to which causes an abnormal immune response that causes worsening airway inflammation. This irritates bronchial smooth muscles that spasm and constrict (bronchial constriction). This is responsive to bronchial dilators (beta adrenergic medicines) like Albuterol. This is because they are lined with beta 2 adrenergic receptors. Albuterol attaches to them and causes bronchial smooth muscles to relax, thereby opening airways and relieving asthma symptoms. This same type of bronchial constriction occurs with cystic fibrosis and in patients with chronic bronchitis, so it works for them too.

Pulmonary Edema. Heart failure. It causes an audible upper airway wheeze. It causes orthopnea. It causes severe dyspnea. It also causes increased intrathoracic pressure, and this squeezes airways, causing bronchoconstriction. This is not responsive to bronchodilators. Yet, because these patients wheeze and have dyspnea, the "feel good" solution here is to order a bunch of albuterol treatments, none of which do any good.

Pneumonia. I explained this in my post "Links between pneumonia and COPD."  I wrote, "It’s an infection of the air exchange units in your lungs, mainly the respiratory bronchioles and alveoli. An immune response causes this area to become inflamed. White blood cells (WBCs) are sent to the area of infection. The purpose of this response is to trap, kill, and remove the pathogens. As the disease progresses, the accumulation of WBCs cause pus to fill these areas, making them poor air exchange units. This means they become poor at allowing blood to cross into the bloodstream, resulting in a drop in blood oxygen levels."

A natural response to this by physicians is to order bronchodilators. However, unless a person has asthma, pneumonia does not cause bronchospasm. Bronchodilators are 0.5 microns, ideal for impacting bronchial walls. Terminal airways, respiratory airways, and alveoli are less than 0.2 microns, so bronchodilators don't even get that far. And, even if they did, there are not beta 2 adrenergic receptors there, so they do not good. Bronchodilators are not anti inflammatory medicines, and therefore are useless for pneumonia. However, despite this fact, a common criteria or admission to the hospital is three failed breathing treatments. This is a good criteria, considering (as you now know) albuterol is useless for pneumonia. The treatments will fail no matter how many you give because pneumonia is not bronchospasm.

Some doctors have sited studies showing albuterol increases sputum production as evidence it helps with pneumonia. However, what the hell does increased sputum production do with treating pneumonia? For more on this, check out Rick's post, "A World of Bronchodilator Lies." Also check out his post called, "Does Albuterol Treat Pneumonia?"

Emphysema. I explained this in my post "Bullous Emphysema." It's caused by the destruction of elastic tissue. This results in inflammation and breakdown of alveolar walls. Alveoli lose their elasticity, or ability to regain their normal shape after normal inhalation. "They eventually rupture, creating air spaces. Lacking elastic tissue, alveoli lose their ability to contract during exhalation. When the elastic tissue of enough alveoli are destroyed, these portions of the lungs expand all the way to the rib cage, giving the person the appearance of a barrel chest.  As the lungs are pulled outward, this causes bronchial airways to become stretched, thereby making them narrow (bronchial constriction). This causes increased resistance to air flowing through airways during both inspiration and expiration, slowing the flow of air. This is airway obstruction that does not respond to rescue medicine."

But we give bronchodilators to these patients anyway. However, despite this, most emphysema patients (a.k.a. pink puffers) claim they do not notice any difference afterwords.

Lung Cancer. Lung cancer takes up space in the lungs and prevents gas exchange from occurring. It results in wheezing and dyspnea. Albuterol is often given to these patients, but it will not make the cancer go away, and will not help these patients unless asthmatic bronchospasm is occurring, which is more than likely not the case unless there is also a diagnosis of asthma or chronic bronchitis.

Pleural Effuston. This is where you have excessive fluid buildup around the lungs. Because it can cause shortness of breath, the logical solution by physicians is to order Albuterol. However, albuterol does not suck fluid out of lungs, and therefore will not benefit this medical condition. It doesn't matter, because it will be ordered anyway.

Pneumothorax.  This is also called a collapsed lung. The belief among the medical community is that albuterol will re-inflate airways. The reality is that this is not going to happen. What is needed is a chest tube. The use of a chest tube in and of itself is often an indicator of the need for albuterol. However, Albuterol does not speed up time from chest tube insertion to complete recovery, at least not since the last time I checked.

Rickets. It is the softening of the bones in children. Albuterol will not help. However, and unfortunately already busy respiratory therapists, Albuterol will probably still be ordered for these patients.

Audible wheezes. If it's audible, it cannot be bronchospasm. It's audible because secretions are sitting on the vocal cords. This is very common when a person has pulmonary edema, such as what occurs in heart failure. What I say here makes sense, because true bronchospasm can only be heard by auscultation; it cannot be heard by the unaided ear. However, despite this fact, bronchodilators are so often prescribed for audible wheezes. I would go as far to say that about 80% of breathing treatments in the emergency room are for heart failure, which is the most common cause of audible wheezes. Another cause is dehydration, something that occurs in the aging and in ETOH and detox patients.

Further reading:

• RT Reform
• Bronchodilator Reforrm
• Bronchodilator Reform Part II
• A world of bronchodilator lies
• The dilemma of bronchodilator reform
• A letter to end bronchodilator abuse
• Faux respiratory therapy lexicon
• The Ventolin Pill
• The 9 different types of wheezes
• How to hear bronchospasm
• Lungsound lexicon
• Laryngospasm: It's often confused for a wheeze
• Rhonchi-eeeeeeeeze

Bronchodilators now treat inflammation too????

Wow! It just never stops folks. I was in the ER when one of our regular asthma patients was having a discussion with the ER doc. What impressed me was what the doc said.

"Well," he said, "I think what you have going on in your lungs right now is inflammation. Soooo, I'm going to give you some steroids and some breathing treatments to help with that."

"Holy...!!!" It almost slipped out, yet somehow I managed to catch myself. I was stunned at this new revelation. I was stunned because I actually heard it. I bet anything he had no idea his humble RT was standing behind him right at that very moment.

We educated folk know that bronchodilators are, well, bronchodilators. They, in essence, dilate bronchioles, which are the air passages in our lungs. Actually, what they do is relax spasming bronchioles when they are spasming. If they are not spasming, they do not dilate lungs.

Likewise, while asthmatic lungs are chronically inflamed, and therefore hypersensitive to one's asthma triggers. Thus, when the asthmatic is exposed to said asthma triggers, the inflamed airways respond by causing the muscles surrounding the bronchi oles to spasm. A bronchodilator, if given, will calm the muscles down and, thus, dilate the air passages.

It must be noted that bronchospasming is a side effect of a greater problem -- which is acute worsening of otherwise chronic inflammation. This inflammation is not treated with bronchodilators, but inhaled or systemic corticosteroids depending on the severity of the inflammation.

So, if doctors believe bronchodilators really do treat inflammation, this explains why bronchodilators are ordered for bronchiolitis which causes inflammation of the bronchioles, and pneumonia, which causes inflammation of the alveoli.

This is interesting. Why does it take so long for physicians to share this wisdom. We'll have to add this new medicine to our Ventolin types list. We'll call this one inflammatonex or inflammatolin.

An apology

One of the best parts of reading blogs is you are getting honesty. One of the worst parts of reading a blog is you are getting honesty.

The thing about honesty is it allows us to see things as they truly are and not so much how the clique or political world wants us to see them. And, unfortunately, the worst part about honesty is it can hurt.

One of my biggest fears when I started blogging was that I'd get a bunch of comments from people telling me I was an idiot for my opinions. For no other reason than no one with an opinion is an idiot.

On one regional political community I did get quite a few such comments, and I learned it was easier to ignore them than to respond. Yet when I started my blogs, I feared the worst.

Ironically, I have hardly ever received a harsh comment. In fact, I have another blog I write about politics, and I have never had a harsh comment on that site either. So, for the most part, I've been very fortunate.

By harsh comment I don't mean comments where people disagree with me. That I can handle. As in the real world, we know that no two people have the same opinion on anything. While my wife and I are both of the same political affiliation, and vote for basically the same type of people, we can get into some heated discussion about something we both have basically the same opinion. That's just life. It's what makes life fun and even interesting.

By harsh comment I mean those that say, "You're an idiot and a liar."

Yet after nearly three years of blogging, I've learned that evil comments are the least of my concerns. Even greater is myself -- the blogger. As a blogger, I am the sole writer, editor and publisher -- not good. A blog is about writing what's on your mind that you think others might want to learn about or at least read. Yet like any other person, a writers mood often comes across in his writing.

Newspapers and magazines and most websites have separate people writing, editing and publishing, and the reason is to make sure there is a good checks and balance system in place to prevent harmful and wrong material from going to print. As a writer, it's not easy to be your own editor and publisher. It's a chore. It's a lot of work. It's hard. It's a pain.

Do you see what I'm getting at? As a respiratory therapist, there are days when it's so slow at work I have time to write productive posts. Yet, on the rare occasion when it's ridiculously busy,
and I'm running around ragged because our doctors order breathing treatments that aren't needed on every patient, well, of course you know what's going to be on my mind. This causes fatigue, or what we like to refer to as burnout.

So this must have been the mood I was in when I wrote, "A World of Bronchodilator Lies!" The author in me wrote this based on what was on my mind that day, and somehow the editor and the publisher in me didn't nix it. It's the truth, it's how I really felt, yet perhaps the better part of valor would have been to have written the truth with a better tone.

In that post I wrote about a post that was written about pneumonia on another website, where the author wrote that an Albuterol breathing treatment would help thin and remove secretions. I wrote about how that is not true, and that the doctor who approved of that being published was either a liar or ignorant.

Of course he responded with the following comment:

"You should consult the journal Chest as bronchiodilators have, in fact, been shown to remove mucus.

If you wish to be taken seriously by anyone with even a basic knowledge of medicine and pharmocology, I suggest that you change the tone of your writing. Simply stating things are 'lies' makes you look uneducated and uninformed. You repeatedly lambast other websites for failing to accurately reference, yet you do the same thing yourself. You also have a significant tendency to simply ignore the research which doesn't support your position.

I agree that bronchiolators are over-prescribed (HMOs are in large part to blame for this). But the way your site is presented it is the last site I would send anyone to for information."

Now when you write an opinion, your going to have people disagree with you. That's just common wisdom. Yet to have someone so irate they write you a note telling you how stupid you are is never fun to read. However, when I was a journalist, we often celebrated when we received hate mail because that was a sign you were being read.

I'm not writing this post to apologize for writing that bronchodilators do nothing for pneumonia, because they don't. You don't have to do a study to learn that bronchodilators dilate bronchioles, and when a study is done to show bronchodilators help some patients with pneumonia cough up phlegm, it's because that particular patient was having some bronchospasm. That's common logic.

However, I am apologizing here for my tone. I apologize for calling said doctor a liar or ignorant. I have no proof he is a liar. In fact while I think he is wrong, I'm quite confident he's not ignorant. I'm quite certain there are few ignorant doctors, considering it takes a lot of wisdom to pass the doctor exams, and to become a doctor.

The truth is I do understand that the reason most bronchodilators are ordered is because some person sitting in a leather chair in some office in Lansing or D.C. decided, based on what a doctor told that person, that bronchodilators should be ordered on any patient diagnosed with pneumonia.

This is what we refer to as Intensity of Service. For the hospital to be reimbursed, the hospital has to prove the patient needed to be admitted. Thus, Medicare has unfortunately established a system where if a patient with pneumonia didn't need a bronchodilator at least every six hours for the first 24 hours, chances are he didn't need to be admitted.

Yes, there was a study that showed a bronchodilator helps some pneumonia patients. I've seen the first treatment do as much. Yet sometimes a study is telling you more than what we see with the naked eye. We might miss the basics, that a bronchodilator is a bronchodilator and nothing more.

Yet in the medical field, what works for 3% of patients works for every patient. And therefore it has become common place for bronchodilators to be ordered for every patient admitted with pneumonia. That's the way it is in the medical field. And it's easier for doctors to just go along with this flow than to oppose it, or, as I like to say, to make waves.

This particular doctor asked: where is your evidence. I like to send that question back to the doctor: where is your evidence that bronchodilators do anything for pneumonia. There has never been such a study with any conclusive evidence. Yet because of that, because no study is ever conclusive, it's easier in the medical field, safer in fact, to simply err on the side of caution. If it won't kill you, if it's safe, why not just do it. If it helps 3%, maybe it will help everyone.

So now we have hospitals like the one I work for with an order set for pneumonia that requires Albuterol every 4-6 hours based on the theory it might work for the patient. Yes, order sets, and medical studies, and best practice medicine, and preventative medicine, means there will be over kill. There will be tests, and extra breathing treatments, that will cost the hospital a ton of money.

Yet so long as something is deemed safe, it will be ordered. Why not? If a patient wants a breathing treatment, if medicaid and medicare and an HMO wants a breathing treatment for this patient, then just do it. What's it going to hurt?

Well, that's my job as a blogger to see the other side. It won't hurt the patient. It won't hurt the insurance company or Medicare, because they only pay a flat fee to the hospital anyway. Yet the individual without health insurance still has to pay 100% of the hospital cost. It's this private person who will be hurt by all this needless medicine.

The hospital will be hurt too. Because it will have to absorb the cost of all the medicine and therapies that are not reimbursed by the insurance company or the government.

The other individual who will be hurt is the respiratory therapist and the nurse. When you have 80% of what you do not needed, and you have 30 patients, you are going to become burned out. And, when the RTs and the RNs become burned out, not only does the worker suffer, so does the patient who really needs the services of the RT and RN.

So you see, in this way, preventative medicine does not work except to boost the egos of those who write them. And order sets do not work. Treating every patient the same way is not a good idea, it does not save any patient, it does not prevent any patient from dying, and it does not save money as is the intended purpose.

A better approach to patient care is positive outcome based medicine. This is where you might order a bronchodilator to a pneumonia patient if you think it might help, and if it does you order some more. Yet if it doesn't work, you don't do another. It's basically: do what works and don't do what doesn't works.

To me this is the common sense approach that would not only benefit the patient, but benefit the insurance company, Medicare and HMOs. Yet, more important, it would truly benefit the hospital by allowing them to reduce costs, and benefit the nurses, doctors and respiratory therapists by not forcing them to do 20 things at the same time they are trying to take care of the patients who really need their services.

I also would like to note here that when I started this blog I never expected to have an audience, so gaining or losing readers has never been a concern for me.

Yet I truly do take personal attacks personally (can't help it), and I must continue to remind myself that other people have feelings too. Usually we're all pretty good at that, yet sometimes when you're writing in a world of words and no faces, there's always the tendency to lose that sense of personality.

Yet at the same time we bloggers (well, me anyway) want to be honest and truthful, and to do anything other would make this blog boring, bland, common, and not worth reading.

So I went on a rant here, yet I just wanted to explain what was going through my mind as I wrote, "A World of Bronchodilator Liew!" I must have been in a foul mood that day due to needless burnout, and I was irate, and my internal editor and publisher didn't nix the tone. I don't think the post was bad, but the tone was. When he wrote, "You should change the tone of your writing," he was right. I thank him for that comment.

I don't think the doctor who wrote the above comment would have been so upset had I simply disagreed with him. I think he was upset because I basically called him an idiot and a liar, and he is not. I'm sure he's a good doctor, fine person, wise, intelligent, and, most important, he's obviously a fellow lover of the Internet. For implying otherwise I humbly apologize.

How do you define smart? Idealism -vs- realism

William F. Buckley Jr. once wrote a piece for Playboy -- I actually have never read Playboy -- and the title of the piece, it was brilliant. The title was: "How Do You Define Smart?"

I never read Playboy. Honest -- I never did.

I learned about this article through various other media outlets I read. You know, the one's that warp my mind. Actually, nothing I read ever warps my mind because I'm a free thinker. I believe as long as one is a free thinker nothing and no one can warp him or her.

So I think the question Buckley posed in this playboy article was a brilliant question. The answer to it, though, is multifaceted.

When I was a kid I always thought of my grandpa as smart. I say this knowing my grandpa quit high school despite his principal telling him he'd never amount to anything if he quit. He ended up starting an auto dealership from the ground up, and this ultimately became a Chrysler dealership in Shoreline.

Whenever I had a question he always had the answer. Yet there are old people in Washington and Lord knows many of them sure aren't smart.

So do we become smarter when we become educated? Well, Lord knows there are graduates of Harvard in Washington, and there are tons of ignorant politicians making laws who have no clue what they are doing.

We have many doctors who are definitely educated who don't have a clue what a bronchodilator is supposed to do, and they order bronchodilators for anything that causes a wheeze and treat any person who's short of breath as though they had asthma. And there are doctors who think a 1,000 tidal volume is appropriate for a 5 foot lady just because she's 550 pounds.

So there are lots of doctors who are not smart.

So what is smart?

Here you have a lifelong asthmatic who abused his inhalers because his asthma wasn't controlled, and yet all the other asthmatics he knew were gaining control of theirs. Then one day he woke up and thought, "Hey! Take your medicine, stupid!"

Yet, how can a blogger who has gotten every thing wrong for so long, be called smart. How can someone who did everything wrong in every way, shape, manner, or form be called smart? How does that compute? He's educated; he can string a couple sentences together; proper syntax. What the hell is smart? Why would someone read his blog.

This has always been something that has bugged me. Common sense is smart. Education does not mean you're smart. In fact, education, depending on where you get it, can corrupt you.

There are idiots with degrees all over Washington, DC. There are idiot doctors prescribing medicine and running ventilators. So how do you define smart?

Either way, I don't think it takes a smart person to make a smart decision. All you need are the facts on your side. Yet sometimes talking to people who think they are right yet they are wrong can be frustrating.

Let me explain my situation to you this way by asking you a question. Have you ever been in a situation, you're arguing or not even arguing, you're just discussing things with a group of people, and you know you're right, and you know you can prove it, and it doesn't matter to them.

And the reason that you know you're right is that you know things they don't know. And because they don't even have that baseline of knowledge to chat with you, they can't even understand where you're coming from. They get mad and walk away. Or, better yet, they laugh and mock at you and tell you that you are being ridiculous.

They'll say things like, "Well, that breathing treatment is toooooo doing that pneumonia patient some good. It dilates his lungs so he can cough up that pneumonia."

Yet you know that not only is the 0.5 micron particle size of Albuterol too large to get to the 0.1-2 micron sized alveolar sacs, there are no beta receptors in the Alveoli for the Albuterol to attach to. And even if there were, there are no bronchial muscles in the alveoli, to dilate, so the medicine will have no effect. Likewise, it's not an anti-inflammatory.

Yet your wisdom doesn't matter. You are the unruly one. You're the one who is being lazy and trying to get out of work. You're the grumpy one. Your the one who is out of his or her league. You're the one who's inappropriate. You're the one who's going to be written up if you take your stupid facts too far.

Have you ever been in a situation like that? You can go into politics here too. There are people who have a political position, and then you come into the discussion and say, "Hey! Wait a minute! If you consider this fact, what you guys are saying is poppycock!"

In fact, if I remember right, Socrates was sentenced to death for this exact reason. He questioned authority. He would walk up to successful business men and question them about how to succeed in business, and he'd get some very useful wisdom. Then he'd ask the businessman about how to make, say, horse shoes. The person would talk as though he knew what he was talking about, as though he were an expert in that area too, when Socrates knew he was not an expert in horse shoes. The businessman, in essence, was pretending to know everything, when in fact he was ignorant in nearly every area except running a business.

So, for questioning authority, for encouraging people to think, and to admit they did not know what they did not know, he was sentenced to drink a poison that killed him. Although, Socrates went down in infamy by his dying.

Anyway, they make you feel like an outcast. And that's how I feel every time a doctor orders a stupid breathing treatment and a nurse defends it. I feel like an outcast. I am the one with the facts, I'm being smart here, and yet I'm the outcast because, to the doctor, it "feels" good to order a bronchodilator. It' doesn't matter that it's doing any good, it just feels good to give it.

These bronchodilator-is-a-cure for-everything crowd are the idealists. People like me with the facts on our side are the realists. There is no science to back up their ideology. We know it's fake science. We know it's a fallacy. Yet these people have educations and degrees in the sense they are great nurses and doctors, yet they continue to fall for this crap.

Yet I've been an RT for 14 years. I know these people like the backs of their hands. I know exactly what they are going to say when I confront them even before I say it -- even before they speak.

Yet I'm always the dummy in their eyes. I'm behind the times. I'm "behind on my research," as one doctor recently told me.

I even make jokes about what they'll do on my blog and the jokes come true.

The only way to understand what's going on here is to understand the difference between different ideologies. You have idealism and realism. Education, years on this planet, experience, has nothing to do with how people think. I think it has more to do with idealism and realism.

Idealists don't like it when you come up to them and are truthful. They say that when you do that you are confrontational. You are causing confrontation. Yet, if you don't, you are being an enabler. I think way too many of us RTs are enablers: we enable doctors and nurses to get away with their false theories about bronchodilators. And all these nurses and doctors think that they're really smarter than everybody else by not having firm opinions on things.

I'm open-minded, I study both sides of the issue, and then I make an informed decision. If that's you, you are one of the biggest dupes, because you are sitting around judging both sides while one of them is lying through their teeth with everything they say to you.

The bronchodilator idealists will say they have the truth on their side, and 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 it 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.

Bronchodilators are but a small thing and a safe thing thankfully. Yet when you challenge these idealists on their political views, that's when it gets real interesting. Yet when you consider the cost of all the needless bronchodilators given daily, and the costs of employing RTs to dole them out, you'll realize how deep, complicated, and puzzling this really gets.

So I have to consider these things very seriously, the nature of the evidence, the seriousness of the charge that bronchodilators cure everything from rickets to pneumonia, these people are saying we really are saving the planet with Albuterol and so forth. (To get off topic for a minute, I recently read a book written in 1913 about asthma that spent 24 pages trying to prove Rickets was the cause of asthma. He also tried to prove via 24 more pages that asthma was a disease of toxicity, and it was related to urine. He was wrong, but the same principle applies: idealism versus realism).

Many people look at people like me and you as being realists. And they link realism with being judgemental -- which is true. If that's the case, I am more than happy to judge.

So, to come full circle: what is smart? Well, I'm going to tell you. Anyone with an average brain
can see idealism. We know what it is doing to the planet. We know what it is doing to the health care industry. We know what it is doing to the economy with it's regulations and taxes and government programs to create their ideal world.

We know what it is doing to the lungs (Well, nothing if you consider bronchodilators for pneumonia and CHF and rheumatoid arthritis and rickets.)

All you have to do is look at Detroit and California to see where idealism will take you. All you have to do is look at all the failing nations. Look at the old Soviet Union. Look at Cuba. Look at France for crying out loud. France is about to go bankrupt because idealists have been running it for years, if it isn't bankrupt already. Creditors have recently decided France bonds are junk bonds, and no one will loan that country any more money because it has no credibility. Sure idealists have good intentions, but good intentions and sound economics don't always jibe.

All you have to do is look at what is going on in Washington. All you have to do is look at all the people who are scared because the people in Washington want us to be scared. All you have to do is look at your own emergency room at all the people who really don't need to be there, who are complaining because you aren't taking care of them in a timely manner.

That's where idealism has taken us. That's what happens when we all become sheep and never think and never question and never judge. Everywhere idealism has taken you you'll see real disaster.

Don't these idealists understand that it might sound good to give out free health care, but all this free health care has done is make health care more unaffordable, as when you increase demand (more patients) and the supply stays the same (same # of nurses and doctors) the price goes up. Since Medicare and Medicaid have been started, all that's happened to the price of medicine is it's gone up and up and up. Heck, now we have federalized medicine, so one should expect this to get even worse. Although, they'll say, it was done with "good intentions."

Bronchodilator abuse may be a small piece of the pie, but it's a perfect example of what is wrong with our health care system. And even while you have 24 million or so who have no health insurance who really want it, we're going to screw up the whole system for all those who have it and are happy. That's idealism. It's all with the intent of creating equality for everyone, but it results in inequality. Unless you consider that everyone with a lung problem gets a bronchodilator regardless of need and regardless of cost.

I think, if we were real smart as a nation, we'd listen to the people like you and me at the bottom of the ladder, the people who actually see what is going on, the people with average brains and average educations, to get ideas for real reform.

I know I'm right because I know who these idealists are. They will not look at it ideologically and the only way they're going to be able to solve our problems is if he asks, "What are we doing here?" The numbers don't make sense. It's a total waste of time here. I don't see the point in doing all this if the numbers are so far off. Is this really science that we're dealing with?" Because if they asked these questions, they'd realize how humorous all their bronchodilator fallacies are. They'd realize our U.S. health care system really is the best in the world as is (or as it was).

Yet they won't ask these questions. They'll continue to believe in their idealist theories and they will continue to bog down the medical system with waste. I know, because I know these people like the backs of my hands.

A scientists should not take the idealistic route because that would pollute science. Yet we see that all the time too. Look at the global warming scandal for one example. I'm neither a believer nor a disbeliever in the global warming theory, yet you have those who support it -- even scientists, willing to do anything to show it is real -- even lie and twist facts. If global warming is real, let the facts and stats speak. So you can see why it's so easy for politicians, scientists, doctors, nurses and even RTs to become rapt in idealism.

But I'm just telling you, folks, the only way to understand this with certitude, with confidence, and then to be able to explain it to others is to understand what being a realist means, and what being an idealist means. Once you understand that it is so easy, because all you have to know is
that everything idealists say -- I know this sounds extreme -- everything they say is a lie. That's basically it. Once you come to accept that, then rest is easy.

Idealists will tell you world peace is possible, while idealists know it's not. Realists believe if we get rid of all our nuclear weapons all the bad guys will all of a sudden go away and the world will be at peace. A realist will look into the past and see that there was war way before nuclear weapons were discovered. Realists know there will always be some scum ready to take advantage of the good guy who is not prepared, which is what would happen if the U.S. ever truly disarmed.

Idealists will tell you that if you raise taxes high enough you will be able to afford enough government programs to help all the needy and to get rid of all the poor. I know this because I've seen the studies, and I've asked questions of them. They really believe some day world poverty will end if we stick to idealist programs. Yet, the realist will know from historical fact that increased taxes raise more money up front, but in the long run revenue will go down, and the country won't be able to afford all the programs. That's what's going on in the U.S. right now.

Idealists will tell you bronchodilators work for all that wheezes, or for all annoying lung sounds, or for all lung diseases. The realist at the bedside giving the treatment sees the truth, that the treatment did nothing.

Once you know that everything doctors and nurses who think bronchodilators cure everything is a lie, the rest is easy. It's easy to understand. You might not want to accept that, might be too tough. "Oh, my gosh, I don't want to think half the doctors and nurses are lying." Well, think about it, they're either lying, or they are simply flat out ignorant. Those are the only options.

Ignorance is not a bad thing. I'm ignorant about what nurses do, and I don't try to do their job. Doctors know much more about how to fix patients. Yet, when it comes to bronchodilators, no one knows more than the realist RT at the bedside who mumbles under his breath, "I'm just wasting my time giving this treatment." And, in the next breath, is defending the doctor's stupid order because he wants to keep his job.

Believe it or not, despite what I just wrote, respiratory therapy is a great career. The nursing program has advanced brilliantly over the years, and the challenge now before us RTs is to advance the RT program forward, which will not happen if idealism continues. Yet it won't happen either if we RTs continue to be enablers, and no one stands up and, in a professional manner, works to make the needed changes. To me this kind of challenge is fun, because I know the facts are on my side. Yet, at the same time, vexing, frustrating, and even daunting.

We gotta face it, folks, because this is, as they say in football training camp, nut-cracking time.

Faux Respiratory Therapy Lexicon

Basic Definitions:

1. Amnesia: This is what occurs when a night shifter goes to days for a long enough period of time. He, or she, forgets what it was like to work nights. Synonym: Night Shift Suppression Syndrome.

2. Night Shift Suppression Syndrome: See Amnesia above.

3. RT Grumpiness: This is what happens to RTs who develop apathy due to too many stupid doctor orders and burnout.

4. RT Deja Vu: Catching yourself repeating yourself to a patient. Catching yourself repeating yourself to a patient. Habit of asking questions automatically at that point in the procedure. Other signs include but are not limited to: Selective hearing, Lack of attention, Burnout, Brain infarct, Exhaustion.

5. RT idealism: The belief that perfection is possible, and an ideal setting for RTs is likely in the near or distant future where there will never be unindicated procedures ordered by doctors.

6. RT Realism: The wisdom that perfection is not possible, and the ideal profession is not possible, and that we must work within the means of reality.

7. RT Procrastinate: Delay doing an ordered procedure with the hope that you won't have to do it, or the hope (see below) the patient will realize it's not needed and refuse, or the nurse will forget about it.

8. RT Hope:You delay, and then you do what the doctor ordered hoping the patient will realize he doesn't want it, it's inconvenient, and refuse the therapy. However, more often than not, RT hope merely comes down to RT frustration

9. RT Frustration: Irritation that a patient says something like, "Well, the doctor ordered it, so I must need it."

10. RT Feel Stupid: A really awkward feeling an RT gets when he has to do a breathing treatment on a young, physically fit person who can blow 4,000 liters on his incentive spirometer, has no prior medical history, never smoked, has no lung disease and has absolutely no need for a breathing treatment. 11

11Rhonchi-eeeeeeeeze: if you takeRhonchi, and you realize that it was a word that originated in ancient Greece, yet when it was translated to Latin during the Roman Inquisition the pronunciation of the i's became eeeeeeeeeeeeeeeeeeeee. Therefore, if you pronounce rhonchieeeeeeeeeeeeeeee correctly, the i sounds like eeeeeeeeeeeeeeeeeeeee which sounds like wheeeeeeeeeeze, and there fore a bronchodilator is indicated.

12. Bronchodilator fallacies: Ignoring scientific fact and believing bronchodilators treat all respiratory ailments and all that wheezes. Synonym: bronchodilator lies; bronchodilator ignorance (see below)

13. Bronchodilator lies: Telling people that bronchodilators will help them (or their mother or father or friend) when all bronchodilators do is treat bronchospasm. Giving a patient false hope by falling back on that inevitable breathing treatment.

14. Bronchodilator ignorance: When the most intelligent amonst us believe in the myth that a bronchodilator breathing treatment cures everything from rickets to a bad mood, from patient anxiety to a nurses arrogance.

15. Treatment Stacking: Giving breathing treatments to more than one patient in more than one patient room. You'll be leaving one patient unattended while treating another. Ideally one should not stack, yet sometimes we have no choice.

16. Bronchodilator Reform: An ongoing request by RTs to educate RNs and physicians that bronchodilators are bronchodilators and nothing more.

17. Anti-irritation meds: A new line of medicine that doesn't yet exist to treat RT apathy, cynicism and vexation caused by annoying requests and stupid doctor orders.

18. RT Professionalism: RTs who radiate professionalism through their speech, manner and dress are more likely to be given a high degree of autonomy on the job, something every RT covets. It's your privelidge which must be earned and maintained through professional accountability. You must also keep up to date on your RT wisdom, and go above and beyond without complaining, and with a friendly disposition.

19. RT Autonomy: Something you earn through professionalism.

20. RT enablers: We RTs and RNs tend to let doctors get away with anything because we fail to question their authority. We, thus, enable them to get away with whatever they want. We fear them for whatever reason. We fear the wrath of doctors, and the wrath of our bosses for rocking the boat. If we ever want doctors to be held accountable, we need to start questioning them, although we don't: we enable. This is why we have bronchodilator abuse, tylenol abuse, and patients on ventilators three weeks too long. We fear not just doctors, but our own bosses. Due to this attitude on our own part, we have become enablers.

21. RT Equanimity: RT Equanimity is an important tool, essential for things running smoothly in the hospital setting. When an RT is cool, calm and collected, it shows he's compitent and confident at his skills.

22. RT Walk: When someone else can tell how busy an RT is by how he or she walks. A moseyed walk means slow, and a rush means busy.

23. Bronchodilator honesty: This is where get tired of being politically correct and lying to patients and their family and honestly, and humbly, tell them in an appropriate fashion that Albuterol won't benefit any ailment that isn't bronchospasm.

24. Bronchodilator osmosis: Calming vibes sent from the Ventolin amps in your pocket that is absorbed by osmisis by other people in the room. So, just by RT being in the room, this has a calming effect on disgruntled patients.

25. Respiratory Fate: The realization you were born to be an RT, and that the grass isn't always greener on the other side. The realization you are better off creating challenges and enjoying these challenges as opposed to getting frustrated with the monotony and politics of the job.

26.  Faux  Pneumonia: A fictitious diagnosis of pneumonia simply because pneumonia is the most reimbursable diagnosis.

27.  Bronchodilator honesty:  You are honest to the patient and tell them when you thing a breathing treatment is not indicated; you tell them they have a right to refuse.

28.  Bronchodilator lies:  1)  You are politically correct and tell the patient a bronchodilator will help a patient breathe better when you know this is a bunch of bull.  2)  When a doctor or scientists explains that a bronchodilator will do something you know it can't, such as help a patient expectorate pneumonia.

29.  Treatment stacking:  Concurrent therapy.  This is doing more than one treatment at a time.  By professional organizations it's viewed as bad because the patient safety may be a concern.  However, considering most treatments are not needed and this results in treatment overload, it's often necessary, convenient, and harmless.

30.  Treatment overload:  When more bronchodilator breathing treatments are ordered than are indicated.  This leads to RT passivism and RT apathy

31.  RT passivism:  Not responding to a situation that should foster emotion.  Someone dies and you don't care. Someone can't breathe and you don't care.

32.  RT apathy:  Lacking emotion.

32.  Respiratory Therapy Apathy Syndrome:  When an RT gets tired of doing BS procedures he develops apathy toward his job and his patinets.  This may foster uncharacteristic mood swings and verbal outbursts even when asked to do something useful.  This is often the result of bronchodilator abuse

33.  Bronchodilator Abuse:  1)  When unnecessary breathing treatments are ordered due to doctor belief that bronchodilators cure all annoying lung sounds and all causes of dyspnea.  2)  When unecessary breathing treatments are ordered due to reimbursement criteria set by the government.

34.  Reimbursement criteria:  Government set criteria that blackmails hospitals into ordering procedures for a particular DRG (such as breathing treatments for pneumonia patients) that aren't needed so the government has an excuse to refuse reimbursement when said procedures are not ordered

35.  Dyspnea:  1)  Short of breath  2) feeling of air hunger 3)  Feeling you can't catch your breath  4)  Many doctors and nurses mistake dyspnea for bronchospasm.

36.  Paradoxical bronchospasm:  2)  The belief that long term use of Albuterol (s-isomer) in some patients causes underlying bronchospasm.  It's been proven in studies but has never been evidenced in real life.  2) An excuse to market Xopenex as a stronger and safer medicine than Albuterol

37.  Bronchodilator stupidity:  If it proves their own theories it's believed.  Example:  Studies that show Albuterol enhances sputum production are believed wholeheartedly, yet studies that show Albuterol causes inert bronchospasm are conveniently ignored.

38.  Enhanced Sputum Production Hoax:  The belief that Albuterol will cause patients to cough up a loogy.

39.  Cough suppressant Hoax:  The belief that Albuterol will cause a patient to stop coughing.

40.  Wheeze:  Any annoying lung sound.  Requires bronchodilator.

41.  Bronchodilator Faux Thinking:  The process of calling an RT instead of racking your brain.

42.  Bronchodilator Faux Science:  Instead of using science doctors and nurses order Albuterol.

43.  Bronchodilator Osmosis:  A spirit of equinimity that eminates even from unopened amps of Albuterol.  Hence, just the presence of an RT can relax an unruly or anxious patient.

44.  RT enablers:  When an RT tells a doctor or RT boss what he expects that doctor or boss wants to hear instead of the truth.  The goal here is to keep your job by lying and being politically correct.

45.  Keystone Committee:  1)  A committee with a set goal of making sure clinical pathways (i.e. order sets) are created so that government set reimbursement criteria is met so the hospital can make as much money as possible.    2)  The process of creating clinical pathways (i.e. order sets) so every procedure imaginable is given to every patient with every DRG with the hopes of covering all our bases.  The idea here is that if we do everything the patient is bound to get better eventually.  3)  If you order everything for every patient you're bound to hit with something.  It often results in a disregard for the risk of RT and RN burnout and apathy.

46.  RT Equanimity:  When an RT is cool, calm and collected, it shows he's competent and confident at his skills.  It's the most important RT trait.  It allows the nurse and doctor to concentrate on their jobs instead of yours.  It also helps every one else stay calm

47.  RT Preparedness:  An RT who keeps up on his RT wisdom so he stays ahead of the game and is ready for any situation at all times.  Thus, a well prepared RT is the calmest person in the room.  See RT equanimity.

48.  Faux Confidence:  The bronchodilators-treat-all-lung-ailments-and-all-annoying-lung-noise doctors who still believe they're on the right side of history when they believe in faux and outdated ideas such as the hypoxic drive hoax and hoaxonex.

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

50.  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.

51.  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.

52.  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.

53.  Order sets:  The idea that if you do everything for every patient you'll hit on something and the patient will eventually go home.  It's a way to guarantee patient reimbursement.  It's socialism at it's best.

54.  Protocols:  Capitalism.  Individualism.  It's a policy that allows for common sense decisions to be made at the point of care by qualified medical professionals.  It reduces hospital costs, improves patient outcomes, and improves RT apathy.

55.  Hospital costs:  1)  The price the hospital has to swallow for doing procedures.  2)  It's the flat fee the government (CMS) pays minus the price the hospital incurs in taking care of the patient.

56.  Overhead:  The fewer the procedures needed to care for a patient the more money will be left over as profit once the government (CMS) reimburses the hospital for that patient.  Protocols result in fewer needless procedures and more overhead (profit) for that patient, and order sets and covering your bases reduce overhead and profit for that patient.

57. RT Confrontational: An RT who's willing to question  stupid doctor orders

58.  RT Enabler: 1)  An RT who's afraid to confront a doctor who orders something in opposition to proven facts and science. They are afraid to cause controversy. Antonym:  RT Confrontational.  2) They allow doctors and nurses to get away with their false theories like the hypocic drive theory, or that Albuterol cures all annoying lung sounds. 

59.  Idealist RT: Idealists will tell you bronchodilators work for all that wheezes, or for all annoying lung sounds, or for all lung diseases.  They keep their mouths shut like good little boys and girls and don't question any doctor orders.

60.  Realist RT:   The realist at the bedside giving the treatment sees the truth, that the treatment did nothing.  They will also tell you if it did something.  They get annoyed when senseless and unindicated breathing treatments are ordered.

61. 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.

62.  Thought:  Call RT

63.  RT ignorance:  When an RT thinks he knows everything.  He knows how to do the nurse's job and doctor's job.

64.  RT Burnout:  Physical exhaustion from working too hard.

65.  RT Apathy:  The loss of empathy for patients because of all the BS therapies that are ordered. 

66.  Respiratory Therapy Apathy Syndrome (RATS):  It's when RT apathy becomes chronic.  It should not be mistaken for RT burnout.  The RT starts to suffer from uncharacteristic and unexpected mod swings and verbal outbursts when they are asked to do menial tasks.  They develop a feeling that much of what they do is a waste of time.  They develop a feeling that nothing they do matters, and they have little energy even for doing useful tasks.  They often become humble when they should be aggressive because they've given up hope that anything will change.  They become obedient and unresisting, and accepting.  They give up and let doctors win because such RTs have come to terms that they cannot beat the doctor clique.  At some point, this 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 thinks is right.  He feels he is well educated and trained, but is unable to use his skills. He feels he's not allowed to think.  He becomes an observer, a neb jockey, because he begins to think he thinks doesn't matter. 

67.  RT Politics:  Not making waves.  Defending stupid doctor orders and not questioning ignorance and stupidity just to keep the peace.

68.  Priming the pump:  It's when you waste 1-4 puffs of the medicine so that when you take it for real you are getting the maximum medicine available.  It's ideal to recommend it, but most patients don't want to waste valueable medicine they paid for.

69. Neb jockies:  A respiratory therapist who is limited to administeringnebs without regrd to the respiratory cre professional's opinion or whether it has any therapeutic benefit to the patient and without regard to the other knowledge and skills that an RT possesses.

70.  Pulmonary Toilet:  Do every thing you can to flush all the junk out of a patient's lungs.  Do it even if the patient is already full.  Do it even if the patient has nothing in there.  Examples include mucomyst, chest physiotherapy (CPT), etc. 

71.  Faux Pneumonia:  The patient displays no evidence of pneumonia (labs normal, xray normal, assessment normal, etc.) yet the diagnosis made by the physician is pneumonia.  One common explanation is this is the most reimbursable diagnosis.

72.  Plamonia:  (n) A faux diagnosis of pneumonia for a patient admitted to the hospital awaiting placement to a nursing home; pneumonia for pacement

73.  Faux diagnosis:  (n)  A fictitious diagnosis to assure patient meets criteria for reimbursement (see faux pneumonia)

74.  Positional crackles:  crackles that move with position; while lying on right side crackles will be on right side, when sitting the crackles will be in bases (they move, like water, to the area of least resistance).

75.  Ventilitize:  The process of loading up a patient with so much ventolin there will be no further need to ever need hospitalization again. 

 76:  Germ spreaders: Every person admitted to the ER with sniffles, sneezes, body aches and pains, is ordered to get a beta adrenergic aerosol so we can spread their germs by means of aerosol.

77.  Respiratory intensivists:  An RT who exists just to do breathing treatments required so the insurance company is happy enough to flip the bill.

78.  Desensitize:  1)  To make less sensitive; Make someone less likely to feel shock or distress at scenes of cruelty, at other people's pain or suffering, or at death, due to overexposure

79.  Desensitization:  The process of becoming less sensitive to stuff you are overexposed to

80.  Respiratory Therapy Desensitization:  The process of a respiratory therapist doing so many breathing treatments on people who don't need them that he grumbles and gripes even when a person does need them.

81.  Automaton:  An indivudual who acts in a mechanical/ robotic fashion; he just does things by order of habit; he does a he is told

82.  RT Automaton:  An RT who treats all patients in a mechanical/ robotic fashion; they do not go off the beaten path because they are trained to do as they are told and that is that. For example, when a patient says, "Why am I getting this treatment; I'm breathing fine?" the RT is trained to say, "Because the doctor ordered it.  Our doctors are the smartest in the world."

83.  Automatize:  Automatic response to same event every time

84.  Respiratory Therapy Automazation:  The process of becoming an automaton, and , thus, treating all patients the same; speaking to all patients the same, speaking in a robotic cadence; speaking too loud even to those who can hear; responding with a grunt, curse and shudder every time your pager goes off

85.  Bronchodilator Defenders:  These are clinicians who defend any bronchodilator order.  They are often found saying things like "the doctor ordered it" or "it certainly can't hurt."

86.  Imaginary Wheezes:  An indication for bronchodilators. Used in a quote:  "Hey, can you fetch me an inhaler for this man's imaginary wheezes.

87.  Imaginary Bronchospasm:  An indication for bronchodilators.  Used in a quote:  "Hey, can you fetch me an inhaler for this man's imaginary bronchospasm."

Types of Respiratory Therapists:

1. Ancillary staff: These are workers who are told what to do, and do them as instructed without asking questions.

2. Professional staff: These are professionals who are involved in the care of the patient and are a part of the team that "thinks" of solutions to acute and/or chronic problems the patient is confronted with.

3. Button Pushers: Respiratory Therapists who take care of ventilators and do nothing more than follow doctor's orders and push the bottons on the vent. They are ancillary staff. They may assess and have ideas, but do not communicate with physicians, and make little effort to participate as a team member to the benefit of the patient.

4. Respiratory Therapy Nurses: A term that might give the RT profession the respect we have earned and well deserve, as the term "nurses' in itself should bring about the respect of a profession that is often treated as an ancillary service.

5. Dragons: These are the RT Bosses. They guard the RT Cave during the day and have their watchful eyes peering upon everything you do, yearning for you to make the tiniest little mistake. When they catch you they pounce even before you get a chance to dot the i or cross the t. Usually, they are home sleeping at night, resulting in a more relaxed work atmosphere.

6. Queen Bees: These are all the supervisors. They take the heat from the worker bees so the dragons don't have to deal with piddly little things; like things that don't involve money. One of their biggest responsibilities is doing the schedule, and they often get pounded by unhappy bees if the schedule is not to the respective bee's liking. While they get paid just a smidge more than worker bees, they get paid way less than the dragons. Yet, while these are usually aspiring dragons, they do not complain. Now, it also must be noted that Queen Mother Bees are often in a money mindset just like dragons. For example, you are not allowed to have overtime, because the farther under budget the Queens keeps the department, the bigger the dragon's bonus at the end of the year. This is probably the most stressful job in the hospital and the least respected, as while the worker bees come at her with their problems, the Queen is also getting constant "heat" from the dragons to keep the department under budget. This is actually a lose lose job. But someone has to do it. You have to remember that queens are great people like you and me with a job to do and a family to support. And, besides, you might be one some day.

7. RT Bosses: (See Queen Bees and Dragons) These are the bosses or hospital administrators. If you want to learn more about these unique individuals click here, click here and then click here. These individuals all where suit coats, and will usually present with smile and, of course, they will want a hug or a hand shake. They love money. Everything is all about money. They want every i to be dotted and every t crossed so as to make as much money for the hospital as possible. They want to keep the worker bees just Happy enough so they want to keep working, they also want to make sure money keeps flowing in.

8. Worker Bees: These are all the Peon RNs, RTs, environmental experts, computer whizzes, x-ray techs, lab staffers, and all the other individuals who swarm around the hospital making the place look good so the dragons can make their annual bonuses.

9.   RT Automatons: RTs who are trained to do and say the same thing every time a certain procedure is done on a patient, while disregarding uniqueness of the patient and the clinician.

10. The stepping stones: These are the RTs who use the career of RT as a stepping stone to a more illustrious medical profession. In my humble opinion, this is the way to go. What better way to learn about medicine than through the eyes of an RT. I'm serious here.

11. The quitters: These are the RTs who don't like to work. Some "Quitters" take a job of RT because they think it will be an easy job and they won't have to do anything. As soon as they learn what RTs really do, they either quit or are forced out the door.

12. The contents: They are the happy-go-lucky RTs who never complain. They are the RTs you love to give report to because they are always happy. They rarely make any effort at learning new information other than what is required. They usually prefer not to work with critical patients, and when they do they never question doctors and they prefer to be button pushers. Usually, you will see these RTs happily knocking off treatments on the floors.

13. The complainers: This composes probably about 60% of all RTs. These are usually very intelligent people who love the career of respiratory therapy in theory, but hate the reality of it. They are usually well up on all the new technologies, and are very quick to question doctors or offer suggestions. However, while they are not happy, they do nothing to better their career field. After working for a while, they become frustrated and content and they give up. One of the reasons they are so frustrated is that they have decided that they are too old to get another job, or have families which makes changing jobs difficult. Yet, while they complain, they do not support change.

14. The optimists (or learners): These are the RTs who write blogs. They may or may not be more intelligent than complainers, but they love to learn. These are the RTs that consistently do research on the Internet and read magazines. These are the RTs that attend every seminar possible. These are the RTs who write the protocols and make recommendations for new equipment, and then write the policy and procedures for this new equipment. These are the RTs who learn about things like Graphics and educate the rest on how to use them. These are the RTs who make the best of their career even though they know there are a lot of forces working against them. Most important, these are the RTs every one in the department loves to talk to because they are good listeners (they listen because they love to learn). More often than not, they work with the leaders to solve these problems as they occur. They often let other RTs take credit for the work they do. They do this to keep morale in the department high. In essence, the optimists are the strings that keep the department together. A department without optimists does not run very well.

15. The leaders: These RTs, while far and few, take charge and lead. They make changes to the RT Cave and they are resented for it. They make sure everything is stocked. They make sure all the i's are dotted and the t's crossed. They are usually opposed to protocols because they don't want to "rock the boat", but they won't say so openly. They listen to the rants of other RTs, but they usually side with the administration on issues. They question RTs who question the status quo. You might hear them at an RT meeting saying something like, "Don't you think protocols might actually create more work for you guys." When they say things like this, they are catering to the complainers, who will work with them to stymie any change. The leaders do no like change because it goes against their philosophy of "do not rock the boat." It is also important to note that while most leaders are good people with normal home lives, they are often hated and revered at work. Complainers often do not get along with them, and optimists are often seen working with them "for the better of the department."

16. Glorified EKG technition: RTs who work for smaller hospitals are are required to do all the EKGs. There are times it feels like this is all they do, and, thus, they are basically well paid and highly qualified EKG techs. What makes this worse is that some omniscient physicians (see physician lexicon) don't even respect the RTs ability to interpret the EKGs and request the doctor be hunted down immediately and handed the EKG. Common Sense Physicians respect RTs to be able to interpret

17.  Lazy RT:  This is an RT who tries to get out of work by trying to convince a nurse all that wheezes is not bronchospasm and therefore a bronchodilator is not indicated. 

18.  Respiratory Therapist:  Provides therapy, educates, and offers expert opinions to doctors and nurses. Education, experience and thought are needed to benefit the patient.

19.  Respiratory Jockey:  Someone who just does what he's told to do.  Less thouht is needed.

20.  Old School:  Some of the wisest respiratory therapists among us are your "Old School RTs."  They've been wearing out carpets and tile on hospital floors since the 1960, 70s and 80s.  Their minds are filled with so much RT wisdom they're often utilized as living Respiratory Therapy Encyclopedias. Although, they continue to defend old-disproved theories, such as the one that says IPPB is useful for some patients.  They just don't want to let go.  Yet despite this flaw, we love them.