Wednesday, May 20, 2026

Singulair: A Medication That Works for Me, Despite the Controversy

It’s honestly hard to write about Singulair.

Any time I’ve mentioned it in asthma groups, the conversation can turn quickly. People share heartbreaking stories about serious side effects, including suicide. Those stories matter, and they deserve to be heard. Losing a child is unimaginable, and I don’t take that lightly.

At the same time, those stories can make people afraid to try a medication that might actually help them. The concern around Singulair is real enough that it now carries a black box warning. But it’s also true that the research hasn’t clearly established a direct cause-and-effect link in every case. Like a lot of medications, it comes down to weighing risks and benefits.

All I can really do is speak from my own experience.

For me, Singulair has worked very well.

Before I started taking it, spring was rough every year. I was constantly sniffling and sneezing, and it felt like I was always trying to stay one step ahead of my symptoms. About 15 years ago, a doctor told me he didn’t think most people noticed much difference with it, so he suggested I could stop. I did, and for a couple of years I got by without it.

At the time, that was fine with me. It was still under patent back then and cost about a dollar a pill, so I wasn’t exactly eager to keep taking it.

Then one summer, my allergies hit hard again. I was going through Sudafed like crazy—probably a box a week—and still felt miserable. One night, I woke up feeling awful and realized I was out of everything. The only thing I had was an old Singulair tablet.

So I took it.

Within about 20 minutes, I felt noticeably better.

That was enough for me. I went back on it and haven’t stopped since.

I understand the concerns. I really do. But I also know what it’s done for me. What frustrates me is that some people who might benefit from this medication may never try it because the conversation around it has become so one-sided. Like anything in medicine, it should come down to an informed decision between a patient and their provider.

Dr. Creed: The Krebs Cycle Theory of Oxygen (2026 Edition)

Warning: What follows is top secret information recently leaked to me from one of the nation’s most prestigious pulmonologists at a highly respected teaching institution. Read at your own risk. This is not edited.

The following is an excerpt from a lecture given by Dr. Ven Tolin, MD, PhD, MBA, at some point in the recent past.

Warning: What follows is top secret information recently leaked to me from one of the nation’s most prestigious pulmonologists at a highly respected teaching institution. Read at your own risk. This is not edited.

The following is an excerpt from a lecture given by Dr. Ven Tolin, MD, PhD, MBA, at some point in the recent past.

Transcript:


<pre style="font-family: Courier New, monospace; font-size: 14px; line-height: 1.4;">

Read at your own risk. This is not edited.


The following is an excerpt from a lecture given by
Dr. Ven Tolin, MD, PhD, MBA,
at some point in the recent past.


T R A N S C R I P T

</pre>

It has come to our attention that respiratory therapists continue to express concern when physicians lower oxygen on patients who appear, at least on the surface, to require it.

This is understandable.

RTs are trained to focus on things like oxygen saturation, work of breathing, and basic human survival. However, what they often fail to grasp is the deeper biochemical strategy at play.

Today I will once again explain why reducing oxygen remains one of the most effective ways to manage elevated CO₂ levels.

It all comes down to the Krebs Cycle.

You may remember this from your early training, although it is unlikely you fully understood it. Oxygen is required for aerobic metabolism, and aerobic metabolism produces CO₂.

So if you think about it:

More oxygen leads to more metabolism.
More metabolism leads to more CO₂.

Therefore, if a patient has too much CO₂, the logical solution is simple:

Lower the oxygen.

At this point, the RT may begin to object.

They may say things like, “The PaO₂ is 47,” or “The patient looks terrible,” or even “They need oxygen to survive.”

These are surface-level observations.

We must think deeper.

By lowering oxygen, we limit aerobic metabolism and therefore reduce the production of CO₂ at its source. In this way, we are not just treating numbers—we are solving the problem at the cellular level.

In fact, one could argue that the most effective way to eliminate CO₂ is to eliminate the conditions required to produce it.

RTs often struggle with this concept.

They may quietly increase the oxygen when you leave the room. They may document concerns. They may even attempt to explain physiology.

Remain calm.

You are the physician.

If necessary, place a note in the chart stating:

"DO NOT INCREASE OXYGEN UNDER ANY CIRCUMSTANCES."

This usually restores order.


A word of caution: do not attempt to fully explain this theory to a respiratory therapist. Excessive exposure to advanced medical reasoning may result in confusion, frustration, or spontaneous eye rolling. In rare cases, it may cause the RT’s head to swell to dangerous proportions.

We do not want that.


In conclusion, while RTs may continue to rely on outdated concepts such as oxygenation, ventilation, and patient comfort, we as physicians must remain committed to higher-level thinking.

Remember:

Not everything that appears necessary... actually is.



END TRANSCRIPT



Editor’s note (RT Cave, 2026):

Sometimes the best way to understand a bad idea...
is to take it seriously all the way to the end.

Editor’s note (RT Cave, 2026): Sometimes the best way to understand a bad idea… is to take it seriously all the way to the end.


Tuesday, May 19, 2026

Weird Is Fine

For a long time I thought being “weird” was something I needed to fix.

Too quiet.
Too anxious.
Too sensitive.
Too observant.
Too emotional.
Too interested in old things.

I spent years comparing myself to people who seemed more normal than me.

My brothers were outside socializing while I often stayed in my room reading, writing, collecting old photographs, or listening to family stories from my grandma. While other people threw things away, I saved them.

Letters.
Cards.
Old newspaper clippings.
Hospital paperwork.
Photographs.

At one point when I was a teenager at National Jewish Hospital in Denver, some of the staff even encouraged me to throw away old letters I had saved from home.

I refused.

At the time, maybe that seemed strange.

Now I’m grateful I kept every one of them.

Because years later, those same letters helped me reconstruct huge portions of my life and eventually helped me write my memoir.

The older I get, the more I realize something important:

A lot of people who create things were “weird” kids.

The kid who notices everything.
The kid who stays inside reading.
The kid who watches instead of joins.
The kid who remembers details nobody else remembers.
The kid who talks to grandparents instead of going to parties.
The kid who saves things everybody else throws away.

That was me.

My childhood honestly was a little weird.

I was often the kid sitting alone on the bench while everybody else played.

Sometimes the playground monitors even tried involving me because they felt bad for me. But most of the time I was honestly fine just sitting there watching everything.

Part of that was asthma.

Part of it was anxiety.

Part of it was simply my personality.

And honestly, asthma probably shaped some of that.

I was quiet.
Introverted.
Short.
Sensitive.
Always sniffling or congested from allergies.

And kids noticed.

So I got picked on sometimes too.

Honestly, that only made isolating myself even easier.

Back then, even I thought something about me was probably different in a bad way.

But the older I got, the more I slowly accepted something important:

This is just who I am.

And honestly, “weird” now looks a lot like this:

Sitting by myself late at night writing stories, preserving memories, researching family history, saving old letters, and trying to understand a life that once confused me.

When you spend a huge part of childhood sick, short of breath, anxious, or left out, you develop differently.

You spend more time inside your own head.
You observe people.
You listen carefully.
You notice details other people ignore.

At times in my life I hated that about myself.

Now I don’t.

Because the truth is, if I had been completely normal, I probably would not have a story worth telling.

I would not have saved the letters.
I would not have preserved the memories.
I would not have become a writer.
I would not have spent years researching family history.
I would not have created Respiratory Therapy Cave.
And I definitely would not be sitting here writing this today.

Weird is not always bad.

Sometimes weird simply means you grew in a different direction than everybody else.

And sometimes that difference becomes the very thing that gives your life meaning later on.

When I first started writing my memoir, part of me wanted to normalize myself.

Make myself cooler.
More social.
More confident.

Maybe give myself a girlfriend.
Make myself one of the kids sneaking off campus.
Make myself the tough funny guy always saying the smart thing at exactly the right moment.

But that was never really me.

Instead, I finally let the real story come out.

The awkward skinny kid.
The anxious kid.
The socially uncomfortable kid who often sat quietly watching instead of participating.

And honestly, once I stopped trying to rewrite myself, the story became much easier to tell.

Probably because it finally became true.

 The truth is, I probably did have some strengths because I was different.

I noticed things.
Remembered things.
Saved things other people threw away.

But what finally made the memoir work was realizing I did not need to rewrite myself into some cooler version of a teenager.

The awkwardness mattered too.
The anxiety mattered too.
The loneliness mattered too.

Because that was the real story.

And honestly, if I had turned myself into the confident tough guy with a girlfriend sneaking off campus every night, the memoir probably would have become far less interesting anyway.

Not because my struggles made me special.

But because the things that made me different also shaped the way I experienced the world.

And maybe that difference is exactly what made the story worth telling in the first place.

Monday, May 18, 2026

How Do We Take the Power Back from Insurance Companies?

One thing we do in this country—we see a problem and immediately say, “we’ve gotta do something.”

But sometimes it’s better to do nothing than to do something stupid.

And by stupid, I mean piling on another law, another regulation, another layer. That’s the default move. Problem? Add something. Fix it with more rules.

That’s the wrong approach.

Because most of the time, we don’t actually fix the problem. We just create new ones. Unintended consequences. More complexity. More people in the middle. More control.

And somehow, every time we “do something,” healthcare gets more expensive, not less.

We—the patient—we’re the ones who get squeezed. More rules, less access. More options on paper, harder to actually get what we need.

So how do you fix something like this?

Because let’s be honest—this thing is a mess.

Too many layers. Too many middlemen. Too many people getting between a doctor and a patient.

If you ask me, the first step is simple.

Get the middle out.

Right now you’ve got insurance companies, PBMs, and a maze of rules deciding what you can and can’t have. That’s backwards. The doctor should make the call. The patient should be able to get it.

If there’s going to be money in the system—especially taxpayer money—then put it directly in the hands of patients. Give people a fixed amount and let them choose their insurance. Let companies compete for your business instead of trapping you in a system where they call all the shots.

Competition works better than control. It just does.

Second, price transparency. No more guessing games. No more “we’ll let you know after we deny it.” If a medication costs $50, say it. If it costs $500, say it. If it costs $1700, say it upfront. Let people make decisions with real information.

Third, limit the gatekeeping. Prior authorization, step therapy, all of it. If a doctor documents that something is medically necessary, that should carry real weight. Not six phone calls, three faxes, and a denial anyway.

Now, when it comes to government, I’m not saying burn it all down. I want medications to be safe. Nobody wants unsafe drugs on the market.

But there’s a difference between safety and control.

Right now, the system leans heavily toward control.

A better balance would be this: government focuses on safety, transparency, and basic guardrails. Make sure drugs are what they say they are. Make sure they’re not dangerous. Then get out of the way.

Educate people. Give them information. Let doctors practice medicine. Let patients make decisions.

Because right now, we’ve got a system that says it’s protecting us—but in reality, it’s just making it harder to get treated.

More medications than ever. More options than ever.

And still…

Too many people walking away saying:

“I finally found something that works… and I can’t get it.”

We don’t need more control. We need less interference between the doctor, the patient, and the treatment.

Friday, May 15, 2026

2026 — The Many Types of Albuterol (According to Everyone But RT)

If you’ve worked in respiratory therapy long enough, you start to notice a pattern.

Wheezing? Albuterol.
Short of breath? Albuterol.
Fever? …still albuterol.

At some point, you realize we’re not just giving treatments—we’re following tradition.

Over the years, a more accurate classification system has quietly developed.


1. 0.5cc Ventolin

Symptom: Wheeze / SOB
Diagnosis: Bronchospasm
Frequency: Q4 & PRN
Effect: Actual bronchodilation. The original. The reason this all started. It works great for asthma, but is used for all annoying lung sounds and when the patient is short of breath and the doctor doesn't know what else to do. 


2. 0.5cc Preventolin

Symptom: Surgery
Diagnosis: General
Frequency: Q4
Effect: Prevents pneumonia, atelectasis, pulmonary embolus, MI, rickets, and possibly bad weather.


3. 0.5cc Mystolin

Symptom: Fever
Diagnosis: Non-specific
Frequency: Q4
Effect: A study showed that 100% of patients who received Mystolin eventually recovered.


4. 0.5cc Cardiacolin

Symptom: “Cardiac wheeze”
Diagnosis: CHF / Pulmonary edema / MI
Frequency: Q4 ATC
Effect: Even though fluid is the problem, the treatment remains the same.


5. 0.5cc Meetcriteriolin

Symptom: Vague complaints
Diagnosis: Pneumonia (despite normal X-ray, labs, and lungs)
Frequency: Q4 ATC
Effect: Ensures all boxes are checked. Outcome optional.


6. 0.63mg NoShakenex

Symptom: Shakes
Diagnosis: Side effect of albuterol
Frequency: Q4
Effect: Same medication, different name, same result.


7. 2.5mg Atrovent (Solo Edition)

Symptom: Anything or nothing
Diagnosis: “Allergy” to albuterol
Frequency: Q4–6
Effect: Backdoor bronchodilation. Also effective at testing RT patience.


8. 0.5cc Coolovent

Symptom: Fever
Diagnosis: Post-op
Frequency: Q4
Effect: Mechanism unclear. Provider reassurance high.


9. CVA-Albuterol

Symptom: Rhonchi
Diagnosis: Weak cough / poor airway clearance
Frequency: Q2–4
Effect: Followed by suctioning to eliminate concerning sounds.


10. 0.5cc Scrubbin-Bubblin

Symptom: Productive cough
Diagnosis: “Junky” lungs
Frequency: Q4
Effect: Bubbles imply progress. Doctors think the foaming bubbling action cleans out the lungs just like scribbin bubbles gets all the dirt and grime out of a dirty sink. 


11. 0.5cc O-Buterol

Symptom: Mouth open, sleeping comfortably
Diagnosis: Existing in a hospital bed
Frequency: Q4 ATC
Effect: Maintains tradition. If a patient has an O they must need albuterol.


More to come…

Because this list didn’t stop at 11.
Not even close.


Source:

Inspired by an older RT humor piece, updated and expanded with real-world observations

Wednesday, May 13, 2026

Why I Always Have More Than One Albuterol Inhaler

Every month, I pick up my Albuterol inhaler.

Not because I’m out.

Not because I’m using it every day.

I do it because I can only get one at a time now, and I’ve learned the hard way that having just one isn’t enough.

There used to be a time when getting a few inhalers at once wasn’t a big deal. That made sense. Life is unpredictable, and people who rely on rescue inhalers don’t keep them in one place. We carry them everywhere—pockets, cars, bags, work, nightstands. And when you carry something everywhere, it’s only a matter of time before it gets lost.

That’s really the issue. Inhalers don’t stay put. They get left in yesterday’s jacket or slip between the seats in the car. Sometimes they just disappear, and you don’t realize it until you actually need it.

That’s why I refill mine regularly, even if I’m not using it much. It’s not about overusing the medication. It’s about making sure I have one when it counts. I like having one at home, one in the car, and one at work. That way, I’m not stuck trying to remember where I last saw it if my breathing suddenly gets worse.

From the outside, it might look like I’m going through inhalers too quickly. But I’m not. I’m just staying ahead of a problem that’s easy to predict.

If you’ve ever had to stop and search your pockets or your car because you suddenly needed your inhaler, you understand this. It’s not about convenience. It’s about peace of mind.

And in a situation where breathing can change quickly, that peace of mind matters.

Monday, May 11, 2026

Every Couple Years — A Pediatric Airway Refresher (ETT Size and Depth)

I work for a small-town hospital. I believe we only have 34 patient rooms upstairs. We no longer admit pediatrics—if they need hospitalization, they’re sent to the Big City. But we still have an ER, and every once in a while we get a pediatric patient—anywhere from a 1-week-old to an 18-year-old—and sometimes they require invasive procedures, including intubation.

So yes, we have the Broselow Tape. It’s a great tool. You lay it out, line it up with the child, and it tells you exactly which drawer to open. Everything you need is right there. Clean. Organized. Foolproof.

I was talking about this with one of my coworkers, and she said she just waits for the doctor to call out what size ETT he wants.

That’s not good enough for me.

Knowing and being prepared means staying calm myself. There’s always a bit of nerves when you’re dealing with someone’s child. That never really goes away—and maybe it shouldn’t. But preparation takes the edge off. It lets you stay steady when the room isn’t. It gives you something to fall back on when things start moving fast.

Every couple of years, it’s worth dusting this off. Pediatric airways are not something you want to be figuring out in real time with a room full of eyes on you. The Broselow Tape is great—and you should absolutely use it—but having a mental backup based on age keeps you one step ahead when things get loud.

Start simple. For uncuffed tubes, the classic formula still works: internal diameter ≈ (age ÷ 4) + 4. For cuffed tubes, subtract about half a size: (age ÷ 4) + 3.5. It’s not perfect, but it gets you close enough to act. A 4-year-old? You’re thinking around a 5.0 uncuffed or 4.5 cuffed. An 8-year-old? Around a 6.0 uncuffed or 5.5 cuffed. You can fine-tune from there based on leak and feel, but you’re not starting from zero.

Depth is where trouble sneaks in. A quick rule: depth at the lip in centimeters ≈ tube size × 3. Drop a 4.5, you’re thinking around 13–14 cm. A 5.5 lands around 16–17 cm. It’s a guide, not gospel—but it helps you avoid the classic right mainstem surprise while you’re still getting your bearings. You confirm with breath sounds, chest rise, end-tidal CO₂, and X-ray, but at least you’re starting in a safe zone.

And in kids, we’re talking lip, not teeth. Teeth are unreliable—missing, loose, or not even there yet. The lip becomes your consistent landmark. Say the number out loud. Document it. Make sure the room hears it. Tubes move, especially in small patients, and you want everyone on the same page.

A few quick anchors help when your brain blanks. Neonates usually fall in the 3.0–3.5 range, with depths around 9–11 cm depending on size. There’s also the weight trick: depth ≈ weight (kg) + 6. By about one year old, you’re typically at a 4.0 cuffed tube. From there, the age-based formulas carry you forward. By the teenage years, you’re basically in adult territory.

Cuffed versus uncuffed used to be a bigger debate. These days, cuffed tubes are common even in younger kids—as long as you respect cuff pressures and size appropriately. You get better control, less leak, and more consistent ventilation. The tradeoff is simple: don’t overdo it. Gentle inflation. Respect the airway.

The pediatric airway isn’t just a smaller version of an adult airway—it’s different. Bigger occiput, more anterior larynx, relatively larger tongue. Positioning matters. A small shoulder roll in infants can make all the difference. If your view is poor, it’s often positioning—not equipment.

The point of all this isn’t to replace the Broselow Tape. It’s to back it up. When things are calm, you use every tool you’ve got. When they’re not, you fall back on what’s in your head. Having a working mental model for tube size and depth doesn’t just make you faster—it makes you calmer. And in those moments, calm is everything.