Apparently Adults Cannot Be Trusted With Albuterol

I walked into the Walmart pharmacy and asked whether albuterol inhalers were finally available over the counter for around thirty dollars. I had heard that they might be.

The pharmacist shook her head. Not in the United States, she explained. If albuterol became available without a prescription, people might buy it and never see their doctor.

Notice the argument.

She did not say albuterol was too mysterious for ordinary people to understand. She did not say it had suddenly become dangerous after more than forty years of widespread use. The concern was that adults might make the wrong decision about their own medical care.

Therefore, somebody else must make the decision for them.

Apparently, struggling to breathe is not enough evidence that you may need a rescue inhaler. First, you must obtain professional permission.

Let me state the obvious before someone accuses me of claiming that albuterol is completely harmless. It is not. Like any medication, it can be overused, and repeated doses can cause tremors. If someone suddenly needs the inhaler far more often than usual or it stops providing relief, that may mean the asthma itself is getting worse and medical attention is needed.

But “this medication can be misused” is not an argument against over-the-counter access. It is a description of nearly every medication sold in the store. If zero risk were the standard, the pharmacy shelves would be empty.

Albuterol is not an experimental drug. It has been used for more than forty years. As a respiratory therapist, I have administered more albuterol treatments than I could possibly count. As a lifelong asthmatic, I have taken more than I could possibly count, too. Other than Breathin Stephen, I rank second in lifetime albuterol doses.

So that gives me lots of credibility.

In hospitals, we sometimes give treatments back-to-back or even continuously during severe attacks. Those patients are monitored, of course, but albuterol itself is one of the most familiar and thoroughly understood rescue medications in respiratory care history. Over decades of clinical use, we have learned that the side effects of albuterol are essentially negligible.

The real issue is not whether albuterol is perfectly safe. Nothing is perfectly safe.

The issue is whether capable adults should be trusted to make informed decisions for themselves.

The standard defense of the prescription requirement assumes that denying someone albuterol will somehow drive that person into a doctor’s office. But a prescription requirement does not provide insurance, create an available appointment, arrange transportation, pay the office bill, or eliminate social anxiety.

It merely creates another obstacle.

The person who cannot afford a doctor does not suddenly acquire one because Walmart refuses to sell him an inhaler. He may simply go home without the doctor and without the albuterol.

How is that safer?

The human math is not complicated:

It is far better for someone to have affordable albuterol and no doctor than to have neither.

Some people may want advice from a pharmacist, and pharmacists should certainly be available to help them. But advice should be available, not compulsory. I should not have to request permission or endure a lecture every time I purchase a medication I have used safely for decades. And Lord knows I do get them. 

Place clear dosing instructions on the package. Include prominent warnings explaining that frequent use, worsening symptoms, or declining effectiveness requires medical attention. Tell people about the possible side effects.

Then put the inhaler on the shelf.

Give adults the information and allow them to decide what is best for themselves. That is not recklessness. It is personal responsibility.

We trust adults to make consequential decisions every day. Breathing should not be the exception.

Is Modern "Health Insurance" Even Insurance Anymore?

Let’s be honest about what insurance is supposed to be.

Take car insurance. When your car needs an oil change, new tires, brake pads, or a replacement alternator, you generally pay for it yourself. Routine maintenance and predictable repairs are your responsibility.

The actual insurance is there for the expenses you could never reasonably absorb on your own—totaling your car in a major collision, seriously injuring someone, or being sued after an accident.

Health insurance, as it operates today, is nothing like that.

Rather than serving primarily as protection against catastrophic medical bills, it has become an enormously expensive and heavily managed prepayment plan. It is expected to cover routine appointments, minor illnesses, maintenance medications, preventive care, and countless other everyday expenses.

Now imagine if your auto insurance covered oil changes and windshield wipers—but required your mechanic to obtain prior authorization from a desk jockey three towns away before replacing your transmission.

You would immediately recognize that the system was absurd.

Yet that is essentially how American healthcare works. A third-party payer is inserted into nearly every transaction, from a routine office visit to a maintenance inhaler. Doctors and hospitals must employ armies of billing specialists, medical coders, insurance negotiators, and prior-authorization experts just to get paid for providing care.

Insurance companies then employ their own armies of workers to review, delay, approve, or deny those claims.

Every layer adds cost. Every layer adds friction. And eventually, patients pay for all of it through higher premiums, larger deductibles, copays, coinsurance, and medical bills.

Yes, healthcare has other cost problems too: outrageous hospital prices, expensive medications, and massive healthcare systems with little competition. But forcing nearly every healthcare dollar through an enormous administrative bureaucracy makes all of those problems worse.

The irony is that people can pay thousands of dollars a year for health insurance and still be unable to afford to use it. They pay the premium, then face a deductible so high that routine care remains effectively out of reach. If they do need treatment, they may still have to fight the insurer for permission to receive it.

That is not how genuine insurance is supposed to work.

Real insurance pools risk so that nobody is financially destroyed by cancer, a heart attack, a serious accident, or another medical catastrophe. Routine and predictable care should be transparent, competitively priced, and affordable enough to purchase without navigating a maze of claims and approvals.

Instead, we have created a prepayment plan wrapped in red tape—one that tries to manage every doctor visit and prescription while making protection against genuine catastrophe increasingly unaffordable.

And patients are footing the bill for the entire machine.

RT Creed: HFNC Has to Prevent Lung Collapse... Right?

From the Desk of the RT: When Surgeons Play Physicist

Published in the Real RT News

Well, sometimes we get interesting orders. Today we got one for a High-Flow Nasal Cannula by a surgeon to prevent a lung from collapsing when the patient has a hemothorax. Apparently, there's a belief that you can just blow some warm, humidified air up a patient's nose and somehow magically vacuum or push blood out of the pleural space like you're clearing a clogged sink.

It’s always an adventure when a surgeon channels their inner physicist and forgets basic anatomy. A hemothorax is blood sitting outside the lung in the chest cavity, crushing the parenchyma from the outside. Pumping flow through a nasal cannula isn't going to evacuate fluid, fix the pressure gradient, or act like some sort of magical structural pillar holding the lung open. If a lung is getting squashed by a pool of blood, it needs to be drained—not treated with a piece of plastic tubing delivering liters of room air.

Sure, high-flow can wash out dead space and help with oxygenation while you actually wait for someone to fix the underlying problem, but pretending it prevents a collapse from a hemothorax is a stretch. If we started blowing enough positive pressure down someone's nose to push back against fluid filling up their chest cavity, you'd run into major pressure issues before you ever solved the bleed. At the end of the day, keep trusting your clinical training—because sometimes you just have to chuckle at the orders and let science do the talking.

Page 677: The Hemothorax-High-Flow Pneumatic Shunt Method

(An Excerpt from the Real Physicians Medical Manual in Response to RT Insubordination)

Today I would like to present a brilliant surgical theory as to how we can prevent a lung from collapsing when a patient presents with a hemothorax, specifically in direct rebuttal to local respiratory therapists whining about basic physics. Many times an RT will look at you with utter confusion when you place an order for a High-Flow Nasal Cannula to manage a chest full of blood. You know what I mean? The chest tube is sitting right there, but you decide to bypass it with sheer aerodynamic genius.

RTs will cringe at this because they can't seem to grasp the deeper physics of the upper airway. Shallow minds they have, you might say. Your RT will whine, "The blood is outside the lung! Pumping humidified air up the nose isn't going to evacuate fluid or fix the pressure gradient!"

Once again, ignore their silly rants. You may even add a note on the chart that says something like, "Trust the flow, ignore the blood!" That usually sets the RT in his place. Anyway, I digress.

Surely we doctors think too much and RTs not enough, that's my point. RTs need to stop thinking and just do what they're told, because this technique explains why we prescribe high-flow for a completely external pleural space issue.

It has to do with pneumatic mass-displacement. Think of it like clearing a clogged sink by blowing air through the faucet. By delivering high liters per minute through a nasal cannula, we generate a powerful positive-pressure force that travels all the way down the trachea, punches through the visceral pleura, and magically pushes the pooled blood right back out of the chest cavity.

Get the idea? If you have a hemothorax compressing the lung from the outside, you just turn up the high-flow to act as an internal structural pillar holding the lung open. It doesn't matter that the fluid is in the pleural space and not the alveoli. Surely RTs will cringe at this idea, but who cares what RTs think anyway.

How to accomplish absolutely nothing in six hours as an RT

I have been busy all day. Busy busy. Running all over the hospital. And yet, somehow, I have accomplished absolutely nothing.

My first patient was a Bipap setup. The nurse said he was in distress. I walked in and the guy was pale, gray, diaphoretic, looked like death warmed over, and informed me he was nauseated. 

Now, maybe I’m old fashioned, but slapping a tight-fitting positive pressure mask on a nauseated patient seems like a poor life choice. I had visions of projectile vomit firing directly into the mask while the Bipap enthusiastically redistributed it into the lungs.

So I called the doctor and he agreed. No Bipap.

About a half hour later the patient passed away anyway. So that whole mission sort of ended itself.

Then I got called to do an oxygen walk. These are always exciting because sometimes you discover the patient desperately needs oxygen and qualifies for home O2.

This gentleman started at 94%.

Then I walked him.

His oxygen saturation climbed to 98%.

Apparently ambulation cured him.

So that got nowhere fast.

Next stop: ER breathing treatment. The patient had wheezing, shortness of breath, and what appeared to be another heart-failure episode masquerading as asthma. I gave the breathing treatment anyway because that is what we do in healthcare. We obey the sacred ancient traditions.

Shockingly, the Albuterol did not cure the patient’s failing left ventricle.

Medicine remains mysterious.

Then came Room 5.

A nurse informed me the patient needed Bipap immediately because “his gases are worse.”

Now those words will get an RT moving pretty quickly. So I looked at the blood gases.

pH: 7.40
CO2: 72

Which, if you work with COPD patients long enough, basically translates into: “Tuesday.”

The patient himself denied shortness of breath and looked comfortable.

But the nurse insisted he needed Bipap right now.

At this point I was starving. Not hungry. Hangry. The sort of hunger where you start wondering if oxygen tubing is technically edible.

I briefly considered just throwing the patient on Bipap to end the conversation and move on with my life. But instead I did something I hate doing: I interrupted a physician meeting.

I explained the situation.

And lo and behold, the doctor calmly explained he only wanted nighttime Bipap and wanted to see whether the patient qualified for home Bipap.

In other words, this entire panic originated from poor communication.

Later I told a coworker about the exchange and he said, “She’s as dumb as…”

Well. Never mind. We’re trying to be nice here at the RT Cave.

So here I am, six hours into my shift. I have been everywhere in the hospital. I have sweated. Walked miles. Reviewed gases. Dodged unnecessary Bipap setups. Interrupted meetings. Performed sacred aerosol rituals.

And if you really think about it...

I have accomplished absolutely nothing.

Why I'm Leaving Walgreens?

Back in the 1990s, I hated Walgreens.

I honestly don't remember exactly why anymore. I just remember the pharmacists constantly lecturing me about how often I was using my albuterol inhaler. That always bothered me because I had severe asthma. Of course I was using a lot of albuterol. This was before many of the excellent asthma medications we have today. Back then, albuterol wasn't a rescue medication I occasionally needed. It was often the only thing standing between me and an emergency room visit.

Fast forward a few decades.

After my divorce in 2018, I was using Meijer Pharmacy. The problem wasn't the pharmacists. The problem was the wait. Every time I needed a prescription, I felt like I spent half my life standing in line. Eventually I got tired of it.

At the time, I really wanted to switch to Rite Aid. I had used Rite Aid before and always had good experiences there. Unfortunately, there were already rumors that Rite Aid was headed for trouble. As it turned out, those rumors were true. Rite Aid eventually closed, so I ended up going with Walgreens instead.

To be fair, Walgreens in Ludington was pretty good for several years. I had very few complaints.

Then came COVID.

Something changed after that. Whether it was staffing shortages, increased workloads, vaccines, or a combination of everything, the pharmacy became slower and harder to use. The lines got longer. The drive-thru took forever. Calling the pharmacy often meant listening to a phone ring endlessly.

I tolerated it because, frankly, what other choice did I have?

Then Rite Aid closed.

If the lines were bad before, they became even worse afterward.

Recently, my mom asked me to pick up one of her prescriptions at Walmart. I wasn't expecting much. In fact, I had never seriously considered Walmart Pharmacy before.

Then I walked in.

Three employees were working the counter.

No line.

No waiting.

No frustration.

I remember standing there thinking, Well, this is different.

For the first time, I started wondering if Walmart might actually be the better option.

Then came the final straw.

On July 3, I ordered five prescriptions through Walgreens. Two of them were albuterol medications: an inhaler and nebulizer solution. I paid the extra four dollars to have them delivered. Walgreens advertised delivery in two to three days.

Two weeks later, I still didn't have them.

The website continued to show the prescriptions as "in progress."

I called the pharmacy.

The phone rang.

And rang.

And rang.

Nobody answered.

So I called Walgreens corporate customer service.

They were polite enough, but they couldn't solve the problem.

At that point I found myself asking a simple question:

Why am I still using Walgreens?

If I have to wait thirty minutes in line, wait forever in the drive-thru, struggle to reach someone on the phone, and then wait two weeks for medications that were supposed to arrive in three days, what exactly am I getting in return?

The answer is: not much.

This isn't about one delayed order. Every pharmacy makes mistakes. This is about a pattern I've been watching develop for years.

Good customer service matters.

Communication matters.

When people are waiting for medications—especially medications they rely on to breathe—service matters.

I don't wish Walgreens any ill will. In fact, I remember when they did a pretty good job. But somewhere along the way, the customer experience stopped being good enough for me.

So after years of frustration, I think I'm finally done.

Unless something changes dramatically, my next prescription will probably be heading to Walmart.

And honestly, I should have done it sooner.

So I finally picked up the phone and called Walmart Pharmacy.

"Look, here's my issue," I said, explaining everything that had happened with Walgreens, the delays, the unanswered phone calls, and the missing delivery.

The woman on the other end listened for a moment and then said, "Okay, we'll call Walgreens and transfer your prescriptions over."

I was almost caught off guard by how simple it sounded.

"Is there anything you need from me?" I asked.

"Just your name and date of date of birth and phone number."

That was it.

No arguments. No waiting on hold. No explaining my life story.

A few minutes later, the process was already underway.

Maybe Walmart will be better. Maybe it won't. But at least they're answering the phone.

Right now, that's a pretty good start.

Why Health Insurance Was Invented

We spend a lot of time complaining about health insurance today. Patients hate the premiums, doctors hate the paperwork, and hospitals are constantly fighting over what gets covered. We act like the system is broken, but we’re missing the bigger picture. We assume insurance has always been the standard, but for most of our history, it didn’t exist. It didn’t exist for a simple reason: nobody needed it.

Before the 20th century, if you got sick, the doctor came to your house. They’d look you over, try whatever they could, and you either got better or you didn't. There were no ICUs, no ventilators, and no complex surgeries. Because medicine couldn't do much, it didn't cost much. It was a personal expense, just like groceries. Hospitals weren't treatment centers back then, either; they were mostly places you went to die.

Everything shifted in the early 1900s. Medicine finally started to actually work. We got X-rays, blood transfusions, and better anesthesia. Joseph Lister’s antiseptic techniques changed everything. Hospitals transformed from dying rooms into hubs of life-saving technology. But those advances brought a new reality: high costs. By the 1920s, a hospital stay cost twice as much as it had twenty years before. Hospitals were building new wings and buying fancy tech, but they had a huge problem. They were running on a pay-as-you-go model, and they were lucky to collect 60 cents on every dollar they billed.

Then 1929 hit, and the Great Depression made everything worse. The money dried up, but the patients kept coming. That’s when a guy named Justin Ford Kimball stepped in. He wasn't a doctor; he was a former school superintendent managing Baylor University Hospital’s finances. He noticed teachers were landing in the hospital with huge, unpaid bills they couldn't afford on a teacher's salary. Kimball didn't want the hospital to eat those losses, but he knew the teachers were tapped out. So, he made a deal: if every teacher paid 50 cents a month—six dollars a year—the hospital would guarantee them a set number of hospital days if they got sick.

It worked perfectly. It kept the hospital's revenue steady and gave the teachers peace of mind. It even changed patient behavior because people stopped waiting until they were half-dead to seek care. Other hospitals caught on and copied the model. Before long, these plans all unified under a name you definitely know: Blue Cross.

We need to stop looking at health insurance as some ancient, unchangeable institution. It was a financial hack born out of a desperate crisis. What’s ironic—and what most people forget—is that the American Medical Association and a lot of doctors actually hated the idea at first. They were terrified of third-party interference and wanted to keep medicine a direct, personal transaction between doctor and patient. But once the genie was out of the bottle, it never went back in.

We love to blame insurance companies for the cost of medicine, but the reality is that modern medicine created the insurance industry. Without the high-tech, expensive advancements of the early 20th century, there wouldn't have been a reason to invent this system. When you actually look into it, you realize things aren't the way they are because they’re perfect. They’re the way they are because someone faced a problem and tried to solve it—even if that solution ended up creating the mess we’re dealing with today.

When Dad Stops Being the Entertainer

One of the things I've noticed this summer is that my role as a dad is changing.

When my kids were little, I was the entertainer. Every summer I was looking for things to do with them. We'd go to the beach, the pool, playgrounds, Silver Lake, visit my parents, or just find something to get us out of the house. I genuinely enjoyed it. Looking back, some of my favorite memories are simply spending time with my kids.

Now my daughter is seventeen. This summer she's already gone to four different camps, and she has another one coming up. Half the summer is already over, and she's busy living her own life. Today she finally had an afternoon without anything planned, so I texted her and asked if she wanted to go to the pool.

A little while later she replied, "Dad, can I go to a movie at four with my friends?"

What struck me wasn't that she wanted to go to the movie. It was that she hadn't even seen my text because she had been talking with her friends. She was completely absorbed in her own world.

And I thought, that's exactly what a seventeen-year-old is supposed to be doing.

It made me realize that I don't really have to entertain her anymore. That chapter is coming to an end. Instead of being the entertainer, I'm becoming home base. I'm the person she checks in with before she goes somewhere. I'm the place she comes home to afterward. That's a different role than I had ten years ago, but it's not a bad one.

Sure, there's a little sadness in it. I miss the little girl who always wanted to spend the day with Dad. At the same time, I'm happy for her. She's making friends, she's becoming independent, and she's building a life of her own. That's exactly what I've wanted for her all along.

The funny thing is, this change gives me something too. I have more time to work on projects that I've put off for years. I'm writing my memoir. I have more time to spend with friends. I have time to pursue interests that were harder to fit into life when my weekends revolved around entertaining the kids.

Every stage of parenting has been enjoyable in its own way. I loved being the entertainer. I think I'm going to enjoy being home base too.