The Outsider: A Poem About Fixing Our Profession

I had some time this past weekend at work, so I played with words and wrote this poem. I hope you enjoy it. Please share your interpretation or thoughts in the comments below.

Section 1: The Outsider

As a child, he sat alone, glasses taped at the bridge,
nose red from the endless sniffles, the quiet weight of his own company pressing like winter’s chill.
They saw him as different – an outsider marked by silence and the half-shy glances he cast downward.
They laughed, taunted, cast him off,
and he grew used to the solitude,

He found solace in the pages of books,
in thoughts they would never bother to understand.
He learned there was a world within himself, a different world –
one that didn’t need their approval or laughter.
And in that silence, he discovered a strength,
a better kind of different.

He was the outsider.

Section 2: The Outsider’s Aspiration

The outsider knows what he wants to do.
He wants to be a thinker, writer, teacher,
To do things that make sense,
What needs to be done,
What's proven to work.

Section 3: Love for People vs. Restrictions of the System

He wants to work with people,
because he loves people.
He loves to listen to their stories,
to teach the right way,
rooted in scientific fact.

So he chose a path in healthcare,
becoming a respiratory therapist,
drawn by the chance to help, to heal,
to be there in people’s most vulnerable moments.
He thrives on the human connection.

But the system won’t let him think freely,
won’t let him speak the truth,
without the risk of becoming an outcast,
without fear of losing his job—
a reality that caught him by surprise.

Section 3:  The Shifter and Historical Parallels

He entered the paradigm with fresh eyes,
an ability to see what is and is not.
And he began to shift it,
creating a new way,
one that would make more sense for his job.
He is the paradigm shifter.

He knows how Copernicus felt,
when he proved the Earth wasn’t flat,
yet had to keep it a secret,
for the last 30 years of his life,
fearing he’d be silenced forever.

Section 4: Institutional Stagnation and Paradigm Paralysis

He feels like a pawn.
They place him where they want
And expect him to do his job
The way it's always been done
Even if what he does doesn't matter.

It's called a paradigm paralysis,
The greatest obstacle to progress.
The inability to see the truth
Or the refusal to see the truth,
Is the greatest obstacle of all.

It's a paradigm paralysis,
Not seeing beyond the current thought process.
It's not seeing out of the box.
It's being stuck in a pattern,
And not seeing a better way.

Section 5: Questioning Established Practices

While your mind is shut, his is open.
He sees the foolishness of your ways.
He sees the observer of reality,
Watching you do that and do this,
Just as they've done for years.

"Why do you do it that way?" he asks.
"That's how we've always done it," you say.
"But do you ever ask why?" he presses.
"Do you ever stop to think—
Why prescribe a bronchodilator for pneumonia,
When it’s meant for asthma?"

Section 6: Historical and Modern Medical Myths

You'd think people would want the truth.
Yet for 2,000 years doctors studied Galen
And they did even after the truth got out,
That Galen never dissected a human corpse.
Instead, he dissected an ape.

Galen described an eight-segment sternum.
And even while the Galen passage was read,
While the chest was being dissected,
And a three-segment sternum was revealed,
Nary a person thought to say, "Galen was wrong!"

Andreas Vesalius did say Galen was wrong,
And he proved Galen was wrong,
Yet he was called a liar and a quack.
"What Galen says is true!" his peers hailed.
They were stuck in paradigm paralysis.

Section 7: Modern Medical Paradigm Paralysis

That's why there's no cure for asthma,
Because all dyspnea is STILL treated as asthma.
Hippocrates defined dyspnea as asthma.
And so we still treat all dyspnea as asthma,
Even though the evidence shows it's not.

Bronchodilators are bronchodilators,
Yet they are used to treat cardiac asthma,
And pneumonia, and collapsed lungs,
Lung cancer, kidney failure, croup,
And rickets along with bronchospasm.

It's called wasted medicine for no reason.
He's a respiratory therapist for 12 hours
And he sees bronchodilator abuse first hand,
He knows it has no effect on the patient,
And so does the patient.

Yet few patients question the procedure,
Because doctors have earned their trust,
And so few think to question,
Anything a doctor orders.
They just want to get better.

In fact, even most doctors know the truth,
Yet they have no choice but to order them,
Because that's how it's been done forever.
And doing it any other way would make sense,
Yet it wouldn't make sense to them.

Even if a doctor knows the truth he can't speak it,
Because he'd be an outcast among his peers,
He'd be castigated by the doctor clique,
And reminded that the truth doesn't matter,
Because bronchodilators are thought to cure everything.

The COPD patient was on 100% oxygen
For eight hours in the Emergency Room,
And the patient did not stop breathing.
Yet later he was ordered on 28% oxygen
Because of the hypoxic drive myth.

He watched as the patient's dyspnea worsened,
As his skin turned from pink to blue.
He called the doctor who refused more oxygen.
The patient suffered as a result,
Of the paradigm paralysis.

Yet even if the doctor knew the truth,
He'd have to accept the myth as truth,
Because the clique accepts the myth,
And the courts accept the myth,
And, hence, the myth becomes the truth.

Section 8: Desire for Change and Personal Constraints

He knows it and you may know it too,
Yet what is he, what are you to do?
You know about paradigm paralysis.
You know it from your observation.
You know it by scientific fact.

He doesn't want to be the first to speak,
And neither do any of his peers.
So he keeps his mouth shut,
And you keep your mouth shut,
And nothing ever changes.

He knows we could probably cure asthma
Because the wisdom exists right here.
Yet it's just beyond our scope of understanding.
It exists just outside the box,
Just outside the paradigm.

And so he carries on—

The weight of what’s wrong pressing at his mind,
Yet he grits his teeth and moves forward.
He has a family to feed, bills to pay.
It’s worth it, he tells himself,
For he loves to think, to wonder, to dream.
He also loves his patients, truly enjoys helping people,
And he endures as a respiratory therapist,
Because his coworkers—his great crew at the down-home hospital—
Make the long hours lighter.

Section 9: Resolution and Acceptance

Paradigm paralysis prohibits people

From seeing valuable information,

even what's right before our eyes.

Yet he sees it, and he remains silent,

Just like Copernicus did.

So progress is slow, even STALLED!
Morale among the workers is low,
And resources are wasted,
Money is wasted,
Time wasted.

He feels like a pawn, stuck on the wrong path,
Yet to others, it's the only path they've ever known,
Because they don’t see path B, the way out.
All they see is the same pattern, path A,
A path that’s been worn down by time,
And yet, no one dares to ask if it's the right one.

He knows what he wants to do.
He wants to be a thinker, writer, teacher,
To do things that make sense,
What needs to be done,
What's proven to work.

He discovered a new paradigm,
and he's therefore the outsider.
He doesn't understand the current paradigm,
Yet he does understand the new one.
He's an outcast if he says what he knows.

Section 10: The Solution:

To create a blog,
To write poems of what he learns and thinks,
To share his ideas with the world,
Hoping others will learn and shift the paradigm for the better.
It's a small move, but as Laennec learned,
Sometimes the shift happens long after the shifter—the outsider—has gone.

He's the fresh eye and the hope
For everyone who wants to fix the system.
Yet he needs courage to speak up.
He knows what to do:
He must make waves—hence the small waves created via his blog.

He cannot quit his job,
So he did this.
Because he has four young mouths to feed,
He’ll suck it up,
Keep his mouth shut tight,
And do what he loves.

He loves reading, observing, and listening to new ideas.
He loves to question the things he’s ordered to do.
He loves to draw a line from point A to point B,
And ask, "Why can’t we do it this way?"
He’s the outsider. And now, he's also the blogger—
A small but meaningful act.

He’s the outsider—
Seeing what must change,
Bound by what cannot.

Obamacare Policies Hit Rural Communities Hard: Needs To Be Revised

In 2010, Congress passed, and President Obama signed, the Affordable Care Act (ACA), also known as Obamacare. While the ACA has expanded health insurance access for millions, certain policies within the law have led to serious challenges—especially for small, independent hospitals in rural areas.

One of these policies, the Hospital Readmissions Reduction Program (HRRP), penalizes hospitals financially if patients with conditions like heart failure or COPD are readmitted within 30 days. Although the program aims to improve care and reduce preventable readmissions, it has placed smaller hospitals in a tight spot when caring for patients with advanced, complex conditions that often require ongoing attention.

A former hospital worker shared how their boss predicted the impact of the ACA when it was signed into law. “Our hospital has been independently run since 1904. I’m proud of our board and president for keeping us afloat all these years,” he said. “But with the new policy denying reimbursement for COPD and heart failure patients readmitted within 30 days, I predict that within five years, our hospital will be forced to merge with a larger facility.”

He was right. By 2015, that hospital, like many others across the country, had merged with a larger network—a trend accelerated by an ACA provision that streamlines hospital mergers. Intended to reduce costs and expand access, these mergers have brought unintended consequences for rural communities.

While joining larger hospital systems can bring benefits, such as higher pay and improved resources, it also centralizes essential services. Local jobs in billing, scheduling, and administration, which were once provided by local residents, are now handled in urban centers, reducing rural employment opportunities and lessening the economic impact of these facilities on small towns.

This centralization has also made it harder for patients to see doctors, as hospital staff are now consolidated in larger facilities with overcrowded schedules. Many specialized services, previously available locally, have moved to hospitals in big cities. This requires patients to drive longer distances, often navigating traffic and difficult parking.

The HRRP has faced criticism from healthcare professionals, who argue that the penalties disproportionately impact smaller hospitals. While the program intends to improve discharge planning and follow-up care, in practice, it often forces hospitals to add costly administrative staff to meet the regulatory demands without actually improving patient outcomes.

“Many of the patients we see with severe COPD or heart failure are in the later stages of their disease, so avoiding readmissions isn’t always possible,” one healthcare worker noted. “They’re often readmitted for complications we can’t control, yet Medicare penalizes us even if they come back with an unrelated issue.”

Healthcare experts say that these financial penalties add strain to smaller hospitals and may ultimately reduce the quality of care in rural areas. In some cases, hospitals are forced to merge or reduce local staff to avoid penalties, leaving rural patients with fewer options for advanced care. Many are now required to travel to larger cities for specialized treatments that were once accessible locally.

As these issues come to light, some advocates are calling for Congress to revisit the ACA and amend policies that encourage hospital mergers. They propose new legislation that could break up large hospital systems while still allowing for inter-hospital collaboration to reduce costs and improve care. Restoring independent hospitals could bring back essential local jobs in scheduling, billing, and other areas while improving healthcare access for smaller communities.

Advocates argue that patients in rural areas would benefit greatly from more specialists nearby, reducing the need to travel long distances for routine care. They believe revisiting the ACA could help rural patients and local economies alike, creating a healthcare system that better serves communities beyond major cities.

In my humble opinion, many aspects of Obamacare need to be reevaluated, if not completely revised. With over 20,000 pages, the bill may need to be scrapped and rewritten from the ground up. Better yet, perhaps it's time to consider scrapping the entire system and allowing capitalism to work—something that has never truly been tried in healthcare.

Chapter 3: The Dawn of Homo Sapiens Sapiens and Early Medicine

Modern humans, known as Homo sapiens sapiens, first appeared in Africa around 200,000 years ago. By approximately 100,000 years ago, they began migrating out of Africa, eventually spreading across the globe. These early humans were more anatomically and behaviorally advanced than their predecessors, including Homo habilis, Homo erectus, and earlier forms of Homo sapiens . Their bodies were more suited for walking long distances, allowing them to travel to various parts of the world in search of food. As they adapted to different environments, they also developed better tools and hunting techniques .

As Patricia Netzley notes in her book World History Series: The Stone Age, these early Homo sapiens sapiens lacked the pronounced facial features of the Neanderthals and had taller, less robust bodies. In appearance, they were quite similar to modern humans. Netzley explains, "Longer legs gave them the ability to travel longer distances, which meant they came into contact with many other tribes of people. This exposure to other cultures and ideas may be the source of their greater creativity compared to their ancestors" . Additionally, these humans made a wide variety of tools, utilizing materials such as rock, bone, antlers, ivory, and wood . They fashioned weapons like saws, chisels, flint axes, spears, bows, and arrows. Thin pieces of bone were used as needles to sew hides into clothing . These advancements enabled them to hunt larger animals, like the Woolly Mammoth, and they used every part of the animals they killed—eating the meat, using the bones for tools, and creating ornaments and beads from leftover materials .

They likely developed a form of communication, possibly both verbal and artistic. Cave paintings found in several locations suggest that these early humans used art to record their activities and relay knowledge to future generations . Language, though speculative, must have existed to facilitate hunting coordination, knowledge-sharing, and the teaching of traditions, myths, and medicinal practices .

While there is little direct evidence of medical practices from this period, it’s reasonable to assume that Homo sapiens sapiens developed rudimentary forms of medicine. They likely provided care to the injured and sick, experimenting with herbs and natural substances as remedies. As they had no concept of internal diseases, their explanations of ailments likely involved the supernatural—perhaps attributing sickness to spirits or demons. Netzley hypothesizes that such beliefs led to the development of rituals, incantations, and prayers aimed at appeasing these spirits .

According to historian Fielding Hudson Garrison, primitive people often worshiped natural forces and elements, like the sun, moon, and storms, which they believed were controlled by spirits. Disease was thought to be caused by malevolent forces and could only be cured by appeasing these spirits . Garrison explains that these early humans would offer sacrifices and engage in rituals to ward off disease or misfortune. They might have believed that diseases were caused by human enemies with supernatural powers or by offended spirits of the dead .

Given the prevalence of respiratory diseases today, it's plausible that early humans experienced symptoms similar to asthma or bronchitis. While these diseases may not have existed in their current forms, infections and environmental factors could have caused airway inflammation, leading to breathing difficulties .

As empathy developed within these early communities, humans began to care for one another more attentively. Mothers would comfort their children when they were hurt, using simple remedies such as applying mud to burns or massaging sore muscles. These actions represented the earliest forms of caregiving, laying the foundation for more formalized medical practices .

By the time Homo sapiens sapiens had fully established themselves across various regions, they had created complex societies with spiritual beliefs, healing practices, and sophisticated tools. These developments mark the dawn of medicine, which would evolve as human understanding of the body and disease grew over time .

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References:

1. Netzley, Patricia D. World History Series: The Stone Age, San Diego, CA: Lucent Books, 1998.
2. Roberts, J.M. The Illustrated History of the World: Prehistory and the First Civilizations: Volume I, New York: Oxford University Press, 1999.
3. BBC Science and Nature, "Neanderthal: Their Bodies Were Well Equipped to Cope with the Ice Age," http://www.bbc.co.uk/sn/tvradio/programmes/horizon/neanderthal_prog_summary.shtml (accessed April 4, 2013).
4. Garrison, Fielding Hudson. An Introduction to the History of Medicine, 3rd ed., Philadelphia and London: W.B. Saunders Company, 1922.
5. Sigerist, Henry E. History of Medicine: Volume I: Primitive and Archaic Medicine, New York: Oxford University Press, 1951.

Understanding Different Asthma Phases: My Take on Episodes, Flare-ups, and Attacks

When it comes to asthma, we often hear terms like "episodes," "flare-ups," and "attacks" thrown around. But what do they really mean? Are they the same, or is there a difference? Let’s break it down, based on my personal experience as both a respiratory therapist and an asthmatic.

Asthma Attacks: The "Stop Everything" Moment

An asthma attack is what I consider the most severe phase. It’s when symptoms like shortness of breath hit you hard, forcing you to stop whatever you’re doing. It’s no longer about managing the condition quietly in the background. At this point, you need to take immediate action—whether that’s using your inhaler, moving away from a trigger, or seeking medical help.

"That asthma attack hit me like a wall—I had to rush to the ER."

In cases like this, it's all about following your asthma action plan and not delaying treatment. Waiting too long can lead to a situation that could get out of control.

Asthma Flare-ups: A Slow Burn

Flare-ups, in contrast, can feel more like a gradual build-up of symptoms. You might notice mild breathlessness that comes and goes. Sometimes, it feels like a nuisance rather than a major issue. But, if left unchecked, flare-ups can worsen and eventually lead to an asthma attack.

"I had a week of persistent wheezing before the attack—it was a warning sign I should have acted on earlier."

Think of flare-ups as your body waving a caution flag. It’s manageable, but it’s also a reminder to stay vigilant and adjust your treatment if needed.

Asthma Episodes: The Catch-all Term

“Episodes” is a more generic term often used in research or by healthcare professionals to describe any occurrence of asthma symptoms, no matter how mild or severe. This term doesn’t quite distinguish between an attack or a flare-up—it just means you’ve experienced symptoms.

"The patient had multiple asthma episodes over the course of the month, varying from mild to severe."

For most of us in day-to-day life, “episodes” isn’t a term we commonly use. But it’s helpful to know when reading medical literature or research.

Breathing Between the Storms

Ideally, between attacks or flare-ups, we should experience periods of normal breathing. For most asthmatics, lung function should stay at or above 80% of the predicted value during these calm periods. This means you should feel like yourself on most days, with little to no asthma symptoms.

"On a good day, I feel like I don’t even have asthma—my breathing is completely normal."

Remission: When Asthma Takes a Break

Sometimes, especially after childhood, asthma can seem to go into remission. This means you go long periods—months or even years—without any significant symptoms. However, asthma never truly goes away. It can always resurface, even after a long break.

"Childhood asthma can sometimes go into remission, but it’s important to remember it can return later in life."

Asthma Forgetfulness: The Sneaky Risk

When you’ve been feeling good for a while, it’s easy to forget you have asthma. This can lead to overconfidence, like skipping medication or exposing yourself to known triggers. It’s a lesson many of us have learned the hard way.

"I once thought I was free of asthma, only to have it come back full force. Lesson learned—don’t get too complacent."

What’s Your Experience?

Asthma is unique for everyone, and the terms we use can vary. What matters most is understanding your own symptoms and having a plan in place for when things go awry. How do you describe your asthma experience? Let me know in the comments below.

The flaws of those who make the rules

Jim Leyland was a good team manager for the Detroit Tigers. He laid down the law when he needed to. But he was also very good with maintaining the morale and motivating his players. 

There’s an art to making rules. It’s better to have no rule than to create a bad one. If you make a rule, ensure it serves a purpose, and most importantly, make sure it doesn’t cause harm. Rules made just for the sake of it are pointless. Put simply: it’s better to do nothing than to do something stupid.

Rules are generally created to improve a situation—or at least attempt to. Take, for instance, administrators trying to reduce infections in the emergency room. A noble goal, no doubt.

Now, consider an example involving suction equipment. For 30 years, we’ve ensured the ER trauma rooms are ready for anything. In a CODE situation, there’s no time to set up equipment, which is why we always have the suction canister ready, tubing attached, and a Yankauer nearby.

One day, I rushed into the ER for a CODE BLUE. The doctor was ready to intubate, and I had set up the endotracheal tube. But when I went to turn on the suction—nothing. No canister, no tubing, no Yankauer.

The equipment was there, but still sealed in its packaging. It took precious minutes to unwrap and set up, slowing us down at a critical moment.

During the post-CODE debrief, we learned why. The person responsible for following Joint Commission (JCAHO) guidelines had taken the suction apart, stating that JCAHO required everything to stay packaged until use. I replied, “If JCAHO has a rule preventing us from setting up vital equipment, then that rule needs to be changed. We need it ready when it matters.”

In this case, the rule that was meant to help ended up hindering care. This exemplifies the idea of letting us do our jobs without unnecessary interference.

Several years ago, a policy was introduced requiring us to rinse out nebulizers after each treatment with sterile water. This added unnecessary time spent in the room, and despite administration's insistence, no therapist complied. Eventually, the policy was forgotten. This serves as a reminder: you can make a rule, but you can’t force compliance unless you want to monitor us constantly. However, that would only decrease morale.

To conclude, I used to attend administrative meetings regularly. One time, during a discussion about an incident, an administrator said, “We have to do something.” I cautiously replied, “It’s better to do nothing than to do something stupid.” The point is to carefully consider both the benefits and consequences of any rule you make.

To illustrate this point, consider Jim Leyland, former manager of the Detroit Tigers. After a game where a third baseman made a costly error, a reporter asked Leyland what he said to the player. Leyland responded, “I didn’t say anything. He knows what he did wrong and will take the necessary actions to correct it.” He added that if the player repeatedly made the same mistake, he might intervene. This approach of allowing individuals to learn from their mistakes, rather than enforcing unnecessary rules, is a strategy hospital administrators would do well to adopt.

Asthma History: Chapter 2: The Origins of Human Empathy and Illness

The first Homo sapiens, our direct ancestors, appeared around 200,000 to 300,000 years ago in Africa. Even before that, human-like species, or hominins, walked the Earth for millions of years. These early hominins, including species like Homo habilis and Homo erectus, paved the way for modern humans with their ability to adapt, invent tools, and form social groups.

While we can never know exactly what life was like for early humans, we do know they faced many challenges. These challenges—finding food, shelter, and avoiding predators—often required cooperation and care within their small communities. Empathy, in its earliest form, likely evolved from the need to support one another for survival. Sharing food, protecting the sick or injured, and caring for offspring were vital to their existence.

The Role of Disease in Early Human Life

It’s impossible to know precisely what diseases afflicted early humans, as there are no written records or medical descriptions from that time. However, it’s safe to assume that, much like today, infections and injuries were common causes of death. Viruses and bacteria existed long before humans, so early humans likely suffered from respiratory infections, colds, and other illnesses.

But what about asthma and other chronic diseases? While it's difficult to say if asthma, as we understand it today, existed in ancient times, respiratory symptoms like wheezing, coughing, and shortness of breath could have occurred, particularly in response to infections, smoke from fires, or environmental factors. Chronic diseases often affect older populations, and most early humans did not live long enough to develop them. However, it is possible that some children developed asthma-like symptoms.

Given that asthma tends to develop in childhood, it’s conceivable that children may have suffered from it in prehistoric times. With no effective way to diagnose or treat severe asthma attacks, these children might have died without anyone fully understanding what was happening. Their symptoms may have been dismissed as the result of an illness or bad air, with no one recognizing the chronic nature of the condition.

Early Humans and Empathy

While we can't be certain whether asthma existed, we do know that early humans, including Neanderthals, demonstrated care for their fellow beings. Archaeological evidence shows that Neanderthals, who lived from about 400,000 to 40,000 years ago, cared for their sick and injured. For instance, remains of Neanderthal skeletons show signs of long-term injuries, suggesting that others helped them survive for many years after their accidents—an early form of empathy in action.

It is also believed that Neanderthals and other early humans practiced burial rituals, providing food or tools to accompany their dead in the afterlife. These behaviors suggest that they had developed emotional bonds, cared for one another, and possibly had early forms of communication and tradition.

The Birth of Early Medicine

The act of caring for the sick—whether offering food, water, or shelter—can be considered the earliest form of medicine, though not in the sense we know today. These early people likely had no concept of disease as we understand it. However, they observed the effects of illness and injury, and they learned to respond to it with empathy, offering what little comfort they could.

While the term “healthcare” would be anachronistic, early human empathy laid the groundwork for the development of communal support systems. This would have been essential for survival, as caring for the injured or sick helped ensure the tribe’s strength and longevity.

The Evolution of Human Adaptation

About 1.8 million years ago, Homo erectus emerged. These early humans were remarkable for their ability to migrate and adapt to various environments. They were the first to use fire, around 400,000 years ago, which allowed them to cook food, stay warm, and protect themselves from predators. Fire also provided them with more leisure time, which may have contributed to social bonding, storytelling, and further cognitive development.

As they migrated out of Africa, Homo erectus and later species like Homo neanderthalensis adapted to new environments by inventing tools, developing hunting strategies, and learning to cope with colder climates. These adaptations were crucial as the climate fluctuated and food sources became scarce. Empathy and cooperation continued to play a central role in survival, especially during times of crisis.

The Neanderthals and Their Legacy

Neanderthals, though not direct ancestors of modern humans, were close relatives. They lived in small groups, mainly in caves, and relied on hunting and gathering. Archaeological evidence suggests that Neanderthals cared for their sick and disabled, providing food and shelter for those unable to hunt. For example, one burial site revealed the remains of a man who had lived for many years without the use of one arm, indicating that others must have helped him survive.

Around 45,000 years ago, the climate in Europe began to change rapidly, transforming the forests on which the Neanderthals depended into open plains. This sudden shift in their environment, combined with the arrival of modern humans, may have contributed to their extinction. Homo sapiens, with more advanced tools and social structures, were better able to adapt to the changing landscape.

Empathy and Early Medicine in Context

In a world where survival depended on cooperation, early humans and their ancestors had to care for one another. They shared food, provided warmth, and nursed the sick—basic acts of empathy that can be seen as the foundations of medicine. However, these early forms of care were not guided by medical knowledge but rather by necessity and emotional bonds.

While there is no evidence that diseases like asthma were prevalent, respiratory symptoms likely existed due to infections or environmental factors. What we do know is that early humans, including Neanderthals, demonstrated care for their fellow beings, offering what could be seen as the earliest forms of healthcare.

Today, we continue to build on the legacy of empathy and caregiving that has been part of human evolution for millions of years.

References:

1. Netzley, Patricia D, "World History Series: The Stone Age," 1998, San Diego, CA, Lucent Books
2. Roberts, J.M., "The illustrated History of the World: Prehistory and the first civilizations: volume I," 1999, New York, Oxford University Press
3. "Neanderthal: Their bodies were well equopped to cope with the ice age, so why did the Neanderthals die out when it ended," bbc.co.uk, Science and Nature, http://www.bbc.co.uk/sn/tvradio/programmes/horizon/neanderthal_prog_summary.shtml, accessed 4/4/13
4. Garrison, Fielding Hudson, "An Introduction to the history of medicine," 1921, 3rd edition, Philadelphia and London, W.B. Saunders and Company

Problem With Nocturnal Oxygen Qualifications

Generally speaking, we consider an SpO2 of 90% as acceptable. This is because an SpO2 of 90% typically correlates with a PaO2 of around 60 mmHg, and anything below a PaO2 of 60 mmHg is considered hypoxia that requires treatment with supplemental oxygen.

Medicare, in setting guidelines for oxygen qualification, aims to ensure that people truly need oxygen. So, they set the qualification threshold at 88%. If your oxygen saturation is 88% or less while resting or with exertion, you qualify for home oxygen therapy.

In this case, I have no issue with the guideline—it makes sense. However, qualifying for nighttime or sleep oxygen is a different story. During the day, a saturation of 88% means you qualify for oxygen. But at night, you not only need to drop below 88%, it also has to remain that low for a minimum of five minutes.

For example, in a study we did last night, a patient's SpO2 dipped to 83%, which is considered low. But because of Medicare’s nighttime oxygen requirements, this person doesn’t qualify for oxygen. Even if their SpO2 dropped to 70%, they wouldn’t qualify unless it stayed below 88% for at least five minutes.

I believe this is a flaw in the system. Granted, lower oxygen levels during sleep are often considered normal, but setting a time-based threshold seems unnecessarily rigid. Perhaps Medicare could instead adopt a threshold like 85%—and if anyone’s SpO2 falls below that, even briefly, they should qualify for nighttime oxygen therapy. This would account for those whose saturation dips significantly, even if the drop doesn’t last the full five minutes.

Truly, Medicare does not always have the patient’s best interests in mind when setting qualification policies. What seems to guide their decision-making more is how they can save money. While the guidelines ensure that only those who really need oxygen get it, the rigid thresholds—especially for nighttime oxygen—can leave some patients without necessary support. It seems less about patient care and more about cutting costs.