Finally a doctor who sees things my way

For years my RT co-workers and I have been trying to change the EKG policy in the ER so that EKGs are only ordered on people who need them, as opposed to every person who walks into the door with CP, stomach pain, back pain, toe pain, etc.

However, our boss doesn't like to rock the boat, and he didn't want to have to go out of his way to try to convince the ER RNs and doctors that they need to be more specific on who they order EKGs on. Or, better yet, it's all about money, and the more EKGs we do, the more money we make.

And our medical director did a review of the EKGs ordered in ER, and the reasons why they were ordered, and he agreed that there were many frivolous reasons for EKGs being ordered, however he was also reluctant to overrule the ER EKG policy where the nurses get to order the EKG on any patients they think one is needed on.

Yet today I went to ER to do an EKG on a 24-year-old female with CP. To me it sounded like she had a little chest cold or something, but considering I was overruled on my attempt to get rid of these frivolous EKGs, I had no choice but to complete the procedure.

Yet this time, as I handed the EKG to Dr. Honk, he said, "I don't think we need to do an EKG on every 24 year old with CP."

"I just do what I'm told," I said. "The nurses order the procedure, and I do the test."

"Well, Ill have to have a talk with them, because I wouldn't have ordered this EKG."

Awesome, I thought. Finally a doctor who's anti-useless therapies. And now that I think of it, he doesn't order breathing treatments on every patient who comes through the ER doors complaining of a common cold either.

Wow. If Dr. Krane, of whom usually works my nights, was working, not only would I be doing the EKG, but I'd be doing a breathing treatment "to ease that chest pressure." And I'd be coming up with a new name for a new 'olin for the bottom of this blog.

I'll have to have this Dr. Honk talk with Dr. Krane and have him knock some sense into her.

Reimbursement criteria going a bit overboard

I had to laugh as my co-worker today told me that he was approached by the lady in charge of double checking charts to make sure we are complying with quality management.

The basic purpose of her job is to make sure that charting is as such that we will be reimbursed for therapy. She also has to make sure that the patient meets criteria for payment.

"Hey Dale," she said, "What is it with all these Q4 breathing treatments being given 10 minutes late or 10 minutes early.

Dale told me he looked at her with a blank face. What was he to say? He told her that we are a busy department, and because this is a job with many interruptions, we have to have some leeway in doing our therapies.

"But," she said, "In order for our insurance to pay, Q4 treatments have to be done every four hours exactly."

Dale said, "At first I thought she was joking, then I realized she was being serious."

What is the medical world coming to. Not only are we incapable of deciding who really needs breathing treatments, we have to do them exactly when we are told.

However, that's not going to happen.

Treatment plan for man with a lung tumor

The following note was not found in the "Doctor's Notes" section of the patient's chart for reason that would be obvious to doctors who follow the "New Doctors Creed." It would create too many questions doctors do not want to answer if that were done, especially among RTs who think they know everything about medicine.

The following, my friends, is a note that was left on the coffee table in the doctor's lounge. Only us here at the RT Cave have access to this stuff; you will find this no where else. Trust me, you cannot make this stuff up.

Tx Plan for George GooGoohead (fake name for Hippa purposes):The mass is to be treated with CPT. This is a very delicate procedure that demands a unique approach. The idea is to percuss the mass to a manageable size, and then dislodge it so it may be safely coughed out. Great care must be taken not to dislodge the mass before it is percussed to optimal size. Any suggestion for aerosolized drugs that will help shrink the mass will be welcomed and immediately implemented (perhaps alternate treatments with Mucomyst and Atovent???). Please complete this task before I report to work Friday in the a.m.

Sincerely:

Dr. Bighead (fake name for purposes of protecting brilliant doctor from harassment from irritated RTs in case this note is not protected properly by you guys -- God forbid.)

The following is a response to this note by another distinguished doctor:

Dr. Strictler and I ordered Q2 Aerosols and CPT to go along with the alternating Atrovent and Mucomyst aerosols that you recommended. Brilliant idea by the way. We ordered the above therapies because we believed the mass shrinking wasn't progressing fast enough. George must have gotten wind of the benefits of this new approach to lung mass removal (perhaps he had been talking with the nurses), because he's been calling for his treatments lately instead of refusing them. He now should have a much greater chance of being cured and, hopefully, of being discharged by you when you return on Friday.

Sincerely,

Dr. Bonehead.

We here at the RT Cave hope you RTs heed this information and use it to your further understanding why such therapies on cancer treatments may be indicated and ordered by doctors of whom are definitely smarter than you, especially when it comes to respiratory therapy.

Ventolin now productive mucus thinner

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

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

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

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

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

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

So there!!!

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

I did smile, though.

She said, "What's so funny!"

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

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

To see a full list of 'olins check here.

Cardiac asthma should not be treated as asthma

I have spent so much time writing about and educating nurses and students about cardiac asthma that I have decided it needs a post of its own.

And, considering about half of all breathing treatments I do are either for pneumonia or cardiac asthma, I am hereby convinced that even doctors have no clue what the difference between true asthma and cardiac asthma is.

According to the Mayoclinic.com, here is the definition of Cardiac Asthma:

The term "cardiac asthma" refers to wheezing associated with congestive heart failure. It isn't true asthma. As a result of congestive heart failure, fluid can build up in the lungs (pulmonary dema). This causes signs and symptoms — such as shortness of breath, coughing and wheezing — that may mimic asthma. True asthma is a chronic condition caused by inflammation of the airways, which can lead to breathing difficulties. The distinction is important because treatments for asthma and heart failure are very different

Cardiac asthma is mainly caused due to increased pressure in the pulmonary vessels causing fluid to fill the air sacs, "preventing them from absorbing oxygen," and making the person feel extremely short-of-breath.  This same increased pulmonary vessel pressure (increased pulmonary vascular resistance) in turn squeezes the bronchioles and causes the wheeze and other symptoms that mimic real asthma, and this is why this "problem" is quite often mistaken for asthma and treated with bronchodilators. Secretions sitting on the vocal cord may enhance the wheeze, often causing it to be audible. (Keep in mind that a true bronchospasm wheeze cannot be heard sans stethoscope).

When Cardiac Asthma is treated as bronchospasm, all we are doing is putting adding more fluid to lungs that are already filled with fluid. What we need to do is give these patients diuretics to get rid of some of the fluid, or other cardiac drugs to increase the force and contractility of the heart to reduce pulmonary pressure.

Another good strategy worth trialing is CPAP or BiPAP, as the incrased airway pressure has been shown to reduce preload and afterload to reduce the work the heart has to do to pump blood through the body. This can reduce the feeling of air hunger until the medicines take effect.

Other than the heart, there are other diseases that can cause pulmonary edema and cardiac asthma, and these include pneumonia, exposure to toxins, and high altitudes. It is the job of the nurse, the respiratory therapist, and doctor to determine the true cause of the symptoms. It is the doctors job to properly diagnose and treat.

We'll consider this RT Cave rule #26: Cardiac Asthma should not be treated as asthma. Throat wheezes, upper airway wheezes, and dyspnea on exertion are signs of cardiac asthma, and a wise medical specialist will not confuse the two.

RT saves life and then gets no respect from RT boss

One of my day shift co-workers did an EKG on an out-patient and it was normal. Then the patient told him that she was fine when she was just sitting there, but got SOB and her heart felt funny every time he walked.

"Well, go run up and down the hall and come back and we'll do another EKG," my co-worker said.

The patient did, and my co-worker did the second EKG, which turned out to be abnormal.

So said co-worker called the patient's doctor and the doctor said, "Excellent job of thinking off the cuff there." The patient is currently admitted in the critical care.

Said co-worker told the head RT boss about this situation, and RT boss said, "WHAT! YOU DID WHAT?"

"I had him run up and down the hall, and then I got this EKG." My co-worker showed the boss the abnormal one. "If I wouldn't have done that, the only EKG I would have got was this one, and it looks normal. Would you feel comfortable sending this patient home with this normal EKG on file, when every time he moves he gets this abnormal EKG?"

"Well, you better chart the hell out of this," the head RT boss said.

Here you go out of your way to save a patient's life, and not even that is good enough to please the RT bosses. This is another example of how they have lost touch with everyday RTing.

The hypoxic drive theory: reality or simply a hoax?

(This is part one of a six post series.)

One of the theories that evolved as the field of respiratory therapy evolved was the THEORY of the hypoxic drive. That is where if a patient's oxygen level gets low enough, the patient's brain will signal the patient to breathe.

While CO2 is usually what causes people to breathe, when the levels of CO2 is chronically high, particularly in patients with chronic bronchitis who have developed a chronically elevated CO2 level (CO2 retainer) "that cannot be lowered significantly regardless of patient effort," according to Egan, Fundamentals of Respiratory care, (page 336 volume 6, 1995), CO2 no longer effects a patients drive to breathe, and low levels of oxygen (hypoxemia) "drives ventilation quite strongly."

Due to this theory, it is recommended that people who are CO2 retainers not be placed on oxygen greater than what is absolutely necessary. Generally, the accepted wisdom is that a PO2 level of 50-60 torr is the target PO2 we reach for with these patients, which is equivalent to an SpO2 of 80 to 90%.

And, if a patient is given too much oxygen, the theory suggests, this patient will lose his drive to breathe, his CO2 becomes much higher, he ultimately becomes lethargic, and will at some point stop breathing. Therefore, we medical workers in charge of the patient want to avoid using FiO2s greater than 40% for the most part.

However, also according to Egan, (page 707, volume 6, 1995) while hypoventilation is a hazard of oxygen therapy, "this harmful effect should never stop us from giving oxygen to a patient in need. Preventing hypoxia should always be the first priority."

So far I've stated the obvious that all of you wise RTs already know, but what happens if you have a chronic CO2 retainer patient on 100% oxygen to maintain a PO2 of 40%? Will that patient lose his drive to breathe?

In my professional experience, I have seen maybe two patients who became lethargic when the oxygen was turned up, but I have also seen many patients in this situation be placed on a 60% or greater FiO2s and never have his drive to breathe suppressed.

The point of this post is this: Is the hypoxic drive theory a hoax?

As I reported in a previous post, I accidentally mentioned that I am not necessarily a fan of the hypoxic drive theory to an RT student. I did not go into detail as I caught myself. However, the following week she told me she "in passing" mentioned this to her teacher, who said, "What are they filling your head with?"

Yes, it is true that we have to be careful what we tell our RT students, but at the same time we want them to be aware that what they learn in school is not exactly the same as what occurs in real life here at the hospital. And, the truth to the matter is, the hypoxic drive theory is just a THEORY.

In the next few weeks I will review briefly why people breathe, and then I will share some information I have that challenges the hypoxic drive theory. My goal here is not to convince you that the hypoxic drive theory is a hoax, but to inform you of other theories out there that might more accurately describe your patient's condition.

Stay tuned.

WARNING: As I stated earlier, the hypoxic drive theory is the gold standard theory of respiratory care. Most doctors live by it. If a doctor says lower the oxygen level on a patient because he is a CO2 retainer, it is your job to do what he says, even though you have proof that a) the patient is not a retainer, and b) the patient is a retainer and the oxygen is not harming the paitent. You may try to convince him otherwise, and he may also grumble and gripe.

WARNING #2: Since the hypoxic drive theory is the gold standard of respiratory care, it is strongly defended by RT teachers. And therefore, for you RT students out there reading this, know that any material opposing the theory will more than likely not be on your RT exam.

NOTE: Despite what I wrote in warning #2, I am now aware that some RT Programs no longer teach the hypoxic drive theory.

(To view part 2, click here.)

Post updated 10/24/2010)

The medical field is humbling -- like baseball

Too bad we all couldn't be professional baseball players and play a kids game for a living. Too bad life couldn't be that easy for all of us.

Then again, professional players will tell you fast that, "baseball is a humbling sport." If I could have a dime for every time I've heard that I'd be rich.

Well, so is the medical field a humbling profession, or any other profession where you deal with a lot of people on a regular basis. If you are over confident, and your patient dies, the next time you won't be so confident will you.

According to dictionary.com, humble is to not be proud or arrogant. Some people in the medical field, and you know who I'm referring to, are so not proud and so not arrogant that they have lost all sense of personality. They are blunt, short and nearly impossible to get along with.

You know what? Sometimes parents can be humbled in this way. And that's why some poet wrote this really great poem that went something like, "sometimes you need to stop and smell the roses."

My point is that while it's good to be humble in every way, something that often comes with age, experience, stress, death, threat of losing ones job, etc., it's also important to be a good person to other people around you, and to have some fun.

In other words, don't be a stick in the mud.

We have to listen to our bosses and doctors, keep our mouths shut even when we disagree with an administrative decision or stupid doctor order, for fear that we might lose our jobs. If a major leaguer loses his job, so what: he's already set for life financially.

If I could be a humble baseball player, one who's greatest stress would be whether he'd go into a major slump and be booed at home, that would be a far better place to be humbled than the real world.

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

The real RT world -vs- the RT student world

I have an RT student who follows me every Thursday. She is in her first clinical rotation, but she's such a good worker that I'm actually able to allow her to do several procedures on her own. She even does EKGs.

While I do let her do some procedures by herself at this stage, most of the time I'm with her, and sharing with her my opinion on this and on that. This way it is more of an educational experience for her, as opposed to just sending her out to do my work.

Yes, I do have to slow way down when she is with me, but I actually enjoy it. To be able to share the knowledge I've obtained is something I like to do. I don't know if I ever wrote this before on this blog, but I actually had my choices limited once to either being an RT or a teacher.

And the only reason I chose to be an RT was because I could start working right away, as opposed to waiting four years before I could teach. The bottom line in me choosing to be an RT was that I needed money right now.

Thus, when I get the opportunity to teach, I really enjoy it. But I told her that she needs to be careful what we teach her, because what goes on in the real RT world is not the same as what occurs in the teaching world. And, while it is our job to teach our RT students how to be an RT in the real world, it is your RT teachers job to teach them how to pass the exam.

For example, I showed her ABG results from the weekend before where I had a patient with a pH of 7.10 and she said, "The patient was vented, Right?" I said, "No. The patient was placed on BiPAP for 24 hours and now he's fine."

In the real world, I told her, you don't treat the number, you treat the patient individually. However, in the RT student world, the one where you have to prepare for "The Test," you have to intubate any person with a pH less than 7.30. At least that's what I was taught when I was preparing for the test.

Likewise, the theories they teach in school are not the same as theories in real life. For example, I told my student that I'm not sure I really believe in the hypoxic drive theory. I told her I wouldn't tell her why because I didn't want to confuse her.

"But tell me," she insisted.

"After you take your test I'll fill you in," I said.

I almost felt guilty bringing it up. And, the next week she told me her teacher said, "What kind of junk are they filling your head with."

I said, "I didn't tell you why I thought it was a myth, only that it was my opinion that it was. And," I added, "You can even look in that book of yours right there, the one with Egan's name on it, and it's in there that some people believe that the hypoxic drive theory is a myth. I know it's in there because I read it just last night."

"Really?"

"Yeah."

Again I felt guilty for having brought it up, except that it wasn't five minutes later, back in the RT cave, that we were having a hearty RT discussion with Jane Sage, and Jane coincidentally brought up the "hypoxic drive myth."

"If you follow it to a tee," she said, "like you would if you were taking the respiratory exam, you might kill some patients."

"Why is that?" the student asked.

"Well, let's give an example," Mrs. Sage said, "Say you have a patient who is a known COPD retainer, and that patient has an SpO2 of 40. What do you do?"

"You put him on a 40% venti mask or a nasal cannula at 3-4 LPM."

"According to your test, the answer would be yes," Jane said, "But in real life, you would want to give 100% oxygen. Think of it this way, your heart needs oxygen, and if it's oxygen deprived, it will poop out at some point. If you only give that person 100%, he might lose his drive to breath in 20 minutes. But, if you give him 40% FiO2, he might lose his drive to breath due to pure exhaustion and Oxygen depletion in ten minutes."

"Wow, you guys make some good points," the RT student said. "I never learned that in school."

"Well, it's just something to keep in mind that you can apply when you are doing clinicals, but when you are taking your tests you'll want to stick with what your teachers tell you. That's just the way it is in the medical field."

I'm sure we can think of many more examples of the differences between the real RT world and the RT student world.

New Vent protocol biproduct of teamwork

There has been a lot of discussion lately on the blogosphere about how hospitals may be more efficient if there was a more cohesive effort on the part of administrators in involving employees in the process of decision making.

I imagine our hospital is no different in this regards as compared with any other hospital, however we do provide one prime example of what good can come from more than one group of individuals coming together and making decisions to the benefit of all parties involved.

I've written before on this blog about the advantages of the Keystone committee and it's efforts to reduce the incidence of VAP while at the same time saving the hospital millions of dollars per year on wasted medical costs. It's main effort has been by getting administrators, doctors, nurses and respiratory therapists together to figure out a solution.

At Shoreline, the resulting decision was called a ventilator protocol. However, in retrospect, this protocol wasn't really a ventilator protocol, but a ventilator weaning protocol. However, since the protocol has been enacted, the number of days on a ventilator has been chopped by a large margin, and the incidence of VAP has been nearly evaporated.

To further improve the statistics, the doctor in charge of Shoreline's Keystone Committee approached my friend Jane Sage, the RT on the committee, about improving the ventilator protocol. She said that not only did she want it to be a weaning protocol, but she wanted to change the protocol so that RTs could change the rate and tidal volumes based on EtCO2 readings.

Likewise, instead of drawing ABGs every morning and with every vent change, we would now be able to make vent changes without doing the invasive ABG draw, but simply by monitoring the SpO2 and the EtCO2.

These new changes are yet to be approved, but this is a major revelation for an RT department that was protocol depleted as of just two years ago. When Mrs. Sage told me about this doctor approaching her with this new information, I wanted to run out of the hospital and pump my arm into the air shouting ululations like, "Woooo Hoooo."

This, I think, is a quintessential example of what good results can come about when many great minds are put together, as opposed to the administration and doctors getting all the privilege of decision making.

You decide: Landscaping or overtime pay???

We had a discussion recently in the blogosphere about how much better run hospitals would be, and happier the workers like you and me would be, if there was more co-ordination between the administration and hospital employees.

I thought of this as I drove my wife to work this morning, and noticed a bunch of landscaping trucks parked out back. In my opinion, there is already enough money invested in landscaping so the property looks 310% better than any landscaping in my sub-division, so I can't imagine what more would really, truly need to be done.

It reminded me of our last department meeting, when we learned that the hospital was going to be spending millions of dollars funding and redesigning the hospital image, creating a new sign, logo and color scheme for the hospital. Yet, moments later, we learned that the hospital was in a financial crunch, and there would be a lock down on all overtime and on call pay.

A perfect example of this was last Sunday when my boss scolded me because I was swamped on Saturday night and wrote "no lunch" on my time card. What this would amount to was the department paying me time-and-a-half for one half of an hour for me basically doing the work of two people all night long.

In talking with the good folks back in OB, they are no longer allowed to have a person on call. So, when they are in a crunch, when every second is of importance, the nurses will have to get on the phone and start calling every single employee of that department right down the line on the list.

The thing is, since whomever comes in will not get overtime pay unless that person is already over 40 hours for the week, who would want to come in. I sure wouldn't. However, out of due respect for your friends whom are currently in a jam, someone usually bites the bullet and comes in to help.

Quite frankly, I've been known to do the same thing in my department when my co-workers are in a jam. I come in to help even though my company is too cheap, and too short on money, to pay me the well deserved time-and-a-half-pay I should get for being nice, for sacrificing my quality family time.

Yet, while the hospital is busy being cheap with us, it continues to fork out millions of dollars on beautifying the hospital grounds. It would seem to me that there would be a better way of managing the "few" dollars that the hospital has.

There is an answer, and it is to have one or two of us employees sitting on the board so we can put in our two cents worth. So we can make sure the hospital is taking care of us, and not simply its image.

Depressed spouses make themselves sick?

One of the most frustrating things I see in the hospital is when we have an older patient whose spouse just died and the couple had been happily married for over 40 years. We had one man recently who was a very successful member of the community even up until recently.

However his wife died a couple weeks ago, and then he became so depressed he ended up a permanent fixture in the hospital. He got pneumonia, he refused to eat, his medical condition deteriorated, he ended up on a ventilator, and he eventually made it back to the floors and continued to be a depressed mess.

I tell you I have the utmost sympathy for people in this situation. However (and I'm no expert in this area other than by mere observation as an RT), I wonder if they have their priorities straight. I know lots of people who were happily married, only to live on for many glorious years after their spouse passed on.

I consider myself happily married, but I sure would hope that if I passed on that my wife would go on with her life after the initial mourning process. I mean, I know their is nothing more difficult than losing a loved one (especially a child), but I can't imagine the one who passed on would want his best friend to spend the rest of her life mourning.

Being old and being fed up with going to the doctor, about being blind and deaf and having to tackle a million prescriptions every day is one thing. I know when my uncle Donald died recently, I was told he had simply decided he had enough, and then he got his wish a few days later. He was 92.

I understand that. But to be of good health, sound mind and body, and to simply give up living, to me, is a foolish thing to do. And, I might wonder, if that person didn't have his or her priorities in life mixed up. I rarely do this in real life, but I would like to ask these people some questions like:

1. Do you believe in God?
2. Do you place God ahead of your wife?
3. Do you have children?
4. If so, do you prioritize your yourself over your children?
5. Do you have hobbies that you like to enjoy that you can still do?
6. Were you so attached to your wife that her love was the only quality thing in your life?
7. Do you have quality friends?
8. If so, do you place your grief ahead of your quality friends?
9. Do you not care that you are setting a bad example for the ones who still love you?
10. Do you not think you are letting your freinds and family members down by giving up?
11. Do you not care what other people think?
12. Do you realize people feel sorry for you?

Sometimes, when I have time, which often I do here on nights (but not lately), I talk to these patients. I ask them, in an appropriate way (and only when they bring up the topic), the above questions, and sometimes I get them to participate in an intelligent discussion during the treatment. I get them talking about how wonderful his wife was, or career, or something.

And, more often than not, I get a smile. The reason, I think, is that, even while he is depressed, he doesn't want to be a stick in the mud; he doesn't want to share his depression; he understands that there are other people (like me) who still have several quality years of life left.

So they smile. And, I bet more often than not, they eventually recuperate. I bet most of them do. But, unfortunately, some never do. These people become permanent fixtures around the hospital and nursing home arenas. They are the ones who demand attention, ring their call bells every 15 minutes chanting to whomever answers the call with: "Get me this," or "get me that."

Those are the lucky ones. Those are the ones who are still willing to talk, because some of these individuals are so depressed they just lie there and sulk. I feel bad for them at first, but then after a while I wish they would just quit feeling sorry for themselves. I wish they had other priorities in their lives other than the one they lost.

I wonder if they do believe in God. I wonder if they do believe in heaven. Because, as I wrote before, I believe that people that have their priorities together are the best patients. In fact, I bet most of these people don't get sick and avoid the hospital altogether.

I'm no expert in this area, yet here I am just wondering.

Xoponex may soon rival Albuterol in cost

Apparently, Medicare has decided to list Xoponex under the same reimbursement codes as Albuterol, meaning the cost of Xoponex may drop as much as 70-80%. This could mean a lot for any person in need of a rescue drug, because it will provide doctors, RTs and patients with more options.

Of course this decision could be reversed, but if not, it could provide another cost effective option in the care of patients with COPD and asthma. Some studies have shown that patients given Xoponex in the hospital got better faster, other more recent studies show that Xoponex works no better than Albuterol.

And, while some studies initially showed that Xoponex has fewer side effects than Albuterol, more recent studies show otherwise. These new study results may or may not have had an effect on the Medicare boards decision.

Either way, doctors at Shoreline have been instructed to stop using Xoponex as a front line bronchodilator based on the more recent studies. For more information, check out this article.

Personally, based on my experience with Xoponex, I don't think it's worth the added cost. However, if the cost of Xoponex is going to be the same as Albuterol, doctors, RTs, hospitals and, most important, patients will be able to try both meds to see which one works best for them.

the walkin coughin

The other night at Shoreline Medical, I again got called to ER to give a nebulizer tx to a "diff breather". When I arrived I found a sweet little old lady with what sounded like a good case of bronchitis. While talking to her I discovered that she had been in the ER two nights previous and was discharged with home nebs, antibiotics, and just in case, a jolt codiene for her cough. The patient's caregiver told me that she must not have done "it" right as the "sweet little thing" has not gotten any better. " The discharge instructions directed me to give the nebs if she coughed. Well, she didn't cough so I didn't give her any nebs and now she is worse and coughing real bad! "
Now I ask you, when did we start sending every Tom, Dick and Mary home from the ER with home nebs to treat their cough? Do bronchodilators treat a cough? Are the doctors reading something I've missed? The sweet little old lady had coarse rhonchi, no wheezes, and no crackles. And, if you give someone codiene for their cough and then tell the caregiver to give nebs for the cough, just when exactly do you think the patient is going to get around to coughing I ask you? And, where the H--- is the indication for the patient to have nebs at all, let alone home nebs?

Anal RTs in the RT Cave

Usually after 9 p.m. I am by myself, and usually, it seems of late, that all the treatments are due right around 10:p.m. when I'm all alone. Since I'm alone, I usually start at 9:30 and chug along, and expect that by 10:30 I'll be done with all my treatments.

However, it usually doesn't work that way. Being in the field of RT, and having that dam beeper, you can never plan ahead as to when it might go off. And just as I start chugging away at my evening treatments is when ER calls. It's to the point now that I can almost bet on it.

Ideally, on nights when we have seven or more treatments due at 10:00, I think we should have 2 RTs working. However, this trend of being busy will end some day (hopefully soon as far as I'm concerned, however the RT bosses are happy by it), and I'll be so slow around 10 p.m. that I'll be looking for things to do.

So, this gets back then to the inability to plan ahead in this job. Unlike my application for overtime two posts ago, you cannot plan for overtime; you cannot plan when you are going to be busy. It can come at any time of the day or night. It can last up to one hour or three months. You never know.

Last Sunday, when I had that Cerebral Palsy patient come in and I had to spend the majority of my time with him that night, I pretty much didn't do any other treatments. I had to rely on the nurses to call me when a patient needed a treatment, and in a few cases they did the treatment for me. It was that kind of night.

Now, in my defense, by Sunday night, the night in question, I had already had the same patients all weekend, and knew who needed treatments and who didn't. So, when I got busy with this one patient, calling in help to do treatments that aren't indicated in the first place didn't seem to me like a good idea. So, instead of worrying about the un-indicated treatments, I focused on the patients who needed my services and was happy to care for them.

Actually, it got so bad at one point that I walked upstairs with a pack of Albuterol amps and handed them out to the nurses in case their patients called for a treatment, or actually got short of breath. As it turned out only one patient called for a treatment, and he was one of the patients who liked his treatments, but did not need them.

So mooring comes. The ventilator that was supposed to be cleaned during the night was still in shambles in the back room. Stock was dwindling in number as I did not do my job of stocking during the night. And not one of the four QID treatments were started.

Now, none of this would have been a concern of the RTs who work with me on my weekend, but since Monday the other weekend core of RTs work, the A-Team we call them (Anal), the little things matter. And, when I gave report, and it came to light the QIDs were not started, my relief said, "So, why didn't you call someone in to do the QIDs? Now they are all due and I have this vent to take care of."

Keep in mind here that she works solo until the 9-9 RT comes in. "Oh, I'm sorry," I said, being political, "It never even occurred to me. None of these people need treatments anyway, so I wouldn't worry about it."

"But these treatments need to get started," she said anxiously. "What am I supposed to do."

"Just take care of the vent. I'm telling you, none of these people need these treatments. They will be perfectly fine to wait until the Jake comes in at 9. Don't worry about them; trust me."

What I said went right over her head. These are the kind of RTs that have to have every treatment done at exactly the time the doctor ordered them. The Q4s have to be done exactly every four hours, and the Q6 treatments exactly every six hours. That's fine with me that's how they run their ship, but it makes for very little flexibility and high stress if ER calls or something else comes up. These people run around ragged and stressed all day.

Me, and the rest of the people who work on my weekend, are more laid back. We assess our patients so we know who needs them, and we give Q4 hour treatments a half hour leeway, and Q6 hour treatments an hour leeway. That is, unless they really need them. Then we don't dink around.

The Anal RTs are well aware that the treatment might not be indicated, but that doesn't matter: if the doctor ordered it Q4, then it must be done Q4. If the departmental policy says that QIDs have to be started by the noc shift, then that is how it must be. Anything else is grounds for anger and anxiety.

My point is, you can't plan ahead in this profession. You can't be so stuck on the idea of doing Mr. Robinson's treatment at exactly 10:10 because the person who worked before you did Mr. Robinson's last treatment at 6:10. It's only the Anal RTs who work this way, and they tend to be stressed to the max when things don't go as planned.

I suppose, though, that we all have our own way of working, and in the end, we all get the job done because we are all elite RTs. It's just that some of us are flexible and prepared for the interruptions, and don't let them bother us, and other RTs, the Anal RTs, have that anxious edge to them unless things go exactly as planned.

They are great people and fun to work with, and when you follow them you know that all treatments are going to be done, and all equipment stocked, and after hours they might be just as fun to hang out with as any other RT. But the anxious edge to them will be apparent, as they say things like:

"Man, you are going to be busy tonight," or "It was swamped today," "You better have brought your running shoes," or, "I think you better call in for help tonight."

I know, based on experience working with these guys, that I have to get a good report and organize my own worksheet and make my own judgement as to whether I can handle it by myself or not. Chances are, their anxious statements will be way overblown. Not always, but most of the time it is not as busy as they make it appear.

That, my fellow RTs, is the thought of the day.

I ventilated one BIG man and one TINY man

Remember back in October when I was bloggin about how slow it was here at Shoreline? Those days are long gone. I haven't been able to do any blogging at work, which is fine, because I've been enjoying facing some of the challenges that have come my way lately.

Just this past weekend I had a call from ER that a 500 pound man was being brought in who was in respiratory distress. Learning from past experiences, I brought the BiPAP machine with me, and as soon as I saw the patient lying on the cart swallowed amidst about ten EMTs who were called in to help carry this man, I knew instantly that BiPAP would be indicated. He appeared rather obtunded, in obvious respiratory distress, and he was snoring horribly loud (audible gasping actually) and he had long periods of apnea.

As the EMTs transferred this man on the "big man's bed" we brought up from the basement, I got my ABG kid ready to go, and was ready to perform the procedure when I heard the doctor say, "I think he looks almost hypoglycemic. I bet his sugar is only 24" I didn't wait for the result, and just barely pierced the skin when the results came back: "It's 24," the nurse said. "Wow, you were dead on, doc."

"All right, give him some dectrose, and, Rick, you don't need to do that ABG," the doctor said.

But I wanted to get one anyway. This man looked like he had an elevated CO2, and he presented the quintessential example of a man about to crash. I wanted to get the ABG. "Oh, I'm already in," I said. "Yeah, but if you miss..." the doctor started, and I said, "Oh, I got it." Despite the size of the man, he had arteries the size of a tree trunk. He was an easy poke and easy draw.

After I was finished, I turned around and saw an elderly lady being wheeled in. I presumed she was this man's mother, considering the EMTs had talked about her. I asked her how tall she thought her son was, and she told me. Good. Before I get back I'm going to check out my cheat sheet to determine this man's ideal tidal volumes.

I force myself to determine ideal tidal volumes, particularly on very large patients, because I know for a fact that some doctors want to set tidal volumes based on a patient's weight. Man, if they did that to this guy they'd blow him up to smithereens. So I've learned to be prepared with my tidal volumes, and proof that I'm right.

As soon as I had the results I started to plug my BiPAP into the respective outlets, and the doctor said, "Let's hold off on that for now." But he's having periods of apnea. Even if you get his sugar under control, he's still gonna be in trouble. He needs BiPAP. Well, okay, fine. I started to the lab. When these results come back, he'll have no choice but to order me to put this on.

The ABG results: CO2 95, pH 7.01, HCO3 38, PO2 90% on 100% NRB.

These results, particularly the high bicarb level, coupled with the fact this man did not smoke, provided proof that this man was a classic case of Pickwickian syndrome. I've seen it a few times, but this man had an extreme case of it. "He's got Pickwickians," the doctor said. "Put on the BiPAP." Bingo.

Lo and behold, once the BiPAP on, it appeared to me exactly what this patient needed.

Yet, the doctor said, "Based on those gases, he might need to be intubated." Ahhh, he does not need to be intubated. Why is it that some doctors are so quick to intubate?

Keeping my cool, I said, "That's a possibility. He's breathing quite well on this machine."

"True. And his vitals are good too," he said. "Yeah, lets keep him on this so long as his vitals continue to look good." This is a tactic I learned from one of my senior co-workers long ago, trick the doctor into thinking something you wanted to do was his idea.

"You think he's getting good tidal volumes with that."

"He's getting great tidal volumes. 550 to be precise. And, based on my calculations here," I showed him my cheat sheet, and the high and the low tidal volume for a patient the height of this man. "See, a 550 tidal volume is perfect for him."

"I didn't know you could measure a tidal volume on this machine."

"This machine is a lifesaver," I said. "It's prevented many patients from needing the vent. So long as he maintains a drive to breath. If he loses that, then we'll have to intubate."

"This is pretty cool. We may not need to intubate him then." He appeared so happy at this moment, I thought he was going to hug me. He was undoubtedly impressed.

"I bet he is like that every time he sleeps," I said, "I bet you are right on about the Pickwickians." He made my ego go up a notch, so I had to return the favor.

He was right about the Pickwickians, though. The next night, the man was going apneic even with the BiPAP on, and while he was apneic his sats would drop down to the low 40s. So we'd wake him up. And, when he was awake, he was perfectly fine, with a sat in the high 90s. He was also aaox3 by this time too.

But man, every time he fell asleep, he would go apneic, and his sats would drop. To me, he gave the impression of Ondines. You know the story of Ondine. According to Wikipedia, Ondine was a "water nymph who had an unfaithful mortal lover. He swore to her that his "every waking breath would be a testimony of [his] love", and upon witnessing his adultery, she cursed that if he should fall asleep, he would forget to breathe. Eventually, he fell asleep from sheer exhaustion, and his breathing stopped."

I was simply waiting for this man to stop breathing when he was asleep. He did not have Ondines, as Ondines is more of a disease people are born with and is more of a congenital disorder. This man had pickwickians disease.

This is a disorder caused due to obesity, and when the person falls asleep all the flappy skin and adipose tissue collapse the airway causing the apnea. Sometimes BiPAP works, but sometimes it doesn't. In the case of this patient, so far, his BiPAP was not working so well. As I read further about Pickwickians, I learned that a trach and a ventilator at night would probably be indicated for this patient, unless he lost a lot of weight.

After watching him go apneic and having to wake him several times, I had the RN call the doctor, of whom said, "Well, I guess there's nothing we can do about it right now."

Well, what can we do aside from traching him. The best thing we could do was just keep waking him up and hoping he didn't fall asleep and not wake up. Since this man came in on Friday night, I had to deal with him all weekend. It made for an interesting weekend, especially considering on Sunday night I had to intubate the exact opposite end of the spectrum, a 56 pound man with cerebral palsy.

I'll be honest and tell you that I was slightly anxious here because we rarely ever deal with people the size of this man. In my 10 years in this business, I have set up a ventilator on one pediatric child. And, I knew for a fact this doctor was sweating inside, however spirit of equanimity she showed on the outside. Working together as a team her and I, It was the most enjoyable experience for an RT who is rarely challenged working for a small town hospital.

"Does he talk?" the doctor asked the EMTs.

"The caretaker said he does not talk, but he communicates with his eyes," the EMT said. "He cannot move without assistance, but he is normally 'cheerful and full of life, she said'"

"Based on my pediatric calculators for tidal volume," I said to the doctor as I was setting up my ventilator, "we should probably use a tidal volume between 150 and 300." I said probably, because this little man was small and deformed, all scrunched up there on the bed. I cringed even at the thought of intubating this man, and so did the doctor. But it is not our call to decide who not to intubate. We had our hands tied. We had no choice but to do this.

The ABG results: pH 6.90, CO2 90.

Needless to say, this and the other guy took up so much of my time I pretty much ignored the other patients. And, needless to say, only one of them needed his treatments, and I simply provided a few amps of Albuterol at the nurses station and the nurses there were more than happy to do his treatments for me.

Thus, over the weekend, I assisted the ventilations of one man who was the epitomy of large, and then a few days later did the same for a man who was the epitomy of small.

This was a challenging weekend, but one that was, all in all, fun.

Applicaiton for overtime

Because the census was so low in October here at Shoreline, the powers that be decided to make a new policy where all overtime has to be approved by the respective department bosses. Even while our department does not abuse overtime, the RT bosses were forced to buckle down on us too.

So, rather than having to call our boss at 2:00 a.m. tomorrow night, I am writing a slip right now asking for permission to have Paul come in to help out with the treatments I won't have time to do because Mr. Rasmussen is going to code at exactly 2:10 a.m. Wednesday morning.

And I'm also putting in a request to come in and help out next Saturday when, at precisely 4:16 in the evening, a school but is going to collide with a tanker on the expressway, requiring the need for four youngsters to be placed on ventilators. It's not going to be a pretty site, and doing all that work will be way too much for one person, so I figured I'd put in my application so I can help out.

Thursday night nothing is going to happen, so I don't think I'll need any assistance from any of my co-workers, and on Friday night, when Paul is working, it will be slow too. But on Saturday night, after those four kids are transported to the Great River Hospital, the emergency room will become inundated with COPD and asthma patients, a majority of whom will be admitted.

I don't want Paul to have to do the work of two RTs like I did last night, so I'm putting my application in now so he doesn't have to. Hopefully this overtime will be approved.

Doctors have more power than my boss

I was off work for five days already, just long enough to forget how burned out this place made me last week, when Jane Sage called me at home Tuesday evening. Shoot. What did I do wrong now.

It was nothing I did wrong, but what I did right that she wanted to talk to me about. You see, I had spent the last couple years making a cheat sheet of ventilator graphics for myself to use mainly, but when I finished it was so popular around here that now everyone has a copy of it.

Anyway, one policy we have here is that nothing can be posted, filed or even hung on a bulletin board unless it is approved by the forms committee. So, I placed this cheat sheet on my bosses' boss about four times now, and nothing ever happened. However popular it is among my co-workers, the RT think getting it approved would be too much work -- or something.

Once I corned my boss, and she said, bluntly, "The writing is too small and this is much too complicated. If you want to use this form, you can just carry it on your clipboard."

I dropped the idea, until Jane called. My wife answered the phone when I was picking my son up from school.

"Dr. Aerial saw your graphics sheet, and he loved it," she said. "He said he wants one. He wants to understand graphics so people don't have to keep explaining them to him. He wants one of those sheets on the vents."

"Holy cow," I said, "You mean a doctor is actually interested in something I did."

It was true: ego up one notch from zero to one.

It seems we are making progress here at Shoreline, slowly but surely. Or, doctors have more power than my boss.

I'm getting a rock for Christmas

I'm not sure how this conversation came to be, but my 4 YO daughter told me that she wanted to get me a rock for Christmas.

"A rock oughta be interesting," I said, "I'm sure I can find many uses for a rock... Maybe I can use it at work to help me with my breathing treatments."

"Yeah, daddy," she said, "I know you can use it to bash your patients in the head and then you won't have to do breathing treatments on them. Then you can stay home and play games with me."

That's an interesting concept, but I'm afraid it wouldn't work the way she plans. When I relayed this story to my co-worker, she said, "Are you complaining about treatments at home again?"

Actually I don't. Um, really...

We RTs love when we are respected

"You don't have to hunt me down every time you do an EKG," she said. "I am totally confident in your skills."

"Thank you," I said, "I always appreciate when I'm respected. You see we have other doctors who want me to hunt them down every time I do an EKG, so I just got into the habit of it. "

"I think you know what a bad EKG looks like, and you can just give me the EKG when you think there's something I need to see right away."

My heart. Oh, my heart is going to burst. Did she just say what I thought she said? Does she really have respect for me, a lowly RT? Look at her; she's looking at me, not at the nurse standing next to me. She has respect for me. My heart; oh, can my heart handle this? Gather yourself Rick. You need to say something. You need to thank her for respecting the fact that you have an education and several years of experience.

"Thanks. I really appreciate this."

Wow! And you said something half way intelligent. Usually you say something stupid, or you are tongue tied when a doctor compliments you like this. And usually those compliments are so far and few between than when they happen, you worry about your heart. Will you ever stop fluttering? Will my ego jump up a notch? Will I actually develop an ego.

I turned around and there was my student. You heart that compliment, didn't you? "Come on, Alice, now that we have all these EKGs done lets go finish our work upstairs."

Wow. Not only did this doctor give me her confidence, she did so in front of a person, and with other people around.

This is a relatively new doctor here at Shoreline, and I think her and I are going to get along real well. See, my fellow readers, this is all I ask for as an RT: Respect.

Some basic facts about COPD you should know

Perhaps secondary to pneumonia, the second most common type of patients I see on my respiratory therapy treatment sheet are COPD patients. In fact, I've seen so many of these patients I can recognize them by mere sight.

COPD is going to be the focus of this blog for the next month or so. I'm going to be analyzing this disease to provide me and my fellow RTs a nice refresher course, but to better educate my COPD audience as well. The more we RTs know, the better we can benefit our patients, and the more our patients know, the greater likelihood they will avoid having to come in to see us RTs.

I always say when I'm leaving a room knowing that the patient is going to be discharged later that day, "Well, the next time I see you it will be at a grocery store or a restaurant." Then they laugh. And they laugh with me two weeks later when I actually do meet them in a restaurant and barely recognize them because they are wearing street clothes.

But, far too often, we meet again in one of our hospital suites. Sometimes it's only a week or two after they were discharged, and the lucky ones I don't see for another year or so. Either way, the more they know, and the more I know to educate them with, the better off they are, and the more likelihood they can avoid visiting me again.

However, aside from being well educated, they also have to be compliant, or else no amount of education will do any good.

You can look up the definition of COPD via the various links on this blog if you want to. I'm not going to go into detail on that, at least not yet. What I'm going to delve into is deeper than what will be covered on most COPD websites.

I've decided that this week I would simply relay some basic facts regarding COPD that I've obtained via various sources:

1. COPD is the 4th leading cause of death worldwide, yet 75% of those affected remain untreated. It is also the 4th leading cause of death in the U.S.
2. The World Health Organisation estimates 600 million people worldwide have COPD.


3. COPD is projected to be the third leading cause of death by 2020 with only heart disease and cerebrovascular disease accounting for more deaths.


4. Higher prevalence rates for COPD are found in men than in women globally reflecting historic gender differences in smoking behaviour.


5. Prevalence figures for COPD are believed to be underestimated. Sufferers tend not to seek medical advice until the disease has progressed and the condition is severe. Or, in other words, an estimated 30 million Americans have COPD, while only 16 million adult Americans have been diagnosed with disease.[


6. Quality of life is severely affected in patients with COPD, with 80% of patients hospitalised following an exacerbation reporting a health status rated or quoted by a physician as being 'worse than death'.


7. Lost productivity due to COPD can have a devastating effect on the economy, and the greatest emphasis of medical professionals is to improve the quality of life for COPD patients so they can be productive members of society.


8. COPD has a higher mortality rate than asthma (5,438 deaths from asthma in 1998 versus 107,000 deaths from COPD in 1998).)


9. The highest increase in mortality has been in white women, as observed between 1960 and 1998.


10. In 2000, the annual cost to the nation for COPD was estimated to be approximately $30.4 billion. Health care expenditures accounted for $14.7 billion, and indirect costs (decreased income due to loss of work or premature death) were $15.7 billion.


11. In a recent survey, 7 out of 10 smokers could not identify COPD as a top-five killer.


12. In 2002, about 125,000 people died of COPD.


13. While other chronic health diseases such as heart disease and diabetes have decreased in the past 20 years, COPD rates have steadily increased.


14. In a recent survey 66% of Americans did not know that COPD kills more women than men.


15. Women who smoke are more susceptible to developing COPD than are men.


16. Women may develop COPD at an earlier age and with less duration or intensity of smoking


17. U.S. women had more COPD hospitalizations (404,000) than men (322,000) and also had more emergency department visits (898,000) than men (551,000) in 2000.


18. More women than men die of COPD.


19. Cigarette smoking is the leading cause of COPD


20. Breathing in second hand smoke can cause COPD (in fact, I witnessed this with my grandma.)


21. Working around certain kinds of chemicals and breathing in the fumes for many years can cause COPD.


22. Working in a dusty area for many years, air pollution can cause COPD


23. Having a history of frequent childhood lung infections can cause COPD


24. Alpha 1 Antitrypsin Deficiency can cause COPD

Next week I'll focus on ways COPD sufferers can avoid a trip to the ER and live a more productive life. I'll provide some real life examples form my experiences.

Resources: AARP, COPD Coalition, yourlunghealth.org,

The causes of airway obstruction and restriction

Here is a quick review of the two main types of lung diseases: obstructive versus restrictive.

A. Obstructive.  Any disease that causes the airways to become narrowed or blocked in some way. Here are some examples.

Upper Airway obstruction:

1. Rhinitis/ pharyngitis
2. Diphtheria
3. Croup
4. Epiglottis
5. Obstructive Sleep Apnea
6. Laryngeal paralysis
7. Tracheal stenosis
8. Tracheal malacia
9. Foreign body
10. Tetanus

Lower Airway obstruction:

1. Emphysema (COPD)
2. Chronic bronchitis (COPD)
3. Asthma
4. Cystic Fibrosis
5. Bronchiectasis
6. Bronchiolitis
7. Bronchial compression (tumor, lymph nodes)
8. Endobronchial tumors
9. Foreign body
10. Mucus plugging

B. Restrictive. Caused by any condition that decreases the lungs ability to expand and properly ventilate. Here are some examples.

1. Sarcoidosis
2. Interstitial Lung Disease (ILD) or Idiopathic Pulmonary Fibrosis
3. Pneumonia
4. cancer
5. granulomatous disorder
6. obesity
7. pregnancy
8. pneumothorax
9. pleural effusion
10. kyphoscoliosis
11. emphysema (loss of lung tissue)
12. Neuromuscular and neurologic (Guillain-Barre Syndrome, polio myelitis or myasthenia gravis)
13. Pickwickian syndrome
14. Pleurisy

Of the above listed causes of airway obstruction and restriction, which four are benefited by a bronchodilator?  Here's a clue: the answer is not any of the restrictive diseases, or any of the conditions causing upper airway obstruction.

My response to your websearch queries

Here is my weekly response to Internet search engine questions that lead someone to my blog.

1. side effects of respiratory therapy: I will consider a side effect as something negative that could happen. I think that the #1 side effect is burnout, followed closely behind by frustration at not having more control over who gets respiratory therapies, not having more protocols, etc. In some rare cases there has been seen complete animosity toward this profession, which is probably no different from any other career.

2. can i take only serevent for asthma: It's recommended that if Serevent is indicated, Flovent should be taken with it. Thus, if both are prescribed, the patient should talk to his or her doctor about taking Advair, which is a combination of both drugs and only requires one puff in the morning and one at night. For more information regarding Serevent, click here.

3. mixing mucomyst with albuterol: It is mandatory that if Mucomyst be given that Albuterol be given with it. While Mucomyst is supposed to break up thick mucus, it can also cause bronchospasm.

4. what do people think of respiratory therapists: I think that most people don't even know who RTs are until they see us in the hospital. But, once they get to know us, I think we are highly thought of by most patients. We do our own surveys here at shoreline, and most of the comments are excellent when it comes to "what do you think of your RT services."

5. albuterol steam machine: I think you are thinking of an air compressor and a nebulizer. When the air passes through the nebulizer, it forms a mist not steam. And, breathing in this mist is what causes the medicine to get into the lungs and do what it's supposed to do, which is relax bronchial muscles.

6. what are post-op crackles in the lungs caused by?: Can be caused by a lot of things actually, but the general idea is that they are caused because abdominal or thoracic pain from the surgery is preventing the patient from taking in deep enough breaths and stretching the alveoli in the bases of the lungs, and thus making them more prone to pneumonia. Likewise, some pain medicines and sedatives can also make a person take shallow breaths, and this too can cause crackles. It is for this reason we encourage post op patients to use an incentive spirometer and to do cough and deep breathing exercises, of which I wrote about right here.

7. what to do when you dread going to work: We all have those days. What I do is go to work and hope for the best. It's also a good idea to get a good nights (or in my case days) sleep.

8. respiratory school formulas printout: I actually have a list of the relevent formulas I can post if you want me to.

9. how often should a patient use combivent: Recommended QID or no more than Q4. If you need it more often see your doctor. However, there are exceptions to this guideline.

10. how does ventolin work in the respiratory system: The Ventolin particles are nebulized into a particle size of 0.5 microns and work their way into the bronchioles, where they bind with beta adrenergic receptor cells and cause bronchodilation.

11. does nasal cannula make pneumothorax worse in children : Why would it?

12. advantage of using a mist tent over nasal cannula : A mist tent is good for use with a child with croup in that it provides a cool mist to help reduce swelling in the throat. However, at Shoreline we've decided the mist tent more or less just gets in the way of caring for the child, and we've pretty much scrapped them. If a child need oxygen, we use nasal cannulas. However, the mist tent is still always an option.

13. which is stronger ventolin mdi or ventolin aerosol mask: According to scientific data obtained, an MDI used with a spacer and used correctly should be just as effective as a Ventolin nebulizer treatment. And, a nebulizer taken with a mouth piece is more effective than via a mask, and a mask is more effective than a blowby treatment.

14. does singulair make it easier to cough up flem from lungs? : Not that I know. Singulair blocks the release of leukotreins which cause bronchospasm.

15. which should be given first if both are ordered serevent or flovent: Good question. Check out my answer to #2, and then I'd have to say Serevent because it's a bronchodilator. Considering neither has an immediate effect, I would guess that it doesn't matter. Any one else care to chime in here?

16. best respiratory therapist: Who decides? Is the person who loves button pushing really better than the RT sage? I wouldn't think so.

17. using bipap in place on ippb : I have debated this with some of the older RTs who will defend the IPPB machine to the death, but I think that all the IPPB does is over distend the good alveoli. I can produce some reliable studies that have come to the same conclusion.

18. continuous albuterol with bipap vision: Connect the neb as close to the mask as you can get it and have at it.

19. what does a respiratory therapist wear: Well, I wear scrubs and a white lab coat. Boring hey?

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.

The last thing I want to think about is... work

Sometimes the best part of working is not working. The days off are the best part of having a good job. The being able to actually take a day, or a week in my case, away from the workplace to stop and smell the roses.

Well, there are no roses out right now, but the cool, refreshing 59 degree breeze that's out there is very refreshing, especially after that long and dreary winter we had this year. Man, it seemed that snow was never going to go away.

But it did. And my kids and I have been getting out as much as we can these past few days and enjoying every moment of it. In a way, these first few warm days are kind of similar to those days in Florida in the middle of winter. We appreciate every moment of it.

So, need it be said, that respiratory therapy is the furthest thing from my mind these past few days. And, considering how busy it was the past few weeks at Shoreline, the last thing I want to think about right now is respiratory therapy stuff. I want to stay far away from that as I can.

Funny thing, I'm not even on vacation right now, just my regular days off. Well deserved I say.

A more detailed description of slippage

So long as we are on the topic of slippage (I wrote about it here), perhaps we should expound on this a bit. We are all expected to maintain a certain level of dignity. We are all supposed to maintain a certain level of modesty. We are all supposed to maintain a certain level of respect for our superiors, friends and co-workers.

Slippage: failure to maintain an expected level, fulfill a goal, meet a deadline, etc.; loss, decline, or delay; a falling off -- dictionary.com

When we are out in public, many of us try to maintain a certain level in our appearance. When we go to work, for example, we are expected to look our best, to smell our best, to wear our best smile and personality. We are supposed to be the utmost professionals when we are amongst our co-workers and, most important, our patients.

When things happen that we disagree with, when a doctor orders something we think is going to harm the patient, it is our job to bring this to light in a professional manner. When a doctor orders something stupid, it is expected that we will not complain. It is also expected that we will not complain when we disagree with an administrative decision. We, as expected, will be the utmost professionals and, to put it lightly, just do as we are told.

The gossipers will gossip. The unhappy people will complain. As I am doing my rounds through the hospital I hear these things going on, and I wouldn't necessarily call all of it slippage. There are certain people who are hotheads, and they tend to argue with every single person every single time something meets their disapproval. I would not call that slippage. I would call this disrespectful, perhaps.

When someone does something that is expected of them, it is not called slippage. When the hot head gets hot, it is not slippage because that is the standard that person has set for himself. Sure, he might not be very popular, but his being a jack ass is not slippage. When the complainers complain, when the gossipers gossip, that is not slippage either, unless it comes from an unexpected source.

Slippage, therefore, is when a person does something he that is completely out of character. Slippage might be what you would call it when a person who is normally quiet and reserved bursts out of his shell and tells you all the things he hates about his job; or a person who is respected in the community gets drunk and starts talking about how many women he has gone to be with.

Ah, to find a perfect example, one might simply look at the headlines in the newspaper. When Ted Turner ran his mouth the other day and said the world is going to be destroyed in ten years because the world is overpopulated, I would not call that slippage because we expect such nonsense from him.

Then again, when Mel Gibson rattled on about how he hates the Jews when he was drunk one night, that is slippage. We did not expect such filth from him. Sure, we might have suspected that he held such opinions, but he had made an effort to maintain a certain level of dignity, or respect prior to that one night, and had kept his mouth shut.

When you keep your mouth shut you greatly decrease your chances of slippage. When you do not drink or do drugs, you greatly diminish your opportunities for slippage. However, we all have our moments. I have had my moments. You have had your moments. We all remember our parents, or someone we loved, having their moments too. Our friends definitely have their moments too. That's life.

When our perfect example of equanimity, Dr. Cool head, got ticked off because he was working all weekend and was called every hour on a very stressful weekend at Shoreline Medical, and he blew up at the kind nurse who called him for the first time ever at 4:00 a.m., that would be a good example of slippage. It was totally out of character for him.

I can give you two of my own personal examples of slippage. For example #1, you can see my blog entry from yesterday. For example #2, I can tell you this normally reserved, humble, and greatly respected RT had just spent the greater part of the night with one young lady in respiratory distress and had just headed upstairs to take care of more short-of-breath patients, when he was paged to go back to the ER and set up a holter monitor.

Many times he had thought to himself how ridiculous it was for a doctor to order an outpatient procedure to be done in the emergency room, but, ou of respect, he grumbled to himself but not to the middle person who gave the order, and definitely not to the doctor and, most important, he was the utmost professional in front of the patient.

But not last night. Last night he provided a perfect example of slippage. Last night he stormed down the the emergency room and told the nurses and the doctor point blank that he would not be setting up "that stupid thing that shouldn't even be ordered in the emergency room."

"You mean you don't have a holter monitor," one nurse said.

"No. I have no clue if we have one or not. What I'm saying is I'm not setting one up right now period. I have a sick patient right down here that I've spend the majority of the night with, I have a Q1 hour treatment upstairs, I don't have time to spend a half hour setting up a holter."

"Well, can you just bring the holter down if you have one."

"Are you going to do it?"

"No. That's your job."

Ah, slippage. What alcohol did for Mr. Gibson's mouth being burned out did with mine. Slippage.

Later in the night, after I had reasoned with myself and had reluctantly dedicated a portion of my time to set up the holter (and was the utmost professional with the patient of course), I met these emergency room nurses up in the CCU when they transferred a patient up there.

"Hey, and thanks for your help," I said. "Oh, and sorry I was so grumpy last night."

"Oh, I didn't think you were grumpy," one of the RNs said, smiling.

"Oh yes I was," I said.

"Oh yes he was," said the second RN. "I've never seen him get upset before. He's always so calm and cool."

"It was a little slippage," I said.

We all participate in slippage from time to time. I would like anyone who has not participated in slippage to raise his or her hand. If you haven't' slipped before, that would mean you are perfect. And, as the old saying goes, perfection in itself is a flaw.

Which brings us back to that infamous RT Cave rule: We night shifters never hold what one of us does or says as a result of exhaustion or burnout against one another. Because we all slip from time to time.

So long as we don't slip too far.

A little tounge slippage due to pure exhaustion

I missed an RT Wisdom yesterday. This is my blog, and I have the right to skip a day of blogging if I choose. However it lays there in the back of my mind, that yearning to stop what I'm doing, to rush to the Internet (that awful addiction). Yet there are other responsibilities that preclude fun.

There is no boss here to make me blog every day. And, unfortunately, no profit loss either. I have a post written for yesterday, actually. I just didn't have the time to post it yesterday. It was one of those days. It was one of those nights. It was another night from hell. It was a night with a lot of slippage.

Today, instead of educating anyone on some deep RT Wisdom, I'm going to take a moment to write about slippage. It has something to do with the 2 a.m. syndrome that any of you night shift RTs and RN and DRs will be fully aware of, but you day shifters may well not be aware of.

And, there is this thing called amnesia too, which occurs when a night shifter goes to days for a long enough period of time. He, or she, forgets what it was like to work nights. It's called former night shift suppression syndrome. How's that for a cool name that popped up extemporaneously to my humble RT mind.

When you are so busy at work and your boss has to come in at 2:30 in the morning for two straight days to do all the useless breathing treatments so you can take care of the critical patients, you know your busy.

When you have one person doing the work of two, as this humble RT did Thursday through Sunday, it makes for arduously long nights. And, strangely enough, on the final two days of a long, long, long stretch, even though there were two of us through most of the night these past two nights, the journey was still arduously long -- go figure.

It's amazing how much more you can accomplish when you have fresh legs, body, and an invigorated mind and spirit, as opposed to fatigued legs, burning feet, and wearied spirit. With even fewer tasks at hand, the ability to get all of them done in a timely manner is severely hampered.

And, while this RT finally has a moment to rest and to eat his dinner at 2:30 in the morning of the final night, and his boss is sitting in the other room taking off her coat and hat and is organizing her paperwork, she says, "You know, I'm really tired."

"Ah," I think to my humble RT self, "I'm not going to go there. I'm not going to say one word, even though I wanted to say something like, "You're tired. I just worked the night shift six of the last seven days. You're tired?" At this point, I stifled the slippage.

Instead I smiled and said nothing, because I wanted to keep the peace. I'm cool that way.

However, later on I said, "Man, I think every one in this department is really burned out. I know I am, and I..." She interrupted me before I had a chance to blurt out the rest, which was going to be, "and I know you are too." I had not intended for what followed to occur. I did not intend the slippage.

She interrupted with a lecture, and when the RT is burned out it's one thing, but when the night shift RT is burned out, when this RT has every bone exhausted to the core to the point his body feels like mush -- a wet noodle walking, the fetters normally shackled to his voice box and
tongue loosen, and he simply says what's on his mind. I like to call this 2 a.m. syndrome, because I see it a lot on night shift.

But remember the old RT Cave Rule: Night shift people do not hold it against other night shift people. We know we are tired. We are a team, and therefore we do not get mad at one another. We don't hold grudges. We can't hold grudges.

Boss used to work nights, so perhaps she had a little of this rule left in her, or so I hoped. I prayed the former night shift suppression syndrome did not go to far into her bones, now that she not only advanced to days, but drifted further away when she drifted in the land of The Bosses, where the focus shifted to money. She has, as I describe in this link, become a dragon. And dragons, while they will never admit it, lose their ability to empathize with peon RTs and RNs that they once upon a time worked with. They, like all their fellow dragons, think like dragons.

That aside, what came next was a little slippage.

She said, "I don't buy that. You guys have no right to be burned out. You guys were so slow for so long that I think you simply forgot how it is when you have to work. You forgot how to work. Don't give me this that you guys are burned out. I came in and helped out last night and it felt great. I felt really good about myself. I think you guys forgot how to come in and enjoy yourselves when you have to actually work."

Okay, so here comes the slippage; the 2 a.m. syndrome at full force. It wasn't an angry statement. There was no ulterior motive here, it was simple slippage.

"Um," I thought for a second about not saying anything, but this was the moment I had been waiting for since the last time she brought this up (see this post). I had discussed this with my co-workers, and we all agree on one thing, which is...

"Boss," I said, "if it weren't for all the useless breathing treatments that we do around here, I wouldn't be burned out at all. If it weren't for all the useless breathing treatments on our board, I'd have been able to spend a few minutes with my ventilator patient tonight, or some more quality time with the truly sick people on this board. Instead, I'm running around taking care of people who don't need to be taken care of." There. Got that off my chest. It had been hanging on there for a few weeks.

Her response: "We need those treatments to make money for this department. If we don't make money, you would be out of a job. You guys sit around complaining about getting no work when it's slow, but when it gets busy you complain."

"I never get no work. You know how it is, nobody wants to work night. The lone RT shifter never gets to stay home, not even when it's slow. And I don't mind that really. I certainly don't complain when it's slow. I love it when it's slow. " I get to blog when it's slow.

Like I wrote earlier, she is an administrator, and administrators (dragons) think in terms of money. It's all about money. And which it should be. However, and I didn't say this, but the hospital does not get reimbursed for any of the treatments we do after the initial treatment. We are making no money at all on those treatments.

Despite thinking this, I said, "Look, Boss, I love working. I love my job. I love being an RT. And I love helping people. And I love it that you're here helping me out." Nothing like a little flattery to get you somewhere. "And when I'm waking someone up at 2 in the morning to give them a treatment they don't need, I certainly don't feel joy in that. If anything, I feel stupid." Wow. That was a good line.

"Well," she said. "I don't even want to go there. I don't even want to be having this discussion right now."

"Me neither, Boss, I hate it. I hate that I have to defend myself against the charge that I no longer feel proud of my job, or joy in my work. I feel proud every time I succeed at getting a blood gas, I feel joy every time I suction successfully. I love it when I get to use my brain and determine if someone needs a treatment, an EKG an ABG. I love to use my experiences and my education to benefit poeple. That makes me proud to be an RT. Doing a bunch un-indicated treatments so we make money makes me feel stupid."

"Well," she said, "I'm sorry you feel that way."

"Which is ironic," I forced a laugh so she didn't think I was being too much of a prick, "because I am fully aware the bottom line is money. I understand that completely. It's just that if you want me to feel ultimate joy in my job, or any sort of euphoria, you will talk to the doctors about letting us decide who gets treatments. Heck, if it's slow, I'm sure we'll find a way to add a few extra treatments to the board. And I wouldn't mind doing useless breathing treatments, so long as I decided that.

"It's not that it's hard to slap a neb into someones mouth and give them a treatment. It's that we are swamped right now, we have a lady on BiPap that I've been with for four hours tonight alone, and a vent patient I need to spend time with, and two patients getting Q1 hour treatments who have to have the nurse call me every time they need a treatment because I'm tied up doing frivolous things."

She didn't say anything. Perhaps she was shocked because I'm normally quiet and complain very little. I'm not complaining, though, just stating facts. I ended it there. I couldn't go on anymore if I wanted to. I was drained. I wanted to keep the peace. I had to keep the peace. I did keep the peace. However, the seeds were planted for a later discussion. We went out then and tackled the rest of the shift together as a team.

It was very enjoyable having a fellow RT with me on night shift. It was cool having someone get one ABG while I got the other. It really was. I suppose it's this kind of joy, the companionship of fellow RTs, or the longing for it, that has us night shift RTs ultimately going to days. There is nothing like a good old-fashioned RT teamwork. Nurses are great, but there is nothing like being among our own kind.

That, my fellow blogger friends, is the thought of the day, or thoughts of the day. What do you think? Perhaps I'll have to start a new RT Cave lexicon with all my new definitions.

April Fools

Fool me once, shame on me. Fool myself, shame on me.

It was a nice relaxing day. I needed a day like this to recoup from last weekend, where I worked a four day weekend from hell. You know how it is.

It was 7 p.m., and I stepped outside, took in a deep breath of the cool spring air, observed how the snow was almost gone, and decided I was going to go back inside and relax on the couch with my wife and watch a good movie.

Only, as I walked back into the house, my wife was on the phone. "Oh, here he is, you can talk to him yourself," she said. What's this about, I thought. She handed me the phone.

"Rick," it was Jane Sage from work, "Aren't you supposed to be some place right now?"

"ummm, no." I had no plans, and it was Tuesday, my normal day off. "Why, am I supposed to be to work tonight."

"Yes."

"I had absolutely no clue.

"Take your time coming in. But you picked a bad night to pick up, because it's hell here. I mean real hell. You even have boss coming in in the morning to help."

"You're joking, right?"

"Nope. I'm completely honest." She laughed. I wasn't sure whether to believe her or not.

I hung up. "Jane said it's swamped at work," I said to my wife.

She said, "You do know it's April Fools."

Hmmmm. April Fools hey?

Well, turned out Jane wasn't joking. I decided the joke was still on me, though. I decided that I tricked myself into believing I had the night off. April Fools to me from me.

Preventing Ventilator-Associated Pneumonia

How to prevent Ventilator-Associated Pneumonia has been extensively studied. Here are the most common recommendations. Chances are your hospital has already incorporated most of these.

1. Ventilator Bundles are protocols based on best practice medicine. These should be incorporated in all critical care units to assure all of the following guidelines are met. 
2. Good handwashing
3. Sterile technique (as much as possible)
4. Implementing a ventilator extubation protocol to speed up time from intubation to extubation. 
5. Making sure the cuff pressure is always 30 CWP or greater. The idea here is that this will prevent secretions from leaking around the cuff. Higher pressures are acceptable so long as intubation is short term, which is the goal of any intubation.
6. Tracheotomy should be considered for anyone requiring greater than seven days of mechanical ventilation. 
7. Heated wires should be used to limit opening of the circuit (this seems to be no longer an issue)
8. Inline suctioning (such as a Ballard) should be used instead of tracheal lavage and suctioning. Lavage and suctioning can still be used, although this should be left to the discretion of the respiratory therapist. 
9. The head of bed should be raised 45 degrees at all times to prevent aspiration of stomach contents. This should be started as soon as possible, and may even be started in the emergency room prior to the patient being transferred or admitted to critical care.
10. A feeding tube should be inserted to assure adequate nutrition. 
11. The mouth should be washed with a Chlorhexidine Oral Rinse and suctioned out every two hours (as appropriate). Studies have shown a good mouth cleansing can greatly reduce the chance of VAP.
12. Do not use heat and moisture exchangers unless absolutely necessary, such as when you need to transfer the patient. Studies have shown HMEs tend to increase likelihood of VAP.
13. Sedatives should be limited. There have been a lot of studies and discussions on the use of sedatives on intubated patients. Some suggest limiting sedation in the morning to make sure the patient is awake, cooperative, and understands the plan. Ideally, sedatives should be stopped at least four hours prior to beginning any weaning screen.
14. Studies show that it is most effective if the circuit is changed weekly, as opposed to daily as the best way of preventing VAP.
15. Daily chest-x-ray to monitor for signs of pneumonia
16. Sterile technique and proper technique when inserting lines. We are all instructed to monitor physicians to make sure they use this proper technique.
17. Stress-ulcer prophylaxis (this would be part of the ventilator bundle, and would be a nursing protocol. Ours includes a daily proton pump inhibitor like Prilosec (omeprazole)
18. Prophylactic antibiotic therapy (of course there is controversy here too). This is to prevent infections such as pneumonia and sepsis. 

These are some ideas that have been researched over and over the past several years. Newer studies are changing some of the older ideas we had regarding intubation. For instance, back in 1997 when I attended RT school, we were taught never to exceed a cuff pressure of 24 cwp to prevent the occlusion of blood flow. So, as you can see, this has changed considerably, although it's supposedly all for the better. 

Intubation and mechanical ventilation is not a science: it is an art based on a science. So, as you will learn (or have learned) in this profession, we do the best we can with what we know today, and as we learn more we do better. This is the case with advancements in intubation and extubation, as it is in other areas of healthcare.