My response to your websearch queries

Here is my weekly response to your Internet search engine questions.

1. usually what do an rt do for a patient with pneumothorax: You mean what does an RT do? We pretty much provide supportive care. We might be at his side in case airway management is indicated until he is stabilized with a chest tube. Some of my co-workers have assisted in inserting one before, I haven't.
2. what is the difference between albuterol and atrovent: Albuterol is a rescue inhaler, while Atrovent is used more as preventative bronchodilator.


3. challenges in respiratory therapy: There are many. Any part of the medical field can be challenging. This is what makes it so fun.


4. advair how many days does it take to take effect: 7-10


5. death respiratory therapists: What's your question?


6. respiratory therapist sucks: Here's this statement again. I'll just ignore it.


7. what happens to a copd patient if given too much oxygen: Only 10 percent of COPD patients are CO2 retainers. So, for 90% of COPD patients nothing. However, I have found much research to counter the


8. advantages of mist tents over nasal cannula: None. I see no reason why not simply use a nasal cannula.


9. how many respiratory therapists does a community hospital need? Depends on size of community.


10. copd confused with something else: It happens.


11. why use ventolin to bring down potassium: I ask the same question.


12. dread going to work': Sometimes. That's normal I suppose.


13. how long does it take albuterol to get out of ur system: It should have a relatively immediate effect.


14. copd peak flow: Not recommended. Usually the peek flows get worse after treatments.


15. albuterol weight loss: I wish.


16. duoneb given with spiriva: I've seen it done on occasion, but it's probably more of an oversight. If a patient on Spiriva happens to have an exacerbation, I see no problem giving Duoneb in the emergency room. However, I've seen no studies done on this.


17. ventolin suicidal thoughts: I've never heard of it.


18. respiratory therapist are stupid: Are we?


19. singulair ards: I have never heard of a connection.


20. singulair blood brain barrier: Ventolin is the only medicine that can cross the blood brain barrier. Just kidding.


21. what is normal for 22 years old peak flow meter?: It depends on how tall he is. However, he can determine his own normal value by blowing into it daily for two weeks when he's healthy to get his own personal best.


22. a paper on respiratory therapy: I will not write it for you.


23. what make one respiratory therapist better than another respiratory therapist: Expereince, patience, the ability to use common sense, ability to prioritize, personality, etc.


24. did teddy roosevelt have asthma: yes

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact me at Freadom1776@yahoo.com.

While on the dock the waters stay calm

When we highly qualified RTs are talking amongst ourselves we know far more than the doctors, who are responsible for every functioning part of the patients we take care of, when it comes to the respiratory system. We are the experts. We don't know it all, but we know quite a bit about respiratory.

We are highly educated on the respiratory system. We not only labored through 2.5 years of RT school, where we focused on nothing but respiratory and other systems as they pertain to respiratory, we ate, drank, slept, licked respiratory. And, now that we are full grown RTs, our lives rapt in respiratory, our respiratory experiences growing on a daily basis, yet we are so often left frustrated by doctors who refused to allow us to use our experience, our education that we worked so hard to develop, and to maintain.

It's ironic in a way that we know far more than doctors as to when breathing treatment is indicated, and yet they are the one's with the power to write the orders, and they are the one's with the respect of the nurses and the other doctors and the administrators and the RT bosses. And, based on that, we have no choice but to do what we are told, whether we agree with it or not.

And, worse of all, when we do have an opportunity to portray that our belief is true, we tend to keep our mouths shut, as to not rock the boat; to not make waves. Why? Because we have to work with these doctors, and we have to stay on their good sides. For no amount of joy can come out of working as an RT when the doctors have lost all respect for RTs, and when a doctor is annoyed because an RT is a know-it-all.

So, instead of chancing it, we keep our mouths shut. We stand on the docks. We stay out of the water. We do not make waves.

"Let's do another treatment," the doctor said. "She's still got a lot of wheezes."

"I think those wheezes are all upper airway," I said matter-of-factly.

"No, I hear those wheezes throughout."

Of course you hear those wheezes throughout, the upper airway congestion is radiating throughout the lung fields. I wanted to say that, but was a good boy.

When the treatment was finished, the patient still had that upper airway congestion that did not sound like bronchospasm to me. "Do you feel better?" I said to the patient while the doctor was still in the room.

"No. I feel the same," the patient gasped in her laborious nature.

Like with Dr. Mast the night before, of whom, three days after the patient had been admitted with pneumonia, realized he forgot to order Ventolin. "Gosh, that patient just won't be able to go home if he didn't get that Ventolin in his system."

Here I am, an intelligent RT (at least I think so), who knows darn well the doctor's is wrong (wrong, wrong, wrong, wrong) when it comes to understanding the purpose of Ventolin, but I do not say anything because I want to be nice to him and not hurt his feelings.

However, I might make hints (plant seeds if you will) like, "Yeah, I think it's all in his throat."

But, not wanting to rock the boat, I say nothing. Perhaps that's the problem with us respiratory therapists. Perhaps the reason we fail to make progress with doctors ordering useless breathing treatments is because we tend to prefer the politically correct route, the I don't want to hurt your feelings route.

Perhaps we ought to speak our minds and say what we think, regardless of who might be offended. Regardless that the doctor will look at us like we are the bumbling idiots instead of them being the bumbling idiots.

The thing is, it's far easier not to rock the boat. It's far easier to come into work and simply do as we are told and not say anything about these treatments not being indicated. It's far easier to come into work, do what we are told, and go home never to think of this place until we get back to work in two days or whatever.

It's far easier to do what we are told, and collect that paycheck at the end of the weak. After all, that is the purpose of doing this great job, isn't it? After all, a paycheck is a paycheck.

I wish it were that easy. I wish I could just be content to simply make a paycheck. I love being an RT, as most of us RTs love our jobs. However, playing this game of appeasing doctors, of doing treatments we know are not indicated, just because that's what the doctor orders, is by far the most frustrating part of this job.

I too, like the old RTs close to retirement, who don't want to rock the boat for fear they won't reach that zenith of retirement a few years down the road, don't want to rock the boat. So, like all of us RTs with a kind heart and empathy for the doctors (or fear of them), just do the procedures they order and keep my mouth shut about it. And, on rare occasion, wine about it amongst my co-workers, or right here on this blog.

We love our jobs, I love my job, but there are areas of it I really, really want to improve. Yet, sometimes, as now, it's far easier to stand on the dock, to do as we are told, to stay out of the water, to not make waves as to not rock the boat.

Sure, progress might be slow by this route, but it's the one sure way that the paycheck will continue to find itself on the kitchen table by the end of the week. And, when it comes to your wife and children who depend on you, sometimes that's all that matters -- in the end.

Wavy waters bring questions, and complete happiness is guaranteed in the calm waters.

New 'olin washes pneumonia right out of alveoli

I got to see first hand the other night the revelations that occur to lead a doctor to deciding a patient needs a breathing treatment, as Dr. Mann set down next to me as I was charting on one of the many terminals on 2 Early, the med surge floor. It was real early in the morning, and he started small talk with me. He seemed really cool.

"Hey, hand me that chart would you," he said.

I grabbed the chart he motioned to, and continued on with my charting.

"Hey, you know what?" he said. "This patent's got pneumonia. Wow, I can't believe he's not getting breathing treatments. Well, I'm going to change that."

Wait a minute, I think. That patient has been here for two weeks, and he's breathing fine. I wanted to say that, but I was on such good terms with the doc. I didn't want to spoil a good thing.

I wonder if this is the reason why so many un-needed breathing treatments are ordered, because good RTs like me refuse to face up to a doctor for political reasons. Here I knew for a fact this patient didn't need treatments, but the doctor thought otherwise.

So, why is it that he wanted treatments for this patient. Why? Because the patient had pneumonia. And, somewhere, some time ago, he must have read an article that said that Ventolin goes down deep into the alveoli and washes the pneumonia out.

So, I went in to do the treatment. The patient said, "What the hell do I need that for."

"Are you having trouble breathing?"

"Nope. Never."

"Do you smoke?"

"Nope. Never."

"Hmm," I said, "Let me listen to you." I pulled out my handy-dandy stethoscope and listened to his backside. Perfectly clear.

"So, you agree I don't need that? Or, why do I need it, do you think?"

In this situation, I used to try to make the doctor look good, and lie: "Well," I would say, "It's supposed to help you get rid of your pneumonia, or cough it up at least." I've decided I'm not doing that anymore. I said, "Your doctor ordered it. You have a right to refuse if you want."

"Well, if he ordered it, then I suppose I do need it. What do you think?"

Burned out, I decided to be honest with the patient, "Sometimes doctors order things just out of habit. He may have read some article somewhere..."

"Yep, I know that. That's why it's good to go to the doctor educated."

"Exactly. And don't be afraid to refuse a therapy. Just because a doctor orders something doesn't mean you really need it. Doctors are human beings after all."

"I totally agree," he said. Yet, despite that we both knew the treatment wasn't indicated, I gave the treatment and he took it. And of course we bantered while it was going.

When the treatment was finished, he said, "Well, I'm going to corner that doctor in the morning about this. I don't' fell a bit different after this."

"So, you ever been short-of-breath before"

"Nope. I never even smoked. I really don't think I need that thing anymore."

"Well, be prepared for him to try to talk you into it. He's going to give you a line you know. He'll try to talk you into it."

"I bet he will."

So, we now have a new 'olin. All patients that have been in the hospital for 3-4 days with no difficulty breathing, and all of a sudden Dr. has an epiphany and says, “Hey, this patient’s got pneumonia. I’m ordering Washolin.”

The medicine, according to our fake doctor's creed, is a specially formulated version of Scrubbin-Bubblin designed specifically for pneumonia patients who show no signs of respiratory distress and are not short of breath. This medicine forms a sud-like material, shrinks from 5 microns to 1 micron (exact methodology unknown) finds its way to the alveoli and washes the pneumonia right out.

It works similar to a bronchial wash, only you don't need to bronch the patient. It's an alveolar Wash performed with the magically enhanced formula of Scrubbin-Bubbles version of Ventolin. How about that for a new breath-taking scientific revolution?

Yes, we know RT will bicker, but the patient will say something like, “What the hell do I need that for, I’m not having trouble breathing, and never have in my life.” This is a normal side effect. Don't let that deter you from ordering this highly indicated medicine. If the patient wants to refuse, that's his loss.

By the way, if Dr. accidentally forgets to order Washolin, the patient will still get better and eventually go home.

The list of 'olins on the bottom of this blog has been updated.

Some good asthma/COPD drugs get a bad rap

When I was researching Singulair, I found an article here on the Internet about how Singulair may be linked to depression and suicide thoughts. There were so many complaints of this, that the company that makes Singulair decided to put this as a side-effect on the insert.

You can check out a related link here from Allergy notes, or click here for a full article from Forbes.com.

The same thing happened a few years ago about Serevent. There have been people who have died after taking Serevent. It became so bad that there was talk of actually taking the medicine off the market.

Needless to say, I disregarded both these scares, and now I take both Serevent and Singulair, and neither do I suffer from depression, I also have not died -- at least not yet.

People die of asthma. And it just so happened that in a majority of the cases where an asthmatic has died in recent years, the person was taking Serevent. So some people came to the conclusion that Serevent was a bad med and should be taken off the market, and released statements (like this one, or this one) that scared people.

Yet, as it turned out, there really was nothing wrong with Serevent. Serevent is a good medicine that helps asthmatics better control their asthma. Yet some people decided to abuse Serevent, use it like it were a rescue inhaler instead of one puff twice a day. More than likely, the abuse of Serevent caused the heart to become overstimulated, and the asthmatic dies.

However, and thankfully, the powers that be decided the problem was not so much with Serevent, but with people abusing an otherwise good medicine.

For the record, here is a link to what all doctors should tell their patients about Serevent: click here.

National Jewish makes light of the fears of using Serevent on its website, and in its effort to make sure its patients are fully educated, issued the following statement:

"In a large asthma study, more patients who used Salmeterol died from asthma problems compared to patients who did not use salmeterol. This has received much attention in newspapers and magazines. While the relationship between Serevent® and deaths due to asthma remains unclear, proper use of this medicine can decrease any risks"

To read the rest what National Jewish has to say about Serevent, click here.

The company that makes Singulair, and doctors, have issued statements to their patients that if a patient is currently taking the medicine, and have not had a problem, then they should continue to take it as they have -- as prescribed. If they have a problem, if they have symptoms that are new since they started taking the med, they should stop taking it and talk with their doctor.

That's common sense there, but for PR and legal purposes it has to be said. Likewise, it's something doctors should do anyway -- or at least the pharmacist. Personally, I have never had a doctor go over with me how to use a medicine, or possible side effects. That seems to be a job reserved for RTs and RNs.

But, what if a patient doesn't have contact with an RT or RN? How do these people get proper education on the medicines they take? Is that not the job of the doctor? Or is it the pharmacist?

The pharmacy here gives patients a printout about new medicines, but that's only something knew they've been doing. Only once in my life did a pharmacist ever pull me over and say, "Hey, do you think maybe you are using that thing too often?"

I might have told that pharmacist something like, "Yep, I'll try to behave myself in the future." And then went home and continued to abuse whatever medicine I was abusing -- probably Albuterol at the time.

My doctor never one time told me that I was using this medicine too much. Never. In fact, the only time my doctor ever said anything to me about this was when I brought it up. Then I got the feeling he was telling me what I wanted to hear, and then he promptly left the room before I could ask another stupid and annoying question.

While it is possible that Singulair might have a small chance of causing depression, there is also a good possibility this occurrence of depression was a mere coincidence.

I see this a lot right here in the hospital with Ventolin. I give a breathing treatment with Ventolin to a person, he coincidentally vomits, and the next day I come into work and the patient is ordered on Alupent because the doctor decided the patient was allergic to Ventolin.

Now we have this new drug on the market called Xoponex, which is marketed by the company as not causing the same side effects as Albuterol, and yet, when I give Xoponex, those patients get just as jittery as they were when they used to take Albuterol. Recent studies show there is no difference between the two drugs when it comes to side effects, yet each doctor still holds his or her own opinion.

Many times I meet an extremely short-of-breath patient in the emergency room and note the heart rate is 130. Then I give two breathing treatments to this patient, the doctor goes into the room, notes the heart rate, and says to the patient, "I'm not worried about your heart rate. I think it's just because of all the stimulation from the breathing treatments."

Then the doctor orders another treatment, this time with Xoponex. I don't have a chance to tell the doctor that he is foolish, that the heart rate was up before the patient even had one dose of Albuterol. And, chances are, that his heart rate was up because he was in distress and hypoxic, not because of any medicine he was given.

Now I'm not saying these medicines don't have side effects, nor am I concluding here that Singulair does not cause some people to have suicidal thoughts (however I have yet to have them), or that Albuterol never increases your heart rate (I don't see it very often though), but I think that many of these medicines get a bad rap.

I think these medicines get a bad rap, despite all the good they do, because people who are doing the judging of them refuse to use a little good old fashioned common sense. Instead of assessing the entire situation, they just blame the medicine.

If you take a medicine and you truly notice that something new or different is occurring, then you should stop taking it and consult your doctor. Let's just make sure it's truly a side effect, and not simply an aberration.

Yes, some medicines that are supposed to have euphoric results turn out to be bad after all, like that one medicine that was supposed to be the ideal weight loss medicine that ended up causing cardiac problems. But some medicines that are good, are simply misjudged.

And I certainly pray they don't take a good drug off the market based on a misconception, or symptoms or death that results from lack of patient education more so than the medicine itself; especially when these medicines have the potential to help so many people.

That, my friends, is the thought of the day.

The saga of the 99-year-old man: part 2

I thought I'd take a moment finish my saga of the 99-year-old man I started last Friday. Of course you guessed correctly that he got admitted and was ordered on Q4 breathing treatments. You know the rule: being over 90 is an indication for bronchodilator.

But he was so combative it took four or five of us staffers to hold him down. We are no longer allowed to use restraints because someone decided it's inhumane (even though the patient has no clue where he is), so we had to do this often during the course of the night.

So, I had to give him a treatment. I didn't want to, nor did I think it was indicated, but to be politically correct, I had to at least try to do it. So, while the patient was sleeping, I snuck up from behind him and plucked out the bag part from the mask and...

... it woke up with a vengeance. He leaned forward and clenched the corner of the mask in between his yellow dentures and growled at the full force of his lungs. He made me think of a Lion at full charge. I came within a millimeter of him actually biting my finger off, which I think this man was fully capable of doing.

And his arm flailed up and barely missed my head, and the only reason he missed was because he was swinging blindly, because he was not of his right mind. Well, I suppose he was probably blind to boot. But that's beside the point. I had to use all my muscles to hold this man down, and as I held his hand, he squeezed with the might of a 24-year-old athlete.

He tried to dig his long fingernails into my flesh, and I did everything in my power to prevent this. I even tried to escape his grasp, but I couldn't. I tried as hard as I could, but this 99-year-old out to lunch man had the strength of a bull, and now had me trapped.

However, moments later, while he was still screaming at the top of his lungs, he forgot about me and let go long enough for me to slip the neb into his mask and then he fell asleep. So, after all of that, after showing all of us in the room how strong his lungs were, he still got his full dose of Ventolin whether he needed it or not.

Now, let us fast forward two hours. The patient's nurse asked me and the other nurse in the CCU to assist him in repositioning the patient. We all knew this was not going to be easy. The patient, every time he had been awake all night, screamed at the top of his lungs, keeping all the other patients awake.

So, when I walked into the room, and this 99-year-old man put his arm out in my direction, I flinched. My co-workers laughed at me, but I was very leery of this old man. But brave as I was, I took his grip and, instead of digging into my palm with his nails, he provided a firm grip and he smiled at me.

Then he appeared to pucker his lips and was saying something I couldn't understand.

"He wants to kiss you," the patient's nurse said.

He was right. So, what was I to do? I provided him my hand to kiss. I touched the back of the mask with the back of my hand. "No. No," he chanted, as he made a feeble effort to pull the mask off.

It occurred to me then that he wanted more than just the back of my hand through on the mask, he wanted to kiss my hand. So I offered him my hand to kiss, which he did. But he wanted more than just my hand, he wanted to kiss me on the lips. So I pressed my cheek up to the mask. But he was not satisfied with that, he wanted to kiss me on the lips.

"Ativan does wonders," the nurse said. "It's the true miracle drug."

"Yeah, I see," I said.

"Well, we're done. While you had him side tracked, we did our job. So, now you have to make him happy and just let him kiss you on the lips."

I looked at the man, wondering what his life was like. I will never know what he did during the course of his life, whether he was married, happy, or whatever, but I do know that he did something physical, and was very fit.

And he was a fighter at times, and a lover at times.

Pneumonia: Here's how you can prevent it

As I wrote in yesterdays post, over 3 million people are diagnosed with pneumonia each year, 500,000 require admission to the hospital.

A question I get often from my patients is: "What can I do to prevent myself from getting pneumonia?"

To get a good overall idea of what pneumonia is, and who exactly is at risk, you should check out the post I wrote yesterday, which I will link to here.

Every person, particularly the elderly (over age 65) and/or chronically ill, should keep pneumonia in the back of their mind, because chances are they are at a high risk of getting it. There are a few simple things you guys can do to reduce the risk of getting pneumonia.

Keep in mind, however, that there are no guarantees.

The simplest thing you can do is wash your hands. There is no more effective thing you can do to prevent the transfer of viruses and bacterias than by simply washing your hands often.

Another simple thing you can do is get the pneumonia vaccine offered to you by your doctor. Currently, there are vaccines available for pneumonias caused by pneumococcal pneumonia, Haemophilus influenzae, and influenza virus.

Respiratory-lung-healthcare.net reports that the vaccines are about 80% effective in young adults, but not so effective in those who are at high risk. Likewise, not all pneumonias have a vaccine. Needless to say, that's no revelation there. Many patients who have been diagnosed with pneumonia also say they received the vaccine.

Thus, we obviously cannot rely just on the vaccine to prevent pneumonia.

So, besides vaccines, the best therapies to prevent pneumonia is cough and deep breathing exercises (with a good 3-6 second breath hold), and exercise, even a simple walk around the room can be effective enough to prevent pneumonia.

At our hospital, doctors order all patients at high risk for pneumonia to be provided and instructed on the use of an Incentive Spirometer (IS). It is their belief that any patient can do an IS, and that it's equally effective in preventing pneumonia in all patients. However, that is not always the case in the ideal world.

That in mind, here is the long version of what I tell my patients:

"Many years ago pneumonia was very prevalent in hospitals. Many post-op patients were getting pneumonia, and many of them were dying. Familiar with these statistics, some wise person decided that they were developing pneumonia because they weren't taking in deep breaths.

"Normal healthy people take in three or four sighs every hour. This is the bodies natural mechanism for exercising the parts of the lungs that are not used during normal respiration's.

"However, when you become debilitated in one way or another, you are elderly, weak, sore from breaking your ribs, sore because you had surgery on your chest or abdomen and don't want to take in a deep breath, you have Lou Gehrig's disease, are paralyzed, or something else that diminishes your ability to move or take deep breaths, then you are susceptible to getting pneumonia.

"What you need to do is to concentrate on your breathing, something most people take for granted. While you are home, after eating breakfast, you should concentrate on taking deep breaths. In fact, you should do this once every hour or two. And then you should force yourself to cough.

"You take in a slow deep breath through your nose, hold your breath for three to five seconds, and then you exhale slowly. You should do this five to ten times, and then cough. This whole process helps you to recruit and fill with air any collapsed alveoli that are susceptible to pneumonia, expectorate secretions, and exercise your lungs.

"In the hospital, we encourage those at high risk for pneumonia to not only do this, but we use what we call an incentive spirometer. But, in essence, an incentive spirometer is no more effective for preventing pneumonia than a good cough and deep breathing session with breath hold."

Of course, here is where I show them how to use the IS. Most patients do well with the IS, however, some patients just can't seem to get the hang of it. For these patients, I revert them back to the simple cough and deep breathing exercises.

I have never found a patient not be able to do effective cough and deep breathing exercises, even most dementia and Alzheimer's patients do well with this.

Some RTs and RN, in my humble opinion, get so wrapped up in the idea that the IS must be used to prevent pneumonia, that they focus all their energy on having the patient use it, even though the patient is not using it correctly, or, more than likely, is simply unable to comprehend how to use it.

On these patients, I say, "Forget the IS."

This is just something to keep in mind.

Now, our RT bosses might be mad at me for telling you how to prevent pneumonia, because they want you to get sick so they can make money off you, but not me; I want you guys to be educated on the best means of avoiding the need for our services.

The other thing to keep in mind is that your body is not used to being immobile. If you're not moving around, you open the door for a variety of complications, pneumonia being one of them.

This is why, even after you have a major abdominal or chest surgery, your nurse will have you walking the halls, regardless of your level of pain. You might get some good drugs to help with the pain, such as Morphine, but doing this may still be a challenge.

We here at the RT Cave, when teaching the IS or cough and deep breathing exercisers, encourage our patients to push themselves to that pain threshold. It may be agonizing now, but it will allow you to get out of the hospital quicker, which will not be the case if you get pneumonia.

Immobile hospital patients will be taken care of by qualified RTs and RNs who know the best techniques of preventing pneumonia. For people living at home who are at high risk, it's your job to educate yourself, and that's the purpose of this post.

If you want an incentive spirometer, you'll have to refer to your doctor. If you want to know how to use an incentive spirometer, click here. For a boring but effective video on how to use an IS, click here.

Still, nothing is more effective than simple cough and deep breathing and breath hold exercises to eliminate your odds of getting pneumonia. You healthy people don't have to think about your breathing, but anyone at high risk must and should.

That concludes today's class.

Everything RTs need to know about pneumonia

Normally, a person's lungs are sterile (or so we thought before I wrote this post), or completely free of bacteria, viruses, fungi, or any other little particles that might cause harm to them. However, on occasion, something might make it's way into the lungs and cause what is commonly known as pneumonia.

Simply put, pneumonia is inflammation of the lung parenchyma. The most common cause of pneumonia is bacteria, although it can also be caused by viruses or fungi.

Pneumonia Statistics: According to Medicine.net, "over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia."

It's the sixth leading cause of death in the United States." according to mayoclinic.com, that 5% comes to about 60,000 Americans who die of pneumonia in any given year, most of these patients were compromised in one way or another, be it that they were elderly or had some disease such as cancer, COPD or other chronic illness. It's also the leading cause of death in children.
It can be deadly, but it can also be treated.
Signs and symptoms of pneumonia: Two common types of pneumonia are either viral or bacterial. Here are the signs of symptoms: 1. Shortness of breath 2. Rapid, shallow breathing 3. Auscultation

• Crackles isolated to one lobe is usually bacterial
• Crackles/ rhonchi in bases or throughout is usually viral

4. SpO2 levels decreasing below patient normal value
5. Cough: either dry or productive (green, brown, yellow and/or bloody secretions if bacterial, and clear to white if viral)
6. Chest pain that worsens with deep breath or when coughing
7. Fever, shaking, chills
8. Lab values: Increased WBC and/or increased neutrophils (if bacterial)

9. X-Ray shows dense white patch in infected lobe (bacterial). Viral pneumonias produces faint, widely scattered white streaks or patches
10. Sputum sample: lab may isolate bacteria if caused by bacteria (According to Merck.com, the organism is not isolated in 50% of patients.)
11. Patient may be pale, dusky, blue

12. Patient may be Diaphoretic, loss of appetite, fatigue, and (in elderly) confusion
13. With bacterial pneumonia, elderly patients may even have a decreased temp
Diagnosis of pneumonia:
Aside from a good sputum sample, a good history from the patient or patent's family can help you determine which type of pneumonia the patient has. If the symptoms occurred all of a sudden, then it may be bacterial or mycoplasma. On the other hand, if symptoms occurred following a bout of flu like symptoms, than a virus is probably the culprit.
Was the patient drinking? He may have aspiration pneumonia. Is he immunocompromised? Perhaps he has Pneumocystis carinii. Is it community acquired? It's probably gram-positive bacterium Streptococcus pneumoniae. Was it hospital acquired? Then it's probably Staphylococcus aureus or a gram-negative bacterium such as Klebsiella pneumoniae or Pseudomonas aeruginosa.
A third type of pneumonia is called walking pneumonia, so called because most patients develop mild flu like symptoms and are usually not sick enough to seek medical help. This type of pneumonia is caused my Mycoplasma, and is rarely seen in hospitals.
However, this disease is very common among people who work or hang around where there are lots of other people, and it spreads easily. Walking pneumonia is treated the same way that bacterial pneumonia is treated, with the right anti bacterial.
Another type of pneumonia, which is rare, is fungal pneumonia, which is usually less severe, but can cause a prolonged dry cough that might last for months. Patients with severely compromised immune systems may develop Pneumocystis carinii. This is usually reserved to patients who have AIDS, are receiving chemotherapy, and chronic lungers.
Aspiration pneumonia is where a patient inhales a foreign object, such as vomit (sounds yummy, hey?) This is a major concern for our drug overdose patients or other patients who have lost their gag reflex. Likewise, a drunk, inebriated person who has passed out may also be at high risk of aspiration and, thus, aspiration pneumonia.
Okay, let's back up a second.
What is pneumonia?
Say a bacteria gets past the normal immune responses that keep the lungs sterile, and makes it's way into the lungs. It is inhaled, goes down the trachea, takes a right or left turn at the Corina, goes through the bronchioles, and to the tiny microscopic air sacs at the end of the air passages.
Infections of this area cause inflammation of the tissue, which increases white blood cells to that area to fight the infection.
This results in edema, or fluid buildup in that area of the lung parynchema. This increases ventilation/ perfusion mismatching, thus making it difficult or impossible for oxygen to cross into the blood stream.
Lung compliance is reduced in affected regionThus you can see why pneumonia may cause someone to become short of breath, and have a lower oxygen level. In essence, oxygen is shunted away from the infested area. And, if the pneumonia is untreated, or becomes large enough, can cause serious problems, and even death.
Anyone can get pneumonia, but normally it is reserved to patients who are compromised in one way or another. And, while it is normally treated on an outpatient basis, occasionally a person has to be admitted, and these are the people we see.
Who is at risk for pneumonia?
The following is a list of who is at risk:

1. Chronic diseases such as COPD, AIDS, diabetes of whom are immunocompromised
2. Person's who've had spleen removed
3. Corticosteroids can impair the immune system
4. People who smoke or COPD. These people destroy their cilia, which is one of the bodies prime mechanisms for keeping the lungs sterile. Without cilia, a smoker has a weakened ability to remove secretions, and if they are not removed they can cause pneumonia.
5. People who drink too much
6. People exposed to chemicals or pollutants.
7. Post op patients who refuse to or are unable to take in a deep breath and cough up secretions (this is where scare tactics, cough and deep breathing exercises, incentive spirometers, CPT, and forcing the patient to go for a walk come in handy.)
8. Hospital acquired. This may or may not go hand in hand with #6. Intubated patients are at high risk of ventilator acquired pneumonia.


9. Patients who's immune system is worn down by other illness, and this may also lead to nosocomial infections
10. Heart failure
11. broken ribs
12. Very old and very young
13. people who are debilitated, paralyzed, bedridden, unconscious

How to treat pneumonia:
What medicines or therapies to give the patient is up to the doctor. Usually all of these patients get an antibiotic, however an antibiotic will not benefit patients with viral pneumonia. They will also get something to control fever such as Tylenol and nausea. Fluids are beneficial to help the patient hydrate and spit up phlegm
Bronchodilator breathing treatments are controversial for pneumonia, yet many doctors like to prescribe them due to some studies that show beta adrenergics, along with dilating bronchioles, may also help the patient produce and bring up phlegm.
Likewise, many hospitals have pneumonia order sets that include Albuterol to assure the patient meets Intensity of Service, or to make the Centers for Medicaid and Medicare Services (CMS) will reimburse the hospital. If a bronchodilator is ordered, this often assures Intensity of Service is met.
In my experience that first breathing treatment sometimes opens the patient up a bit because that fluid breaking up may cause bronchospam and a wheeze, especially in COPD and asthma patients.
Since nosocomial pneumonia is the most common infection acquired in hospitals, RTs and RNs have been given the responsibility of working together with patients to prevent pneumonia.
Further reading about pneumonia:
Click here to learn how to prevent pneumonia
Click here to learn about Ventilator Acquired pneumonia (VAP)

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

I know that most people click on my site and leave two minutes later frustrated that my site is not what they were looking for. When, in actuality, if they would have hung around a bit, had a cup of coffee with me, they may have found the answer they were looking for.

Here we go:

1. giving mucomyst iv : I had never heard of it. However, upon doing a quick Google search, I found that it can be given IV. Here's what RXmed.com had to say: "Administered orally or i.v., as an antidote to prevent or lessen hepatic injury which may occur following the ingestion of a potentially hepatotoxic quantity of acetaminophen."
   
2. asthma attack albuterol nebulizer : The medicine has the ability to generate instant relief when a person is having trouble breathing. This and COPD are the two main indications for this medicine.


3. how are asthmatic attack in adults graded : Adults can use a peek flow meter just like children, and they and their doctor can adjust their therapy according to how well they do on their peek flow, likewise pulmonary function testing can be used for this too. Likewise, all asthmatics should maintain an asthma diary to keep track of your symptoms so the next time you see your doctor she knows if current medicines are working, and so she can change the plan accordingly. For more information, click here.
   
4. copd and ventolin treatment : Check out my answer for #2.


5. vaponephrine : This medicine is the watered down version of Epinephrine that can be used as as a bronchodilator like Albuterol, but it has a greater effect on the heart, and if this medicine is given, it is recommended the doctor keep the patient for 1-2 hours after therapy to watch for rebound. Vaponepherine (Racemic Epinepherine), is mostly used for croup, which causes swelling of the upper airway above the vocal chords. At our hospital, it is used only as a last resort, and whether or not it really has the desired effect here is still open to debate. Personally, I don't think it does anything. Vaponepherine is also used on occasion in adults with swollen upper airways, which is usually due to post intubation. Again, it is used here as a last resort. Some doctors do not like using it, and some do. There is one other illness that studies show this medicine to have some efficacy, and that is for young children with RSV. New RSV guidelines recommend trying this medicine to see if it has a benefit, and if not, to discontinue it. Studies have also shown that severe asthma patients do respond to Vaponepherine, especially among patients who have been puffing on their inhaler all day and have saturated their beta receptor cells with Albuterol.


6. obtunded with ards : I do not deal with ARDS patients much at my hospital, so I will have to defer answering this question. The most important thing I would recommend regarding obtunded patients is that they not be given tidal volumes according to their actual weight, but ml/kg ideal body weight. At Shoreline we use 6-10 ml/kg ideal body weight.


7. acute renal failure; respiratory therapist : We do deal with these patients on occasion, and the most pressing respiratory issue here would be pulmonary edema and the patients inability to excrete urine. How these patients are treated is up to the physician, and is usually based on the patient's signs and symptoms. If the patient is in respiratory failure, RT may be required to draw an ABG or, if need be, intubate the patient and set him or her up on a ventilator. At shoreline, if the patient needs dialysis, we ship.


8. pneumothorax : I had a COPD patient with severe respiratory distress once who was initially ordered to receive continuous Albuterol treatments. I started the treatment, listened to the patient, and thought I heard a rub on the right side. Since that can be a sign of a pneumo, I reported my findings to the doctor, who put in a chest tube. Soon thereafter the patient was transferred to the floor and was breathing easy.


9. respiratory therapy teaching materials for kids : You mean for asthma? There is plenty of it. When I was a kid I got a big box of fun stuff to play with that taught me about asthma. I even had this cool game that nobody wanted to play with me. I think I even still have it somewhere in my basement in a box. Perhaps I should try selling it on EBAY. For a good website, click here.


10. respiratory floor charting form : We actually had a good one when I started working at Shoreline, but we've been doing computer charting the past eight years or so. I don't know about other hospitals, but our computer charting is very cool.


11. 90 cartoons large dragon in a cave : Technically speaking, there are no dragons here.


12. are blow-by treatments effective for pediatric patients : Yes. You do lose a lot of medicine to the atmosphere, but I think they are still very effective. That's my personal opinion. I know there is a lot of research that says otherwise, but my personal opinion says yes. We use blowby treatments with almost all of our young kids.


13. protocols of hypokalemia : There is nothing in the RT bag of tricks for this.


14. protocol for bi pap : We do not have a written protocol, however doctors usually write the order for Bipap, and we determine the settings on our own. I wish we were provided this same responsibility with vents.


15. how much does an hour of respiratory therapy cost? : The hospital charges for the procedures we do, not for our time. I wish that I was paid for each procedure I did. If that were the case, I would never complain about a useless breathing treatment, and we RTs would be rich.


16. as a respiratory therapist should i cross over in nursing : If you think you can handle it, I would highly recommend it. The pay is better and there are far more opportunities.


17. does albuterol have alcohol in it : I wish.


18. how many days should it take to know if singulair is working : It usually takes 7-10 days to get into your system. This is one medicine you need to keep in your system, unlike other allergy medicine.
    
19. how long does advair stay in your system : Advair should never leave your system. It is one of the preventative medicines you take on a regular basis and never stop unless your doctor says otherwise.
    
20. give ventolin before atrovent : A good question. Ventolin opens up the bronchioles immediately, so it only makes sense to give Ventolin first. However, one of my teachers argued that Atrovent opens the large airways, in which case, if he is right, then Atrovent should be given first. You decide. What do my fellow RTs think about this?
    
21. vents bipap nursing : I think it's important for RNs to understand some of the basics of both these machines. I don't think RT needs to be called every time a BiPAP patient wants to take off his mask, so the RN should know how to do this. The same with the vent. Especially being the lone RT at night, I teach my RN friends how to do certain things on the vent, like preoxygenate, turn it on standby during suctioning, etc.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.

Happy Easter

Hope everyone enjoys this day, which happens to be the earliest Easter in 95 years. It sure seems weird that there is still several feet of snow on this 31 degree day during the Easter season.

Your RT Cave writer is off work today, and doing nothing but recouping, relaxing, reflecting, spending time with my family, and eating.

ACLS is EASY

While I was studying for ACLS the other night at work, one of my co-
workers who was taking the class for the first time told me she was stressed about it.

"Why?" I said.

"Because there's so much to remember,"

"ACLS is so easy now, you could not even open up your book, go to the class, and still get your ACLS card at the end of the day."

"Really?" he said.

"Really. I mean, I would study, but I certainly wouldn't get all stressed out."

"But what about the Mega Code."

"What Mega Code?"

And I was right on there. I just got back from re-certifying for ACLS, and we didn't even do a Mega Code. Instead of each of us taking turns being team leader, and having to run through a code, all we did was walk through each scenario as a group.

All told, this group Mega Code lasted a mere 10 minutes. Then we took the test as a group, and we were done.

No stress involved.

It's so simple now that I think someone could probably go to the class without studying and do just fine. They pretty much walk you through what you need to know right there, which includes giving us the answers to most of the questions.

And if there are still questions you don't know the answer to, the test was open book and open discussion. How much easier can it get?

I wanted to get the heck out of there, so I did my test by myself and actually got out of the class 45 minutes early while most attendees were busy bantering over which one was right, A or B.

This RT never experienced ACLS of old, where some of my co-workers tell me the Mega Code was a major stressor, but it makes more sense to me the way they do it now.

Now ACLS is more of a learning experience rather than a pass or fail drill. One RN I talked with said it's too simplified, but I personally love this simplified version, and I get out of it just what I need, without the stress.

All told, ACLS is EASY.

The saga of the 99-year-old man: part 1

I gave treatment before I went home Thursday morning to an obtunded 99 year old patient who was wheeled into the emergency room with a non-rebreather plastered to his face. I was informed by the nurse the patient was from a local nursing home and was having trouble breathing.

"We are definitely going to need a breathing treatment on him, Rick," Julie, the patient's nurse told me, "he already had a Duoneb in route." They gave this guy a treatment enroute? Why?

Exhausted after perhaps one of the worst nights on recorded memory, one where I did 12 breathing treatments in the emergency room (two of which were indicated) and 12 EKGs in one four hour span while having a nursing student at the same time, I had long lost my ability to just keep my mouth shut and do what I was told.

So I let the nurse know what I thought about giving a treatment to this guy: "Looks more to me like he's in renal failure or is septic or something like that," I said. "More than likely he's probably wet."

I did an EKG, assessed the patient, and decided the patient did have no signs of bronchospasm. More than anything, he looked like a strong 99-year-old who had had a fulfilling life and was now ready to cross through the pearly gates to meet his maker.

So, after doing the EKG, I went upstairs. "Screw that nurse and her breathing stupid treatment," I thought to myself as I exited through the double doors and out of the emergency room. "I have patients upstairs who actually need treatments."

You guessed it, I as much as made it to the patient floors and was called back to do the treatment. What the, "I wanted to say hell here, but somehow managed to refrain myself as the doctor was standing right next to me, "the heck does he need a breathing treatment for," I grumbled. Honestly, though, I didn't mean to sound grumpy, but the exhaustion and burnout had raped me of my ability to control my cadence.

"Well," the all knowing nurse said, "He's short of breath."

You see, this is what's wrong with the medical field. Instead of actually assessing the patient, and knowing the indications for bronchodilators (for which all my blog readers know I am sure), some nurses think every patient who's short-of-breath needs a breathing treatment, including those patients, like this 99-year-old, who are in respiratory failure secondary to a metabolic problem.

I just want you guys to know that most of the time I an equanimitous guy who does what he's told and keeps his mouth shut and feigns a smile and grumbles to himself instead of verbally releasing into the atmosphere his frustration about an unnecessarily ordered procedure. For the most part, I have a mission to be happy and get along with everyone.

The nurse, who more than likely knew full well how miserable of a night I had (because her night was equally miserable) did not say anything back to me like, "This treatment is too indicated you stupid useless RT who thinks he knows everything." Nope, she did not say that.

And I'm glad she didn't, because I just wanted to go home, refuel and collapse. And, after I finished doing that breathing treatment, the nurse was preparing to insert a syringe into the patients newly inserted IV. I smiled and said, "Well, you don't have to give that," Julie.

"Why would that be?" She looked up at me and smiled. She knew what was coming.

"Because my Allbetterol mist just cured him of all his ailments."

She proceeded to smile and pushed her med.

I didn't tell her this, but also tossed into this mixture some Reserectolin to ease this patients transfer across the pearly gates, and some Waytoolateolin to ease the suffering of the nurse.

For more information on Waytoolateolin or Toolateolin check out this link. If you want to know more about Resurectolin, check out my list of 'olins at the bottom of this blog, of which I will update right now.

Oh, and I forgot to inform you guys that this patient was also a full code. Perhaps that will help you to understand my RT frustration a bit more.

(Note: I will continue the saga of the 99-year-old full code tomorrow.)

The greatest joy of being an RT

One of the greatest joys of being a respiratory therapist is when I have to do a breathing treatment in a room with two sweet little old ladies and they are so happy to see me.

I don't feel I go out of my way to do anything special for them, just provide another person to converse with. Oh, I may offer to sneak them in a pop or something. Or I may do something simple like help one of them take a sip of water.

Then, after I wrap up the treatment, I say something like, "Well, you young ladies behave yourselves now," and I leave the room.

And, as I'm standing just outside the door, I hear the following conversation, which of course is extremely loud because neither of the ladies can hear worth a darn.

"Now, isn't that the nicest young man?"

"Yep," the other says, "He's such a nice one."

Singulair: Another asthma miracle drug

This is my weekly focus on patient education, where I will discuss everything you need to know about (fill in blank).

The theory here is that, as a patient, I think it's good to go to your doctor armed with as much knowledge as possible. I call these posts patient wisdom, and you can refer to them at your convenience by clicking on the patient wisdom link near the top of this blog.

Today's focus is on allergies, asthma and Singulair.

I talked to one of the doctors I respect very much a few months back while I was working, and somehow the topic of discussion changed to me, and how much I love spring, but hate how miserable my allergies are at that time of year.

He said, "I think that every asthmatic should be on Singulair. I prescribe it for all my asthma patients."

So, when I went to my doctor, I said, "So, what would you recommend for allergies?"

My doctor said, "Well, did you try over the counter stuff, like Drixorol, Claratin, benadryl and that type of stuff?"

"Yeah, I've tried it all over the past 25 years, I even had allergy shots as a kid. None of it seemed to work. I was just wondering if you knew of anything stronger I might try, not that I really want more medicine to take or anything."

"Well, there is Singulair."

"Ah, that's what I was leading at. I didn't want to say Singulair just in case you had a better idea."

"Yeah, I suppose we could try that."

There, I got what I wanted. "Since spring is right around the corner, I will know right away if it works."

So, how do you know if Singulair is right for you?

Pretty much, based on my research, Singulair has proven effective for anyone with Allergic Rhinitis (hay fever) and asthma/allergies. For the most part, these two tend to go hand in hand.

Thus, if doctors could somehow prevent allergies, they could control asthma.

Finally, in 1998, after spending millions of dollars and 63 years studying leukotrines and working on a way to block their release, Singulair was approved for use by the FDA.

Singulair has an active ingredient in it called Montelukast sodium, which blocks the action of leukotrien, thus preventing allergies, and preventing bronchospasm caused by allergies, and, in turn, preventing asthma.

So lets back up a bit. What the heck are Leukotrienes? Better yet, what causes allergies in the first place?

When our bodies sense a foreign substance that might cause harm has entered the body, such as a bacteria or virus, it releases chemicals to attack the foreign substance. This is the bodies normal immunologic response to prevent and fight diseases. This is a good response by our immune system.

However, in some people, those of us who are prone to allergies, our immune system responds to harmful things, but also things that are relatively harmless, and generally cause no reaction in people who do not have allergies. In essence, with allergies, our body is fighting itself, and this is bad.

These harmless things that cause allergies are called allergens. Some common allergens are pollens released from trees, mold, hay, grass, dander, and food.

For the most part, if something causes us to have an allergic response, or asthma, we try to identify our triggers, in this case allergens, and avoid them. If you only have one allergen it might be easy to avoid, but for us asthmatics who are allergic to a ton of things, the only way to avoid all of them is to live in a bubble.

Now we all know that's not possible, or at least extremely difficult.

To give you an idea of the allergy process, I'll provide here a pithy example.

Say you are prone to allergies and breathe in a molecule of pollen. Your body fails to recognize it as harmless, and releases a chemical called pollen IgE antibody that binds to mast cells.

Now, at this point, nothing really happens, but the next time you are exposed to pollen, the IgE primed mast cell releases chemical mediators which attach to specific cells in the body causing inflammation.

Leukotreins are one type of chemical mediator which is responsible for inflammation, and are the culprits responsible for causing bronchoconstriction (tightening of the muscles around the airways) and swelling of the airways.

Thus, if we could find a way to block the release of these leukotriens, we could stop, or greatly diminish, an allergy attack, and thus an asthma attack.

And that's where Singulair comes into play. It blocks the release of leukotreins.

It has been proven effective for the management of allergies in asthma, and allergic rhinitis. It usually takes 3-7 days to start working, so, unlike antihistamines, it does not have an immediate effect, and must be taken on a regular basis (every day) to be effective.

In other words, even if you have no symptoms, you should never stop taking this medicine, unless otherwise prescribed by your doctor.

Singulair has not been proven effective as treatment of itchy eyes, itchy nose, sneezing and runny nose. If these symptoms continue to be problems for you, you might want to try an antihistamine, which can be purchased over the counter.

There is one other use for Singulair, and that is for people who have excercise induced asthma.

According to Health Library at CNN.com, "Because exercise-induced asthma has the same symptoms and results from the same airway reaction involved in regular asthma, standard asthma medications can control it."

Patients who experience excercise induced asthma but don't necessarily have a problem with allergins, and do not already take the medicine on a daily basis can take the medicine two hours prior to excersising, but not again for 24 hours thereafter.

Some patients have managed to control their asthma, excersise induced asthma and/or allergic rhinitis with the use of Singulair alone. However, some asthmatics may need other prophylactic therapies, such as Chromolyn or Advair and an occasional use of a rescue medicine such as an Albuterol inhaler.

So there, in a nutshell, is everything you need to know about asthma related allergies and singulair.

For more information, check out this link. Also check out this, the official website of singulair

That concludes today's class.

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

I know that most people click on my site and leave two minutes later frustrated that my site is not what they were looking for. When, in actuality, if they would have hung around a bit, had a cup of coffee with me, they may have found the answer they were looking for.

This is what I'm going to make an effort to do every Monday.

1. vomiting bipap: This is a good question and something that was covered extensively in RT school. There are two types of masks patients can wear who are using BiPAP. There is a nasal mask, and a full face mask. If the patient is wearing a nasal mask, then there's no problem. However, in the hospital setting we use full face masks probably 90% of the time. And, if someone is throwing up with a mask on their face, their risk of aspiration (inhaling the vomit into the lungs and risking pneumonia) increases big time. Take the mask off if a patient is vomiting. If the patient is in the hospital and is on BiPAP to prevent him from needing a vent, intubation might need to be considered to protect the airway.
2. giving mucomyst without a bronchodilator: Mucomyst has the ability to break up thick secretions and making them easier to spit up (theoretically). It can cause bronchospasm, and should always be given with a bronchodilator, such as Albuterol.
3. vaponephrine dose for kids: At Shoreline we use 0.5cc Vaponephrine on all kids. It's safe. I have rarely ever notices an increase in heart rate as a result of this medicine, and usually if the heart rate does increase, it's because of the kid crying because he's annoyed by the RT.
4. efficacy of albuterol with chf: I've repeated this many times on this blog, but Albuterol will do nothing for CHF unless -- UNLESS -- the patient also has an underlying bronchospasm component. If you want to try one treatment to see if it does anything, go for it.
5. is a nurse above a respiratory therapist: Absolutely not. We are a team. Now, RNs are know to have a little more respect in society, but that is slowly changing. The reason is that nurses have been around since the Civil War, and RTs are only just getting started. RNs also get paid more than RTs, but that's only because of the nursing shortage and, partially, because of the respect thing. But, all in all, we are a team.
6. azthmacort: I took asthma cort for about 15 years, and never had much success with it. The main reason for this was compliance, as I was prescribed to use it four times a day. I think it's better to use a steroid inhaler that allows you to use it twice a day to increase compliance. I have better success with Flovent or Advair, but there are other options.
7. barriers to being a good respiratory therapist: Lack of respect I think is the main barrier. And lack of protocols that allow us to really excell at providing the best care to our patients at the least cost to the hospitals. However, due to lack of respect by doctors, many hospitals still do not have respiratory therapy or patient driven protocols. That's a shame, I think, and is the biggest barrier in my mind.
8. albuterol blow-by neonates: I find that most babies do not tolerate masks, however the results of using a mask may vary from patient to patient. If the child is sick enough, he or she might not care. Also, a blowby may result in the loss of 80% or more of the medicine to the atmoshphere. That said, giving a blowby is often better than doing nothing for a child who is having true bronchospasm.
9. should i give my daughter albuterol for croup: Only if there is underlying bronchospasm. Albuterol does absolutely nothing for croup.
10. cpap therapy for copd how it works: CPAP works to improve oxygenation. It helps a patient oxygenate better, and thus allows more oxygen to get into the bloodstream.
11. congestive heart failure croupiness: We hear this a lot in CHF patients. And, more often than not, RNs and RTs mistake this for a wheeze and recommend or order breathing treatments. Actually, this is caused due to increased secretions or fluid in the upper airway, and will not go away with a treatment. I would say that abaout 80% of CHF patients, patients with pulmonary edema, will have this harsh, upper airway, stridorous, croupy sound. This is something they should teach in school, but I'm not sure they do.
12. what is my internet time: Huh?
13. extra shift incentive pay respiratory: What do you mean by extra shift? Do you mean overtime. We get paid overtime for anything over 40 hours just like everybody else.
14. bad experiences with advair: Some people have bad experiences with Advair mostly becaue it has Serevent in it, which can make a person shakey and irritable. I would recommend weaning yourself onto the Advair slowly, instead of starting right out taking it twice a day. I'm patenting that idea. I recently wrote a post about this, check it out by clicking here.
15. stridor and aerosol therapy: See my answer to question #9.
16. duoneb and hyperkalemia: It would be the equivelent of taking an asprin for a heart attack. Need I say more.
17. why respiratory therapists are disrespected: I tried to explain this in my answer to #7 above. Maybe one of my fellow bloggers can word it better than me with a comment.
18. my doctor gave me potassium after an asthma attack why and what does potassium do f: Hopefully he gave potassium because lab results showed hyperkalemia, not because of some frivolous idea that one treatment of Albuterol will decrease Potassium. However, for a further answer, see #16 above.
19. definite sign of impending alcoholism: Okay, sorry sir or maam, but you had to read all of the above to learn that I do not have an answer to this question. Now, I could gather a pretty good educated guess, but I'm pretty sure you'd rather hear from a professional in that area rather than a lowly RT.
20. respiratory therapist 12 hours: I do not know of any hospitals where the RT does not work less than 12 hour shifts.
21. does albuterol breathing treatments make baby sleepy: Actually, it can be soporiphic. I know for it fact it puts some babies and even some adults asleep. Ah, maybe this gives me another idea for an 'olin.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.

New brand of Ventolin now increases potassium

I just made an observation in the emergency room that made me chuckle to myself. Now no one had a clue what I found so amusing, nor did I say anything, but I just couldn't help myself but to find humor in the moment.

One of my favorite all time patients came into the emergency room in dying agony because her legs were cramping. She was so restless I could barely get her to hold still 20 seconds so I could get a good EKG reading. The doctor, however, decided that she was probably having cramps due to a low potassium, and opted to give the patient an awful tasting drink of patassium.

What I found so amusing was that I was giving a breathing treatment to this lady, and just last week this same doctor had me give a treatment because a patient had a high potassium. So, if Albuterol is supposed to lower potassium, why the hell would a doctor give it to a patient with low potassium level.

I mean, this patient was obviously not short-of breath if you know what I mean. When I asked the patient if she was short-of-breath she said, "No. but I'm wheezing."

The nurse interjected, and said, "She has CHF."

"Well, that's no indication for a breathing treatment," I said ruefully.

"She also has treatments at home." Then she definitely needs one now. That should cure her cardiac wheeze. Not. I held my tounge like a good politically correct RT.

Ah, but that's the power of Ventolin. Now, not only does Ventolin lower potassium, but it somehow, miraculously, causes potassium to increase. We'll have to call this new brand of Albuterol Hyper-K-uterol.

Now, for all you non RTs out there, potassium levels can drop if you give a very high amount of Albuterol to a person in a short period of time, such as when we are giving a continuous breathing treatment, or treatments every hour round the clock, or something like that. But one treatment will NOT lower potassium enough to make a difference.

And Ventolin does not increase potassium. I'm being facesious here when I say it does. But still, I find humor in this. I will, if I ever get access to the bottom of my blog again, have to add this to my list of 'olins: Hyper-K-uterol.

Oh, and one more thing. I finally have access to the bottom of my blog, so I will update my 'olin list Sunday night. I have at least 75 more to add, but I'll put up ten or so for you to enjoy by Monday morning.

The Dragons of the RT Cave

I feel bad for you that you have to come back to this place, because it's terribly busy.

Despite that omen from one of my co-workers, it has not been busy at all this weekend. In fact it's been wonderful. And, considering I was prepared for a miserable night, I'm enjoying it that much more.

I don't know if I ever mentioned this before, but the Dragons of the RT Cave wake up early to guard the cave. I usually grab my stuff and run when it starts to stir, and pray it doesn't use it's telekinetic powers to find where I'm hiding.

I have no clue why it wakes so early, but when it does I can smell it. Personally, believe it or not, I like our dragons. They're tough, but they hold down the fort rather well. Still, one of the perks of working night shift is you don't have to deal with dragons, as I write in one of my banner slogans, "the dragons are sleeping at night, if you know what I mean."

And keep in mind that not all dragons are bad. We actually have pretty tame dragons here at Shoreline, and they do a pretty good job of keeping us proles in line, and making sure we have all the best technology to work with. Still, a dragon is a dragon.

From Monday through Friday, however, our dragon hops is sniffing the grounds as early as 2 a.m.. So that means I have to pack up my bags and head to better Pasteur's. Well, I suppose I shouldn't say better Pasteur's as our dragon is quite friendly. It's just that a dragon is a dragon no matter how small, and dragons can get mad and rip your head off, or burn you good.

I used to hide out because it tried to eat my head off every time I got close to it, or so I thought anyway. Every time I forgot to dot an i or cross a t it was right there breathing it's fire hot breath over my head -- breathing fire. While some night shift RTs still fear it, not me anymore. Still, it's good to be wary.

Since those days of long ago, the RT dragon and I have helped each other out enough times now that we are on good terms. Still, having been away from the patient floors as long as it has, it's developed that business mentality -- forgot how it is on the floor per se. And, you guessed it, everything has a monetary bottom line. It has grown it's scales. Now it's a full grown dragon.

I don't make many mistakes anymore, but occasionally I still get a note, or, if I happen to be working when it finds out I did something incorrectly, a telepathic call at. Mainly the goofus mistakes are minor things, but a mistake is a mistake no matter how small.

Recently I left a blood gas syringe by the ABG machine.Could the dragons let this one little slip pass without letting me know about it. No. The lab dragon sent a fireball with a message to the RT cave dragon, who snarled and waited for me to be working so it could call me at four in the morning to let me know about it.

But that was last week. Yesterday I'm sitting in the CCU with Scooter the RN, and my beeper goes off.

Just one morning, I think to myself, just one morning I'd like to go without getting a page from the RT dragon. Not that I don't like it, nor that I can't get along with the dragons, because I do, but it's 4:00 in the morning and I'm tired. Doesn't it get that? This is the time of the morning I just want to do my work or, if I have my work done, just sit around. I don't want to be quizzed.

Like a good boy, and wanting to stay on good terms with it, I picked up the receiver and dialed the extension to the RT cave.

"Hello," the dragon said.

"Yeah, this is Rick," I said into the receiver.

"Hey, Rick. No you didn't do anything wrong. But when you get a minute can you come talk to me."

"Sure, I'll be right there." I hung up the receiver.

"Was that your dragon," Scooter said.

"Yep."

"Well, you said it'd call you right at four. You have it pegged."

I laughed. "Yep, you're right." But I don't wanna go. I just wanna stay here and chill.

But, like a good peon, I left the unit and walked through the hospital to the RT cave. As I walked through med-surg I could swear I could smell that a dragon was here. I could feel it; sense it. It has telekinetic powers after all.

"So how was your night," it said as I approached the entryway to the cave.

"Oh, it wasn't too bad. Actually, it was very slow compared to the last several days I've worked. It was a great break."

"That's too bad," it growled, a puff of smoke billowing from its flared nares. "We need to make money, and we don't make money when you're not doing anything."

I had already been up 24 hours, so I had developed that 2 a.m. loose lipped mentality. I said, "Well, it's one thing being busy, but when we're busy doing a bunch of useless breathing treatments it makes me twice as burned out as if I were actually using my brain."

I followed the dragon around while it unchained the doors. It didn't snap around and throw a fireball at me, so I knew I was still in the good, even though I had more than likely crossed the line with my honesty. I never would have done that a few years ago, but, like I said, I was on good terms with it now.

"I think there are a lot of people here who no longer come to work because they love their jobs. They come here just to get a paycheck. When I used to do your job, I used to do it because I loved my job."

I was NOT going to touch that one. (However, my lack of comment here still haunts me today. This is one of those times where I thought of a good comeback after the conversation was over. I will write about this tomorrow). "I love my job, boss." Am I being political by saying that, or truthful, I think.

"I know you do," it said, "but I think that a lot of you guys are just too complacent lately," she said, "I think it gets slow, and then you guys forget how to work." It stopped and looked at me. "Not just you, but all you guys in general. Those treatments are how we make money. "

"Well, boss," I said, "I don't have a problem working, it's just that if we're going to be doing useless breathing treatment just to make money, I think they should be done during the day when there are two RTs on."

It turned around. I hit a button. Smoke was puffing from its little nares. "It's not just you, but all of you guys have been making a lot of little mistakes lately. Here, I'll show you."

I followed it into the dark cave through a corridor in the back. It was dark and horrifying back there, but I followed her anyway. In a way, being in here reminded me quite often of being in the principals office. I watched as it shuffled through papers on it's desk

"Here, see." it grabbed a stack of paper, flitted through them so I could see all the notes and who they were left for.

"I see that even Dale has made mistakes."

She flitted through the stack again. "Yeah, he's made several."

"Oh, I thought he was perfect."

"None of you guys are perfect."

"Well, it seems that's what you bosses are trying to make us out to be." Of course I won't call them dragons to their faces. That would be a violation of one of the RT cave rules. "Look, boss, we aren't' perfect, we are going to make mistakes."

"Well, you shouldn't."

"At no other hospital I've ever worked at did I ever receive one note, and I know I screwed up many times. I guess the feeling there was, if I make a mistake, and I have to go to court, then it's on my shoulders."

"Well, I guess we have higher standards here."

"I know. We do. And I think it's good. But I think sometimes you guys go overboard. Look, you guys got Paul and Steve up on the edge. They're to the point they hate you. I mean, I know it's not you, you're just doing what you're told, but since you're the one leaving all the notes, you're the one they are going to hate."

"My boss," she said, "makes me do this. He wants me to keep track of every note I write, and if I write six notes then I have to write you guys up for now on. That's why I called you here. I want you to be more careful."

"Boss, if you do that, then you'll have to fire us all. We aren't perfect. You're just opening up a can of worms."

"Hmm, worms, that sounds delicious," said the dragon. Just kidding. She said, "I just do what my bosses tell me."

"Well, if you write us up for every notes, then that means we'll get a verbal warning, and then, the third time, we get fired. By the end of the year you'll have a 100% turnover rate of RTs. We'd all be fired."

"Why is it you have to argue with everything I say." She beamed at me. I jumped back. There was no fire, but I could see it was close to exploding.

"I don't mean to, but we have a right to disagree with you. There's more than just one opinion in this department, and I think we are having a good discussion. There's no way you can make progress, in my opinion, without discussing. Don't you think?"

"You have a good point."

Whew. "Well, I think your bosses should come down here and work like we do, and they'd see how not easy it is to be perfect. They are so far removed from the real work, it's easy for them to make such frivolous policy for you. If they had your job, they wouldn't do what they make you do. "

"That's very true. They wouldn't. And, when Gary had my job, he didn't do any of this. He has me going over every chart, every day, writing down every little mistake I find. It's very exhausting, especially when I have to hear it from... well, not you, but Steve and Paul."

"Gary only has you doing all this stuff because you act as a shield. When us RTs get mad at you, you get the brunt of the spears. Your bosses feel no pain."

"Wow," she said, and smiled. "You hit the nail on the head."

The RT Dragons: They are abounding.

Preparing for a busy night, hoping for a good night; and a brief review of the new Underdog movie

Another nice thing about working 12 hour shifts is your wife can work on your days off and you get plenty of time to spend with the kids, and they never have to go to day care. Then again, there are times when I only see my wife in passing.

After working 12 last night, she trudged into the house this morning with red eyes, slurring her words, and she said, "Sarah said she feels bad for you. She said it's so busy that she had to have someone come in at two in the morning to help her."

"That bad, hey," I said.

"Yep. As she was talking to us she was paged three times."

After driving the boy to school, my wife went to bed and was out almost instantaneously. That left the girl and I home alone, and we decided to watch a movie we rented called Underdog.

Many of you probably don't remember that old cartoon, but back in the day when cartoons weren't on 24 hours a day, my brothers and I used to look forward to Saturday so we could watch cartoons all day. We would even sacrifice sleep and get up early.

At six in the morning we'd sneak off into the livingroom, click on the boob tube, and watch either Bull Winkle, Johhny Quest or Underdog. We loved those shows, however simple they were. They were good entertainment.

Usually I find myself disappointed when Hollywood gets a hold of a classic. When I was a kid I loved the Dukes of Hazzard, but when I took my son to see the movie I found myself wanting to leave the studio after there was sex in the first scene. I suffered through it. I hope this experience didn't scar my son for life.

I expected the Hollywood version of Underdog to be equally disapointing, but it turned out to be pretty good. It was, in my opinion, very fair to the original show.

Fortunately for this RT who has to work all night tonight, my daughter is still at that glorious age where she likes to do the same thing over and over and over and over and over again, and still get the same enjoyment out of it each time.

That in mind, I'm going to put Underdog back in, turn the volume down, and try to take a nap. Sometimes this works with four year old girls. However, sometimes she likes to make sure I'm alive every ten minutes or so by giving me a big kiss and saying something like, "I love you daddy."

Whatever kind of rest I can get, I'll take it, especially considering I'm not rightly looking forward to going to work tonight. And being my first night back after my bi-weekly mini vacation, I'm bound to be awfully tired.

I can handle it, though. I'll just put on my running shoes, plan for the best and hope for the worse... er, plan for the hope and... well, you know what I mean: prepare myself for worse and hope for a good night.

The best perk of being an RT is lots of days off

One thing I really like about working as an RT is 12 hour shifts. If you are going to have to be there for eight hours you might as well stay an extra four. It may get tough sometimes near the end of some busy nights, but the reward for working those four extra hours is more days off.

Basically, I work so I can get days off. And however much you might enjoy being an RT, or an RN, or whatever you do at the hospital, not working is much better than working.

Even if it's an extremely slow night where you have plenty of time to balance your checkbook, finish off two novels and gossip with your pals, that still doesn't beat not working.

Where I work there are only two of us who work the bulk of the night shift hours, so we got together about eight years ago and agreed upon a schedule where I get six days off in a row every other week, and he gets five days off every other week plus every Friday off.

Right now I'm on the tail end of six off. It's nice because it's like a mini vacation without taking any days off.

In the summer when I want to stretch out my six days, I only need to burn 24 PTO hours and I get ten days off. In essence, I calculated last summer that I burned only four days of PTO to get 40 days off in June and July. That's 40 days off right in the heart of summer.

We do have to work every other weekend, but so what. When you work at a hospital, it's far more relaxing and enjoyable working on the weekends than during the week anyway. In fact, if it weren't for graduations and weddings, I'd volunteer to work every weekend.

Anyway, 40 days off in June and July is pretty awesome. There aren't many jobs that give you this much flexability. I suppose, if you are pondering being an RT, this is a pretty darn good incentive.

And, considering it's been very busy at work lately, it makes me appreciate these days off all the more. Days off are nice.

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

Of the 500 queries in my stat counter's memory, I have picked some of the most interesting queries. Keep in mind I do not answer queries if the page the person landed on would have provided them with an appropriate answer.

Yes, this is supposed to be my Monday feature. For now on it will be. We'll also have class on Tuesday and Wednesday as well starting next week.

Here we go:

1. copd patient with left side chest pain: The emergency room staff would treat this as cardiac related until test results show otherwise.
2. What year was Albuterol invented?: I had to look this up. According to Wikipedia, "Salbutamol became available in the United Kingdom in 1969 and in the United States in 1980 under the trade name Ventolin." I never knew about it until 1993.
3. what's it like to be a respiratory therapist? It's rewarding knowing that your skills saved a life or improved someones breathing. We also get to share our vast respiratory knowledge by educating our patients about their respective disease process, and how to live with their illness. We spend a lot of our time going room to room doing breathing treatments that help patients breathe better. I've met a lot of neat people and have had many great conversations doing this. Another part of the job is taking care of critical patients, maintaining their airway when needed and, if necessary, setting them up on life support. This, in my opinion, is the most rewarding and challenging part of the job.
4. Duoneb croup: First of all, croup is caused by a virus, and typically only effects children. It causes swelling of the smooth muscles of the upper airway above the vocal chords, and, as the child is breathing in, you will hear a harsh sound we refer to as stridor. The child's cough may sound like a bark. Duoneb will not benefit croup. However, if there is an underlying bronchospasm component (asthma) along with the croup, Duoneb will relax the lung muscles and make it easier for the patient to breathe. Usually for croup we use a cool mist aerosol to try to relax the muscles of the throat, or, if necessary, we give a racemic epinepherine treatment. Sometimes this works, sometimes it doesn't. For the most part, whether this is used depends on the doctor's preference. The Racemic Epinepherine will relax the smooth muscles in the lungs, but theoretically it will also relax the smooth muscles in the throat, which is what is causing the croup, and is why this is usually the aerosol of choice for croup.
5. Albuterol potassium: Albuterol can lower potassium if it is given excessively. If you use it as prescribed it should not lower your potassium. This, however, is something that should be watched when a patient is receiving continuous breathing treatments in the hospital setting, and might be a good reason not to overuse your Ventolin inhaler at home.
6. nursing home respiratory therapist: Currently, Medicaid won't pay for an RT in the nursing home in Michigan, but I'm not sure about other states. However, before the law was changed, I did work in a nursing home for a while. It was a very slow paced job where pretty much all I did was breathing treatments and incentive spirometers -- lots of incentive spirometers. Occasionally I'd be called to assess a patient in distress, in which case I'd usually recommend sending the patient to the hospital.
7. still use mist tents: Not at my hospital. We hid them in the basement where they are currently collecting dust. We find that it is better for the patient, the parents and the hospital staff to simply use a pediatric nasal cannula if the patient needs oxygen. If a patient needs the mist, then we simply set up a cool mist aerosol. However, I've only done the later in the emergency room.
8. nebulizer for cough spasm: Sure. You can try it. If there is an underlying bronchospasm component, a nebulizer with Albuterol might help.
9. copd sucks: I imagine it does. However, there are many things you can do to help you cope with this illness. Click here for a good article on coping with COPD. Or click here to check out what the COPD doctors and scientists at National Jewish Medical and Research Center have to say about coping with COPD. And here is a good blog of a COPDer who has written many great posts on how to cope with breathing illnesses.
10. asthma attack every 2 weeks: If you are having an asthma attack every two weeks, then you should definitely be on some preventative medications, and you should learn what triggers your asthma and how to avoid them. There is no cure for asthma, but there is no reason why any person in today's world should'nt live a normal productive life. For more information you can check out this link. Another good link for asthma information I will link to right here. You should fully educate yourself about asthma and talk to your doctor about how best to manage it.
11. oxygen weaning protocol: I've never worked at a hospital that doesn't have one. We are allowed to wean oxygen to maintain an SpO2 of 92% or greater on any patient ordered on our oxygen protocol or ventilator protocol, which would include most of our patients. If the oxygen does not stay above 92%, we may increase oxygen to whatever the original order was. However, if a patient suddenly needs a lot more oxygen, say from room air to a 50% venti mask, common sense dictates that a doctor should be notified.
12. Respiratory therapy stories: This would be a good idea for a post. What is the most exciting thing that ever happened to you as an RT? Or what was the weirdest thing you ever saw? I had a an end stage COPD patient once who was extremely short of breath and she shouted, "I JUST WANT TO BE WITH THE LORD!" She did right then.

Keep in mind I receive hundreds of queries a week, and I am limited in space on this weekly column.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.