Respiratory Therapy Cave: Search results for physician's creed

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Monday, August 6, 2007

Real Physician's Creed

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

Sunday, August 9, 2015

The Four Types of Pneumonia

A 1930 edition of the Real Physician's Creed.
It's now so huge it's non-photogenic.

In medical school, most physicians learn from the Real Physician's Creed, which by now is about 300,000 pages and still growing. I only found out about it because one physician is a friend of mine who used to be a respiratory therapist. But he is now retired, so he has given me permission to release some of the contents thereof.

On page 304,403, of edition 4,432, is a note describing the three types of pneumonia. Listed they are as follows:

1. Walking Pneumonia: Don't have it but something must be ordered to make everyone happy.

2. Pneumonia. They really have it and you can see it on the x-ray and everything. Or, as noted, sometimes you can hear it via crackles before you can see it on x-ray. Or, the white blood count is elevated, indicating there is an infection somewhere so it might be pneumonia. It is generally lobal and caused by a bacteria. Treatment is antibioitic to treat the infection and systemic corticosteroids to treat the inflammation. However, you may also treat it with ventolin because one study showed it enhances sputum production which, uh, somehow is twisted into making some doctors think it... well, it does help, errr, bring up the pneumonia... IT JUST DOES!!!

3. Faux-pneumonia. The patient doesn't have it, but you need a better diagnosis than walking pneumonia in order so that the patient may meet criteria. You can see it on the x-ray only if you have the superior vision abilities only taught in medical school, which can be found on page 3,133 of the Creed. (I at present do not have a copy of that page, as this part of the book I have has been destroyed by too many coffee stains).

4. Double Pneumonia. They have twice as much pneumonia than the average person who actually has a diagnosis of pneumonia, which some call real pneumonia as compared with faux pneumonia. It is generally caused by a virus and is deadlier than regular pneumonia. Treatment is to hit it with everything, including systemic corticosteroids to treat inflammation, antibiotic to treat the infection, ventolin to help the patient cough up the pneumonia, and anything else you feel like throwing at it. Usually it involves treating the symptoms. Treatment is generally supportive.

Further reading:

Sunday, May 5, 2013

Real Drs Creed: Hypoxic Drive Hoax Revisited

What follows is what will be added to the new addition to the Real Physician's Creed: How to take care of Pesky RTs. Again, this is TOP SECRET information for physician use only, and was never intended to be released among the RT community.
My source for this TOP SECRET information will be kept anonymous, because if his peers find out he is the leak, he will be banned from the medical community at best, or ridiculed at worse.

Page 10,400

Appendix 8

Real Physician's Creed: Hypoxic Drive Hoax Revisited

Date: April 9, 2012
From: Dr. Al Buterol, M.D., President of physiciansrock.com
To: Dr. Ven Tolin, president of the Dr. Creed Association

Basically the hypoxic drive theory was created as an excuse to get physicians off the hook for when a patient dies of hypoxia. It was originally intended to cover COPD patients, although we have extended it to include patients with severe asthma, lung cancer, cystic fibrosis, etc. It also includes every person who ever smoked, whether they are a CO2 retainer or not.

Since most people smoked in 1962 when Mr. Campbell gave his great presentation to the physicians of the American Medical Association, this theory seemed like a very good idea -- it made us all feel good. And just think about it, if our own fake theories make us feel good, that's a bonus. This new hoax pretty much got us physicians off the hook in most cases where we were sued for a patient dying of anoxia (for those who barely graduated medical school, that means lack of oxygen to the brain). This new hoax pretty much got physicians off the hook in most cases.

However, the bimbo heads in Washington continue their quest to get people to quit smoking, and this has put a damper on our profession. Since fewer people smoke today, this has resulted in increased litigation, and there be your reason for all the increased medical costs and all the warnings on medicine that most people ignore. We owe it all to evil lawyers who now have an open door to suing us because our hoax is no longer valid as often as we'd like due to people no longer being ignorant.

Now it also appears that some incompetent physicians and nosy respiratory therapists are on to our hoax, and are out to expose our efforts. This would be terrible because it would make us out to be wrong, and you know the medical profession is always right.

So my effort by sending out this memo to all my fellow physicians is to remind you of the importance of the hypoxic drive hoax, and the importance of the efforts to ignore RT efforts to inculcate the idea the Hypoxic Drive Theory is really a hoax. We know it is, but we don't want lawyers catching on to this, because that would result in lawsuits when when we intentionally keep COPD patients hypoxic.

Keep up the good work fellow Dr. Creed members. We must continue our quest to keep anyone outside the medical profession ignorant.

Sunday, March 16, 2014

Fullmonary Therapy

I'm sure you guys have heard of fullmonary therapy. It's when a patient produces excessive phlegm, and the patient makes that gurgling noise that nurses and physicians find so annoying. They order fullmonary therapy.

Here is the medical definition of fullmonary therapy per the real physician's creed:

Fulmonary therapy: Mucomyst BID and CPT QID because the patient is full of secretions and you don't know what else to do.

Ventolin is usually ordered as the conjunct therapy to keep the air passages open (air passages that are probably already open), although we would like to recommend fullmoterol brand fenoterol.

Usually when such a therapy is ordered, the RT will go on a rant like this:

The patient's large airways are already full of shit, and now you want to create more shit. This patient already has a week cough, if this is one of the few times times the medicine actually works, he'll drown.

Silly RT rants, hey? If the patient is full, it only makes sense to order fullmonary therapy. Besides, it sounds like a good idea, and it's fully recommended by the authors of the real physician's creed.

Reference:

Buterol, Al, M.D., Ven Tolin, O.D., "The Real Physician's Creed," 75th edition, volume II, New York, London, MentoCase publishing, page 238

Friday, September 12, 2008

The Creed: Length of therapy and ABGs

What follows is what will be added to the new addition to the Real Physician's Creed: How to take care of Pesky RTs. Again, this is TOP SECRET information for physician use only, and was never intended to be released among the RT community.

My source for this TOP SECRET information will be kept anonymous, because if his peers find out he is the leak, he will be banned from the medical community at best, or ridiculed at worse.

Page78

(Section B-3)

Physician's Real Creed: Length of therapy and ABGs:

There has been a new development in the line of bronchodilator therapy as taught at at medical schools around the nation. The following are new additions from the previous edition of this all important physician's creed.

30. If nothing else works, order Ventolin Q4 hours. The theory here is that eventually the Ventolin will break the disease process, and the patient will eventually be well enough to go home.

RTs will wine, something like this:

"I have a patient over on South who's been on breathing treatments for three weeks now. I have to hurry up and get up there, because this next one just might be the one that cures him."
While the RT is being facetious, we know it works. This is why you must follow DR. Rule #376: Once you order a breathing treatment, you must never discontinue it. Because we know, this next one JUST MIGHT BE THE ONE.

31. A low SpO2 is an indication for an ABG, even if the patient is in no respiratory distress.
32. An ABG should definitely be done during a CODE, even though we know what the results will be.

33. When you can't figure out what else could be wrong, an ABG should be ordered to rule out PE and sepsis. RT will cringe the ABG is not indicated, but we don't care. Probably 90% of all ABGs we order are to rule out PE, and of those about 97% are perfectly normal. Still, this is not a useless "unnecessary and useless poke" as RTs will say.

34. Serial a.m. ABGs should be ordered on any patient who was once in respiratory distress. RTs will whine that this is an invasive therapy, or that they have better things to do, or that the patient hasn't been in respiratory distress in three days. None of those complaints matter: we need to make sure the SpO2 is accurate.

35. No matter what RT says, a pH is not automatically normal just because the patient is in no respiratory distress. Just because the pt was "NARDN/ Denies SOB/ SpO2 99% on RA/ LS clear" as the RT charted on the ABG, does not mean the ABG was not indicated.

36. We know that in some hospitals the doctors have to draw their own ABGs. In these hospitals, the number of ABGs dropped by 75% because these doctors realized how un-indicated most of them were(see this Ventworld discussion). We do not want that to happen at your hospital, so DO NOT APPROVE ANY POLICY THAT MAKES YOU DOCTORS HAVE TO DRAW THE ABG. All this would do is give RTs one more reason not to gripe.

Besides, RTs love doing ABGs. And it gives them a reason to keep working. Therefore, they should be happy that we order them.
37. Thus, we doctors must not give into protocols that monitor EtCO2 and SpO2 at the expense of ABGs. If nothing else, we must not be bothered with learning all that stuff about ETCO2s and normal EtCO2 values. What is the normal range of EtCO2 anyway: 35-45, 20-50??? That's for future doctors to worry about. We need to stay in the 1980s as opposed to the 2000s.

Thursday, January 4, 2007

RT Humor

You can't make this stuff up folks. Read the following and you'll soon be privy to the reasons why the quest for bronchodilator reform was started:

They must exist products sold separately from the Real Physician's Creed:

MCAT Question:

Doctors:

Random:

The following are reasons why bronchodilator reform is needed:

Saturday, April 6, 2013

Dr. Creed: How to deal with Brovana

In light of my post, "So why is Brovana feared by RTs, RT bosses and doctors?," the medical director for Shoreline Medical Center, Dr. Hein Olin, sent a letter to the professor, physician and editor in charge of the Real Physician's Creed, Dr. Ven Tolin, who in turn sent the following letter to Hein Olin.

To: Dr. Hein Olin
From: Dr. Ven TolinSent: Thursday, November 15, 2012, 3:50 P.M.Subject: New changes to the Real Physicians Creed

Thank you for your letter of concern regarding that pesky Rick Frea. He has been nothing but trouble since he started his blog in October of 2007. His lies about bronchodilators have many of us on the defense as we are receiving letters on a daily basis from respiratory therapists concerned that most of the treatments we order are a wasted of time. We have made attempts to get his blog off the net, but unfortunately we have failed in our attempts. If you would fire him that would make our job much easier. So why don't you just do that? Of course it's probably too late anyway, as he would just keep "doing what I love to do," as he says on his despicable blog.

Yet I digress. Regarding this new medicine called Brovana. All it is is an attempt by the home care industry to get rid of Albuterol and Duoneb breathing treatments that we feel are necessary. These home care people are just lazy, and trying to get out of work. The respiratory therapists who think Brovana can just be given twice a day without any Duoneb in between are using fake science. Phooey on them. As we have discussed many times, what feels good and sounds good is much more valuable than science. So we have decided long ago that it sounds good to give Duoneb to all patients with lung problems, so we will continue onward with this policy. To change it would make us look like we are indecisive. I suppose it's for this same reason the President (Bush and now Obama) won't get rid of secretaries who perform poorly. We agree it would look poorly on them.

In our 31st edition of the esoteric "Real Physician's Creed" to be released in January of 2013, we will add a new section on Brovana. We will ignore the fact that Brovana is a fast acting medicine that works similar to the rescue inhaler Albuterol. We will continue to deny that giving Duoneb at the same time as Brovana is similar to giving two Duoneb treatments at the same time, and not necessary. We know it is necessary. It's necessary because it feels good. Who cares about science?

Yes we will deal with this Brovana nonsense in the new book. Until then we recommend you simply ignore that evil respiratory therapist Rick Frea. He is nothing but a piddling fool.
_____________
Thankfully I have my sources for getting this information, and I will not reveal my source. Ahahahahahahahahahahahahahahahaha

Saturday, August 15, 2015

Study: EKG goo soothes like VapoRub

The goo on the back of these stickers
proven to work like Vick's VapoRub

A new study that was conducted at the University of Medical Creed Hospital showed that the goo on the back of EKG stickers works similar to Vick's VapoRub and makes breathing easier.

As a part of the study, 8 people complaining of shortness of breath and chest tightness were given an EKG upon admission to the emergency room, followed by two more every two hours, followed by one each morning until discharge. The control group of 2 patients all did not have EKGs done, except for the initial one in the emergency room.

All the patients who had serial EKGs eventually got better, except one male who developed nosocomial COPD and was disqualified. Both the patients in the control group developed physician acquired pulmonary edema and were both disqualified.

Not these!
These don't resemble
Vick's VapoRub

Dr. Bill Senseless, who heads the Faux Pulmonary Research Project at the University, said, "The only conclusion we could make from this was that EKG therapy works to open up airways by osmosis through the skin to the airways. It works similar to Vick's Vapor Rub, only it's more profitable for physicians as we get $40 for just looking at the interpretation already on the EKG."

This study verifies the newly formed belief among the medical community that serial EKGs actually have therapeutic effects. It was for this reason that many health organizations have recommended a minimum of three minutes door to EKG time for all patients complaining of chest pain.

Further studies will not be performed to verify the results. However, a future study will be eventually prove EKG goo has real or perceived cardiac benefits.

Nausea, arm pain, hang nails, and rancid smelling patients are generally treated the same as chest pain and tightness. ACLS recommends a door to EKG time of 10 minutes for chest pain. The Real Physician's Creed recommends a door to EKG time of 10 seconds. Based on these recommendations, the Keystone Collaborate has succeeded in increasing the door to EKG time to three minutes so they have another reason not to pay if they don't want to.

Vick's VapoRub
Not recommended.
Makes stickers not stick

Dr. Senseless said that he has already sent a recommendation to the Real Physician's Creed Association to look into adding an EKG as a top-line treatment for all patients who come to the emergency room complaining of shortness of breath. This should be performed immediately before or immediately after a bronchodilator, repeated Q2 times 3, then Qam.

"And this is the minimum we require," Dr. Senseless added, "If it makes a doctor feel better, more can be ordered. We actually had one nurse recommend an EKG because a patient had a stuffy nose, and it worked like a charm. She said the respiratory therapist complained about wasting his time and that this only worked because it made the patient feel like something was being done. We're used to such sniveling by RTs. We just know it works because because of the Vapo Rub Effect."

Saturday, June 15, 2013

DR. Creed: RTs now required to do gun cessation program?

What follows is what will be added to the new addition to the Real Physician's Creed: How to take care of Pesky RTs. Again, this is TOP SECRET information for physician use only, and was never intended to be released among the RT community.

My source for this TOP SECRET information will be kept anonymous, because if his peers find out he is the leak, he will be banned from the medical community at best, or ridiculed at worse.

Page 10,350

Appendix 9

Physician's Creed: RTs now required to do gun cessation program

So Obama just made the following executive order:

"Preserve the rights of health care providers --" i.e., doctors "-- to protect their patients and communities from gun violence. We should never ask doctors and other health care providers to turn a blind eye to the risks posed by guns in the wrong hands. Doctors and other mental health professionals play an important role in protecting the safety of their patients and the broader community by reporting direct and credible threats of violence to the authorities."

Now, we already know that doctors have enough responsibilities. They are the experts in fixing people. They excel in areas that you and I could only imagine. Yet we also know they are burdened the following:

Threat of lawsuit
Threat of not being paid if a patient doesn't meet criteria for hospital admission
Threat of not being paid if the wrong diagnosis is made (by wrong here I mean a diagnosis that is not reimbursable, such as Asthma, Pneumonia, COPD and Diabetes are)

Consider the following:

Threat of lawsuit has forced doctors to to order every test under the book for even simple ailments, such as common colds and flu. You come in with a sniffle and you end up with an anal check and an MRI
Threat of not meeting criteria likewise results in patients getting stuff they don't need, like a breathing treatment, IV, Q2 neuro checks, Q4 hour anal exams. This also results in every patient getting smoking cessation, and Lord knows most people don't smoke.
Threat of making the wrong diagnosis has resulted in every patient getting diagnosed with pneumonia, flu, diabetes, COPD and asthma, and this has falsely spiked the asthma pneumonia rates

So now we want to add to this that doctors have to ask the person who comes in with a cold if he has a gun under his pillow, and who has access to it. Consider the following example: Patient comes in with a cold. Patient is diagnosed with a cold (after getting 2 anal exams and a spinal tap to rule out GI bleed and stupidity). The patient goes home and shoots his mother.

Now, due to Obama's executive order, that doctor is liable. So, just like the smoking cessation on every patient, now the hospital is going to create an order set that requires that every patient receive gun cessation education.

And, since respiratory therapists have nothing better to do, respiratory therapists will be required to do this. Yes, a gun in the lungs can cause a trauma that an RT will have to be present at.

Yes, consider the following sceneria (perhaps you saw this on Facebook):

Doctor: Tommy, does your daddy have a gun in the house? What kind of gun is it? Where does he keep it? Does it make you feel scared? Does your daddy ever drink beer? How do you feel about your daddy's mental health?

That will be our job. I don't have a problem talking to parents about gun safety, but this is a bit frivolous.

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Saturday, February 13, 2010

Real Dr's Creed: Bronchodilators treat CHF too

Many of the following might seem like nonsense to thinkers like you and me, but the Real Physician's Creed teaches doctors more than what we RTs learn in RT school. Heed, what follows is suruptitious wisdom previously shared only with physicians.

Page82

Section B7

While heart failure was mentioned in section B5 as an indication for bronchodilator, we decided to add this section due to questions ad nauseum regarding the use of bronchodilaotrs for such a purpose.

It is believed that bronchodilators are merely bronchodilators, although we as physicians know that can't possibly be true. Since heart failure causes a wheeze, a bronchodilator is definitely indicated.

The known scientifically proven fact is that heart failure can often cause a prolonged expiratory wheeze and shortness of breath similar to asthma.

This wheeze is caused by increased pressure in the lungs due to pulmonary fluid overload, secondary to left heart failure. Since the increased pressure basically causes the fluid to squeeze the lungs, symptoms mimicking asthma occur.

Now while it might appear a bronchodilator will not resolve this problem because this is not real bronchospasm per se, it sure makes us physicians feel like we are doing something, and it also makes the patient and family feel like we are doing something too.

Yet we are doing something. While it is not scientifically proven, it only makes sense that the 0.5 micron particles of the bronchodilator reach the bronchioles and bind to beta receptors there, these magically shrink to 0.1 microns and reach the alveoli.

From there we know that by a magic osmosis process the Ventolin particles cross over into the blood stream and take up a spot on hemoglobin and sits next to the oxygen molecule, and then it is transported to the kidneys, which have a known affinity to Ventolin.

Once there, the Ventolin attaches to the beta adrenergic receptors that we just know have to be there. Thereby to treat the renal muscle spasm. This also works to undead necrotic kidney tissue and improves the kidney's ability to clean blood and excrete secretions. Thus, along with being a bronchodilator, Ventolin is also a distal tubular dilator.

It can only be stated that while RTs will complain that our methods are not scientifically proven, we know that even with all the data, studies, hypo-the-sisses and hoax theories 'round and 'bout, lets add another.

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.

Saturday, February 6, 2010

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.

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.

Sunday, December 29, 2024

Decoding the Nebulizer: How Hospitalists Choose the Magic Mix

The "REAL Physician's Creed" is a highly classified and esoteric document, designed exclusively for hospitalists. Through our covert and undisclosed sources, we have obtained access to this "document" and its latest update.

Please keep this information strictly to yourself—should your hospitalists discover that you’ve gained access, they may take steps to shut down this blog. Use this insight wisely, not just for your amusement, but to better understand the absurdity behind some of the orders we all encounter.

--------------------------------------------------------------------------

To Whom It May Concern:

In the spirit of evidence-based medicine (or, at least, medicine that feels evidence-based), we at the Real Doctor’s Creed Administration have made some updates to our guiding principles. These are, of course, grounded in the timeless medical philosophy: "If it sounds reasonable, why waste time proving it?"

For instance, research suggests that water is good for the lungs. Rather than waste valuable time with studies, let’s simply agree this makes sense and get on with it. After all, we often ignore inconvenient findings from studies anyway. Consider nebulizers and inhalers. The research clearly states that inhalers with proper technique work just as well as nebulizers. Yet, in our infinite wisdom, we prefer to order QID nebulizers (or Q4ever, meaning "until discharge"). And if respiratory therapy dares to discontinue treatments using their so-called "protocols," we simply re-order them. Because why follow protocol when you can wield authority?

Now, in 2024, we’re embracing the same spirit of untested brilliance with a groundbreaking update to the Creed. We propose that the effectiveness of a treatment be directly correlated with the amount of solution poured into the nebulizer. A simple, elegant idea, isn’t it?

Here’s how it works:

If a patient with COPD, pneumonia, pneumovirus, influenza, parainfluenza, COVID, or heart failure hasn’t improved after two days of Albuterol, Levalbuterol, or Duoneb treatments, don’t bother considering other explanations. Instead, refer to the Creed.
Add more solution to the nebulizer. Not because there’s evidence to support it, but because it feels like we’re doing something. For best results, try:
- 4cc of hypertonic saline (especially if mucus plugging shows up on x-ray)
- Pulmicort, because why not?
- Performist/ Formotorol (and don't bother d/cing the duoneb or albuterol as duplicate orders are okay with us
- Mucomyst (especially if mucus plugging shows up on x-ray)
- If the patient has been using Albuterol alone, switch to Duoneb. The irony of giving a muscarinic to dry out lungs and hypertonic saline and mucomyst to thin and increase secretions can be just ignored.
Ensure treatments are ordered Q4 or Q6. The goal is to maximize the length of treatments, ideally to the point of inconveniencing respiratory therapists. If they’re annoyed, it must be working.

By adhering to this new protocol, we uphold our longstanding commitment to decisions driven not by science, but by intuition, tradition, and the thrill of making things up as we go.

Yours in medicine,
The Real Doctor’s Creed Administration

P.S. If this update creates any confusion among staff, refer them to the nebulizer for clarity. It’s bound to fix something.

Monday, December 31, 2007

Happy new year with the best RT humor of 2007

"Row, row, row, your boat...," Dr. Sam whistled calmly as he felt for the femeral pulse of the limp patient on the ER cot. "Gently down the stream..."

I handed him a bad copy of an EKG fresh off the press. "This is just a rough draft," I said.

He laughed, looked down at the EKG. "Good enough," he said, and returned his equanimitous gaze back upon the patient, and continued humming his happy tune.

Someone laid out a one-liner, and we all laughed. I set my EKG machine to the side and grabbed an ABG kit. "You want one of these I'm sure," I said, looking at the doc.

"Yepper," he said.

Obviously we wouldn't do this if the family were around, and probably not if it were a young person either. And if you were an outsider observing us, you might think we had an odd sence of humor. Truth is, we do. After you work in a hospital a while, you can't help to develop an odd sense of humor.

It is true, that despite what we do for a living, we medical workers still have to live, and we still have to maintain our senses of humor.

So, while the rest of the world is gearing up to watch the rest of the year wind down, I'm sitting here looking up RT humor, some of which I'm printing off. I think I'll post some of these on the bulleton board above where doctors interpret EKGs, and see how long it takes for them to be taken down.

Anyway, I just thought I'd end the new year highlighting some of the greatest medical humor of 2007 that I've found on the Internet. Consider, however, that I've only been doing this since October, so if I missed your brilliant post forgive me.

The following is medical humor at its best, or, since I've only been blogging since October, some brilliant observations I'll throw in here too. These are in no particular order:

1. The seven dwarves of the ICU: It's funny sometimes how unique our patients can be at times. I thought this was a spectacularly funny observation about working in the ICU.

2. Ativan nebs: I put this post up on the board over where the doctors read EKGs in our department, and it is still there 2 months later. Either that means they are avoiding it, or have read it and soon we'll be giving Ativan nebs just because instead of Albuterol just because. Our patients will love us for it, and we'll love the doctors for it, as all those troubled patients will be subdued.

3. The frequent flyer club: This is an absolute must read. Any medical person who has spent time in the ER has made the observation, "Why is he here?" Or, better yet, "The ER seems to be the hangout club of the scum of the earth." This article describes in detail the many different types of frequent flyers.

4. Stereotypical patient: Sometimes when you are working in the hospital you can't help but feel deja vu while walking from room to room. This author paints a humorous picture of the "stereotypical patient."

5. RTs -vs- RNs : This is a serious differentiation between RTs and RNs. After reading this, I spun off the humorous version: What RTs can do that RNs can't.

6. The naked, the fat and the dead: This may not have been meant to be funny, but it cracked me up none-the-less. Don't take offense at this please. I see it as a simple observation.

8. Musants: Doctor humor can sometimes be as bad as RT humor.

9. Physician's Creed: How to take care of pesky RTs : Just so I don't sound like I'm tooting my own horn, I'll quote a comment to this article: "That's possibly the best post EVAHHhhhh."

10. Ways RNs can iritate RTs: I'm sorry, but you can't keep your sanity as an RT if you don't develop a sense of humor. I compiled this and the above Physician's Creed with the help of my cohorts in the RT cave.

11. RCP, RRT, Mr. Bean: This is medical related, well sort of.

12. Weeding out the garden: This is a great analogy about respiratory therapy school.

13. Clinitian resistance to adapting new practices: Not necessarily humor, but a great observation of why RTs are so resistant to change, despite how many of us complain about frivolous orders.

14. Because I could: Here's a little Christmas poem that only a medical person could find humor in.

15. A funny story occured to me...: This is why I became an RT and not an RN.

16. The 11 Rules of Operating Room Etiquette for staff and patients: This is educational and humorous at the same time. It's seems we med workors find humor in just about everything we do.

17. Video of the week: Who thinks of this stuff anyway. Here is a video that is very educational... no, it's not educational, but it's hillarious. If you don't like spiders, you might want to not watch this one.

18. Dr's come in all shapes and sizes: Do you know what kind of doc you have tonight?

19. The dirty, dirty on ER nursing: What does it take to be a nurse? Well, you know I wouldn't be able to handle it, and this article explains why.

20. I heart pulmonologists: There must be something about working with lungs that makes people humorous and fun to work with. Well, you do know all us RTs are... Oh, never mind.

21. I could go on, but I'll stop here. This spot is reserved for all the humor or brilliant ideas not mentioned on this post. Some bloggers write so much funny stuff I couldn't possibly post it all.

Have a great new year.

Sunday, April 27, 2008

Ventolin now productive mucus thinner

The infamous Dr. Krane has impressed me with her wisdom once again. If you guys remember, she is the one who discovered that Xoponex is more than just a bronchodilator, that it is also a humidifier of the airways.

She is also the same doctor who orders treatments in ER "Now, and again in one hour." She is so smart that she knows before the first treatment is given that it will work, and that the patient will be short of breath again in one hour. Awesome. Brilliant. All doctors and RTs ought to worship this lady as the Einstein of Respiratory Therapy. She is obviously a strong supporter of the real physician's creed.

Today, I must inform you (and I am very impressed I must add), that Dr. Krane (fake name mind you), ordered me to do a second treatment on a patient who has a cardiac history and renal failure, and who also had crackles in the left base, which is indicative of pneumonia and not bronchospasm.

As the treatment was going, I asked the patient, "Are you feeling short-of-breath."

"No, actually I feel better," the patient mused.

"I ordered the treatment," Dr. Krane intervened, "because her sats were in the mid 80s and I thought the treatment might help with that, and open her up." Then she added with a snarl: "I also think that she has thick sputum, and that treatment might loosen things up a bit."

So there!!!

I looked at her countenance to see if perhaps she might be smiling. I mean, she was joking right? Nope. No smile. She looked serious as usual.

I did smile, though.

She said, "What's so funny!"

I couldn't answer. Instead, I bit my cheek to prevent myself from laughing further. In my mind, I was laughing at the fact that she just reminded me a new 'olin compliments of the real physician's creed.

It used to be called Mucusolin, and then the name was changed to thinolin during the IPPB rush of the 1980s, but more recently it's called Mucobuterol. It's a revolutionary new medicine, included in ventolin somehow, that has the ability to thin secretions. It is far more effective than Mucomyst.

To see a full list of 'olins check here.

Monday, January 22, 2007

Real Physician's Creed Products

Real Physician's Creed Products:

Wednesday, June 10, 2026

Palbuterol — And Other Things Only RTs Understand

It’s been a while since I created my list of 101 faux versions of albuterol for our Real Physician’s Creed. So I decided to showcase a few more.

Doctors and nurses may be confused… but we know.

If you’ve been around long enough in respiratory care, you start to realize something. Not everything we do is about the medication. Not every treatment fixes what it’s supposed to fix. And sometimes, what actually helps isn’t written anywhere in the order set.

That’s where these come from.

They’re absurd on the surface—but like most good respiratory humor, there’s a little truth hiding underneath.

PALBUTEROL

The medicine may have no effect…
But the company of an RT will.

We’ve all been there.

Treatment ordered. You show up. You assess. You listen. You already know—this isn’t going to change much.

But you stay anyway.

You talk. You reassure. You adjust a pillow. You tweak the oxygen just enough. And somehow… things settle down.

Was it the treatment?

Maybe.

But probably not.

ALLBETEROL

I think that’s all she needs.

There’s a moment in certain rooms where you realize everything doesn’t need to be escalated.

Not every patient needs more machines. More pressure. More noise.

Sometimes they just need someone who knows what they’re looking at… and isn’t panicking.

KNOWBETTEROL

For when you already know… before anyone else does.

You walk in.

Before the chart loads. Before the vitals cycle. Before anyone finishes explaining.

You already have a pretty good idea what’s going on.

Experience does that.

DEEPBREATHEROL

Side effects may include hearing things that weren’t there before.

“Take a deep breath.”

And just like that… crackles, rhonchi, noises everywhere.

Funny how that works.

ORDEROL

Prescribed every four hours… whether it’s needed or not.

No explanation needed.

The Point (Sort Of)

I’ll explain the Real Physician’s Creed more in a future post.

But the short version is this:

It’s not about making fun of doctors. It’s about pointing out the absurdity we sometimes see in medicine… by being just as absurd.

Because if you’ve worked in a hospital long enough, you know—

Some of the most ridiculous things we joke about
aren’t that far from reality.

And sometimes the difference between chaos and calm
isn’t another order…

…it’s just the right person walking into the room.

Sunday, November 23, 2014

The Noninvasive Ventilation Creed

What follows is what will be added to the new addition to the Real Physician's Creed: How to take care of Pesky RTs. Again, this is TOP SECRET information for physician use only, and was never intended to be released among the RT community.

My source for this ESOTERIC information will be kept anonymous, because if his peers find out he is the leak, he will be banned from the medical community at best, or ridiculed at worse.

Page99

(Section B-3)

Physician's Real Creed: The Noninvasive Ventilation Creed:

Noninvasive ventilation (NIV)systems are complicated systems that require extensive training physicians don't have time for. So, in lieu of spending thousands of dollars better spent on cigarettes and alcohol, allow me to simplify NIV so it's easy to memorize and requires little thought.

There are essentially NINE rules for NIV:

1. Know the types of NIV and when they should be ordered:

CPAP: prescribed for observed apnea or just simply obesity
BiPAP: for everything else

2. Know the indications for NIV and how it works:

Pulmonary Edema: it forces fluid out of the lungs
Respiratory Failure: it breathes for them
Hypoxic hypoxemia: it forces oxygen into the lungs
Hypercarbia/ CO2 >45: It sucks CO2 out of the lungs. Warning: Do not wait for CO2 to rise above 47. If it's 46, it's time for BiPAP.
Annoyed physician: If either the patient or RT annoys you

3. Know there are no contraindications, especially if you're too busy to consider intubation:

DNR: put it on anyway
Unconscious/ Obtunded: fluid rarely builds up inside the mask, so it's well worth the risk.
Restraints: same as unconscious
Apneic: use BiPAP because it breathes for them

4. Know that you can adjust the settings at any time without notifying a respiratory therapists. In fact, this can be done occasionally to boost your ego or tick off annoying RTs. If they suspect you did it, deny, deny, deny.

5. Settings: Always order 10/4. Increase settings aggressively to reach and maintain a pH of 7.40 and CO2 of 40. FiO2 should start at 40% and adjust to maintain a PO2 of 106. Or, just pull any numbers out of your head and stick with them no matter what RT says.

6. Special considerations: The increased pulmonary pressure will keep fluid out of the lungs and prevent pulmonary edema. Works well for the following situations.

Unable to give lasix on dyspneic patient
Need to give fluid bolus on dyspneic patient you are afraid to give lasix to due to hypotension (or any other reason)

7. Length of time on BiPAP for effectiveness to be reached is two hours. For this reason, it's important to talk patients into it, or have respiratory therapy force the BiPAP mask onto the patient, for at least two hours. It's rare, although fine, for the patient to be anxious during this time. After the two hour time frame is up the patient may be allowed to refuse. A proper order for this is "Intermittent BiPAP."

8. May be indicated for low blood pressure. Yes, we know that respiratory therapists keep saying that BiPAP is proven to decrease cardiac output and reduce venous return in order to reduce fluid in the lungs. When they say stuff like that just sigh and walk away. We KNOW that BiPAP can piss a patient off, and in this way raise blood pressure. It works well even better when combined with a continuous ventolin infusion.

9. You do not need to order an ABG to prove BiPAP is necessary. If the patient looks like a COPDer or CHFer, order BiPAP. Here's what RT might say, "Dr. Do you want me to do the ABG before setting up BiPAP so we can verify that it's needed?" To this you respond, "Do 'em in whatever order you want, just put the BiPAP on at some point so he can breathe better." So then the RT comes at you with the following ABGs: pH 7.4, CO2 40, HCO3 24, PO2 51, SpO2 86." The RT says, "He says he's breathing great now that I increased his nasal cannula flow to 3lpm from 2lpm. His SpO2 is now 95%." Look, it doesn't matter what the RT says, nor what the numbers say, in this case you must stick with your initial hunch. It's BiPAP all the way baby!

10. Know that BiPAP therapy is basically a glorified IPPB therapy. So, again, it may be ordered as "intermittent BiPAP" for PaCO2 >45. It also may be ordered as glorified BiPAP (i.e. Intermittent BiPAP) to ward off evil spirits.

11. CO2 Retention with normal or normalizing pH. So ABG results show a pH of 7.29 and a CO2 of 79. You know the CO2 is normally in the mid 50s. This is an ideal place to order BiPAP intermittently. This way you can gradually get the CO2 down to the patient's normal range. It's okay to order even if the patient is awake and alert and in no respiratory distress. It's okay to order this especially if the RT grumbles and gripes about it.

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Friday, August 7, 2009

Creed: Croup now to be treated as asthma

I couldn't help getting frustrated the other night as one of my infamous ER doctors ordered Q30 minute breathing treatments for a croupy kid. Since I'm having a much better night tonight I decided to do some research and found nothing on the Internet.

For some reason I gallivanted down to the physicians lounge, and lo and behold what do I find? Sitting right there on the end table next to a couch in all it's fresh white with blue letters naked glory was letter written to one of our physicians.

Here is what the letter said:

From: Dr. Hein Olin
Sent: Thursday, July 30, 2009, 4:50 P.M.
To: Shoreline Medical Physicians
Subject: New changes to the Real Physicians Creed

As you guys and gals were informed in my last memo, the 2010 edition of the Real Physician's Creed has already gone to print. Since we don't want you to wait until next year to implement the new changes and recommendations, and since we know you want to continue to piss those pesky RT varmints with new "stupid" (snicker) doctor orders, I am sending this memo to inform you of the latest change and recommendation.

In the past we recommended treating croup as inflammation of muscles in throat and give the patient racemic epinepherine. We now recommend you change that old habit. What we want you to do now is treat all croup as asthma. Likewise, we recommend you give Pedonephrine once, followed by Croupenex Q30 minutes X 4. If after four Crouponex treatments stridor persists, follow this with one dose of Pedonephrine RN, and then Q30 minute Croupenex until discharge.

If that don't get them riled up nothing will.

Thank you for your consideration. Good luck irritating 'em. Maybe you'll even get one of 'em to roll their eyes at you.

Hein Olin DO
Vice President Real Physicians Creed Association

Well, there you have it. This pretty much clears up the recent trend toward Xopenex for croup.
Those doctors are on to our frustration and are trying to dig a deeper wound. I think it's time we take a stand.
Thanks to my secret sources, I now have the definition of the medicines listed in the above letter. In the next few days I will list them in the Ventolin Types section at the top of this blog.

Thursday, December 5, 2013

Dr. Creed: Pulmicort: the new miracle medicine

To: Dr. Ven Tolin
Company: Doctors Creed Association of America
From: Dr. Sloof Lirpa
Date: 1/14/2013
Subject: Pulmicort

The planning committee for the 64th edition of the Real Physician's Creed met last night, and the hot topic was the use of Budesonide (Pulmicort) on all COPD patients. Dr. John Carlton of The Royal London Hospital reported that he gave pulmicort to a COPD patient suffering from severe shortness of breath, and the next day the patient was better. He tried this again a month later on a patient with a similar condition, and that patient got better the next day too. So he recommended to the committee to add pulmicort as a front line medicine for all patients admitted with asthma, COPD, or pneumonia. He believes that instead of waiting until the patient has been admitted for two weeks, that we start it right away. This way the patient will eventually get better and we can discharge him. I personally would like to endorse Dr. Carlton's idea. Certain pulmonologists in Europe have already begun their own experiments with the medicine, and I highly encourage us to send the memo to pulmonologists in the U.S., and then to add it to the Real Physicians's Creed for the next edition. I would like to see this medicine used with increased frequency throughout the year. I do not feel as though any further testing is indicated.

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Tuesday, November 6, 2007

Physician's Creed: How to take care of pesky RTs

Warning: What follows is top secret information surreptitiously leaked to me via one of the nations elite pulmonologists from an elite teaching hospital. Read at your own risk. This is not edited.

Page76

(Section B-2)

Physician's Creed: How to take care of pesky RTs:

To help themselves feel better about spending two stressful years in the silly respiratory therapy program, Respiratory Care Practitioners too often bellow about protocols because they think they know more than Internists and Pulmonologists. This is simply nonsense. The following is a list of how to deal with a foolish RCP who dares speak his or her mind.

1. All respiratory illnesses should be treated as asthma, thus require bronchodilator

2. Or, all that wheezes should be considered as bronchospasm

3. To clarify 1 and 2, all of the following are indications for bronchodilator, no matter what RTs say:

All annoying lung sounds
CHF (Pulmonary edema)
Pneumonia
Lung Cancer
pneumothorax
Obesity
Rickets
Any surgery
Coughing too much
Not coughing enough
History of smoking
Cold symptoms
Sinusitis
Lupis
M.S.
Stoma
Tracheotomy
Bed ridden (MS, ALS)
MRSA (any origin)
Mechanical Ventilation

4. The best pressure support is 10. Period

5. Doctors need their rest and should never wean on weekend or between 7pm and 7am

6. Tidal Volumes are best set by keen eye, not kg per ideal body weight bla bla bla

7. Even if patient is using Automode, he is considered to be getting mechanical breaths. Vent changes should be made with this in mind.

8. If RT babbles about therapy no longer being indicated, double frequency, change dose and add IPPB.

9. If RRT annoys you, change Albuterol to Xoponex Q3-4, Atrovent Q6, and consider using Pulmicort, Intal and/or Mucomyst. This will make tx last forever (tee hee hee)

10. By the way, it’s okay to mix Atrovent and Mucomyst into the same treatment

11. Never, ever, ever discontinue breathing treatments.

12. Ignore their silly notes.

13. Complain to cardiopulmonary director that RTs are trying to get out of work

14. Prolocols hahahahahahahahahahaha(See note below)

15. OK, we’ll give them a protocol or two to make them happy. We just won’t order it.

16. If RN calls for treatment, it’s indicated. Period. Besides, this prevents them from calling again.

17. You don’t need to assess patient to know bronchodilator is

Page 77

indicated.

18. If you’re worried about side effects, order Xoponex. If RT complains Xoponex is same as Albuterol, see steps 8 and 9.

19. If you have no clue what’s wrong with patient, even if labs and x-ray are normal, the patient has pneumonia.

20. Oh, and if they have pneumonia, then they better get a bronchodilator Q4. Who cares whether or not they have a bronchospasm component.

21. Of course we know the patient will be SOB every four hours. We are that smart you know.

22. If RN and RT work in cahoots to call you because a patient doesn’t look right, and they recommend ABGs be drawn, order Q3 hour treatments and hang up. That will teach them not to bother you.

23. By golly, if you find out a patient has pneumonia and is not on treatments, you better order them right away. Make up for lost time by adding Pulmicort. This speeds effect of bronchodilator.

24. If patient CO2 rises from 40-45, by golly you better order BiPAP regardless of WOB.

25. All COPD patients are retainers. Period. There’s no need to trial patient on higher O2s, because that’s just a waste of time. If the RT complains patient was on 100% FiO2 in ER for 8 hours & was perfectly fine with it, just ignore them, or refer to steps 8 & 9. All of these patients should NEVER receive more than 2lpm or 30% VM, no matter how low their oxygen goes. Yes, we know scientists say fewer than 10% of COPDers are retainers, but they are wrong.

26. Patient should not be allowed to recover in surgery after 7. P.M.; put them on a vent.

27. We don't want our surgical statistics to look bad, so all patient with no hope of survival should be rushed to floor.

28. And, finally, if they call you, act like you are annoyed and in a hurry; grumble, mumble orders, gripe and hang up without saying good-bye.

29. Oh, and as with RN orders (see section B-1, How to take care of pesky RNs), make sure your written orders are illegible.

For further information see section D-3, Why doctors are always right.

Note: Yes, it is true that some of us physicians (myself included) have approved RT protocols at some of our nations elite hospitals in the past. These have proven to be disastrous, and merely work to build up the egos of RTs. Please forgo the insanity, and follow this list to the best of your ability.

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