8 factors may increase risk of fatal asthma

I've been reading this great book called Fatal Asthma lately, in which the authors have pinpointed some factors that might contribute to increasing your chance of having a fatal asthma attack.

Factors that increase your risk of a fatal attack are:

1. Low socioeconomic status: It causes barriers to good care including lack of health insurance and financial ability to pay for meds needed to manage asthma. Plus, poor economic status makes it difficult to get away from poor quality housing such as those infested with common allergens like dust mites, cockroaches and even rodents. Another barrier to good health created here is lack of funds to afford regular doctor visits and the medications required to prevent and treat asthma.
2. Poor social support: It's important to have people around you who understand asthma and can encourage you to take care of yourself, and help you spot early warning signs. If you are a severe asthmatic, it's good to have someone encouraging you to eat right, exercises and take your meds. The same can be true of kids. Also, failure of parents to remove a child from harmful environments (such as second hand smoke, allergens, , dust mites, etc) may be a problem that contributes to uncontrolled and chronic asthma.
3. Smoking: This increases airflow obstruction and usually results in severe asthma.
4. Cardiac disease: Drugs used to treat arrhythmia's may worsen asthma.
5. Substance abuse: This can delay treatment for asthma and require its own separate treatment.
6. Previous near fatal attack: Bronchial sensitivities may persist as steroids and other meds are being weaned, predisposing the asthmatic to an even more severe episode. Plus the fact that one was just released from the hospital may lead one to not wanting to go back, thus delaying treatment upon return of symptoms. Denial that symptoms have returned can also lead to further asthma complications which increase the risk of fatal asthma.
7. Denial: If you don't admit you have a problem you will not get the care you need to manage your disease.
8. Poor perception: Some people may overlook early warnings signs and under treat, and this may result in the asthmatic waiting too long to get the care he or she needs.
9. Location: All of the following may lead to an inability to get proper and quick care: Lack of easy access to medical help, or if the closest hospital is far from where the asthmatic is, or if the asthmatic is alone
10. Allergies: 60-80% of asthmatic children have at least one allergy.

New Ventolin prolongs life -- forever!!

Another usage for Ventolin was discovered by a highly intelligent doctor here at Shoreline Medical today. His name is Dr. Howard Fakename and the new version of ventolin is called KeepMeAlive'olin.

This is a med that has an Atropine, Epinepherine base in it that keeps the heart beating... beating... beating. It also has a Ventolin base that keeps the patient breathing... breathing... breathing.

Pretty neat hey. I have a patient right now on Q4 KMA'olin. He is a frequent visitor from a nearby nursing home who has no signs of respiratory distress right now.  But he does have faux pneumonia (a diagnosis that is reimbursable).

The patient has MS, and has indicated to me he no longer wants to keep living.  However, because his family does not want to let go, and the doctor is aware of this, the patient keeps getting KMA'olin to prolong his life.

Dr. Fakename is currently in the process of writing a paper on the life-prolonging qualities of Ventolin. Yet you have heard it hear first. The medicine is KeepMeAlive'olin.

Modern meds may be cause of fatal asthma

In my research of the history of asthma I have come across a very interesting phenomenon, or a conundrum perhaps. It is that asthma was never considered a fatal disease before the 1900s. Why is that?

The authors of "Fatal Asthma" ask it this way: "If the under treatment of asthma is invoked as an important cause of fatal asthma, then we must explain why people are dying from asthma now, when deaths from the ailment were negligible in the past."

You'd think with all the modern asthma wisdom and all the new medicines on the market today that there would be fewer asthma related deaths and not more.

Some have proposed that pollution may be the cause, but many scientists rule this out because prior to the 1900s air was polluted by coal and wood burning stoves, horses roamed the streets leaving their droppings, streets were of sand that caused dust, people did not shower daily and were often breeding grounds for diseases that triggered asthma. Plus people smoked frequently in public buildings and homes.

All of those obstacles to clean air have been removed. Yet, "Still there is genuine concern about newer sources of pollution, because the asthma rates have been rising in some American cities during the same period as pollution legislation has led to cleaner air. And this remains a possibility.

Another possibility, or theory, is that asthma did not become a fatal disease until 1903 when epinephrine (adrenaline) was first used in hospitals to treat asthma. One doctor observed that it's "possible that mortality from asthma first appeared when adrenaline became available... The pattern of events of no adrenaline, no deaths; some adrenaline, some deaths..."

The conundrum of doing such research, however, is that there is no research of untreated asthma. For the most part, if a doctor has a patient who is suffering with asthma the patient is going to be treated.

However, it wasn't until after "isoprenaline was introduced in a nebulizer formulation during the 1940s when mortality began to increase..."

In the 1960s "asthma mortality increased dramatically." Scientists evaluating the data determined the cause was "due to new methods of treatment. Interest focused initially on the possible role of pressurized metered-dosed-beta-agonsit aerosols, which had been introduced in the early 1960s."

In the 1970s there was a significant jump in New Zealand, and this was associated with a long acting beta agonist fenoterol that patients were allowed to use at home. When some patients were having trouble breathing, they'd often use it more than prescribed. This medicine, like epinepherine and isoprenaline, can have fatal cardiac effects if used in too high of doses.

The debate of whether asthma related deaths were caused by the routine use of these early beta agonists, or if it was that these meds were abused by asthmatics during periods of life threatening asthma "in which the cardiac side effects are likely to be particularly harmful in the presence of severe hypoxia."

However, unlike Albuterol, both of these classic asthma rescue medicines were not selective to the lungs only. They had an equal effect on the heart. When warnings were given out of the adverse side effects of overusing these medicines, the death rate dropped.

Another theory of why there are more fatal asthma episodes now is that asthma was under diagnosed, which may also be the reasoning for the trend the number of asthma cases nearly doubling between 1985 and 2009.

However many scientists have ruled this out. Still it's a theory worth considering.

I would guess the increased incidence of fatal asthma would be due to a combination of all three theories mentioned above, but I would lean toward the theory of modern medicine overuse as the one that makes the most sense to me.

I haven't seen trends after 1998, but I do know that many recent fatal asthma episodes have been linked to Symbicort and Advair, or the long acting bronchodilator within these meds. As was the case with fenoterol in New Zealand in the 1970s, scientists aren't sure if it is the drug itself that is causing fatal asthma, or that the drug is being used as a rescue inhaler for life threatening asthma.

The FDA has recently advised doctors that modern long acting bronchodilators such as those included in Symbicort and Advair (Serevent and Formoterol) are safe and that the benefits far outweigh the risks in managing asthma. Which makes one think the FDA believes abuse of these medicines is the reason for the recent spike in Fatal Asthma.

And, like in the 1970s, I believe, as the word gets out that Symbicort and Advair can have fatal consequences if not used exactly as prescribed, the asthma death rate will again go down once again.

No one knows for certain why episodes of fatal asthma have increased since 1900, and particularly since 1940, but most of the trends point toward the same meds doctors prescribe to treat acute and chronic asthma.

Lack of interest in asthma means less funding

Asthma is one of the oldest ailments known to man. It was documented as far back as ancient Sumeria 5,000 years ago. And yet we still know so little about this disease, however our wisdom has grown.

The truth is that asthma has been growing at such fast rates in recent years that there are few people who don't know anyone who has it. It is a disease as prevalent as coronary artery disease and cancer, and yet funding received for asthma research is far below those diseases.

Why is this? The reason, perhaps, is that less than 3% of the America's population have asthma. And the only other people who care about the disease are those immediate family members who see the asthmatic suffer.

So, you have almost 95% of the population who have no interest in asthma. And it is exactly that 95% of the nation of whom we need to get interested in asthma, because it is that 95% who pay the taxes that will go on to fund future asthma research.

One of the reasons, according to the authors of Fatal Asthma, that so little tax money is available for asthma research is because so few people die of asthma. Yet between 1985 and 1998 asthma deaths doubled to 5,000 per year, but that death toll pales in comparison to other diseases.

So whatever research is going to be done to find a cure, a way to prevent, or to make the lives of those who suffer with it better, is going to have to come from private funding from people like you and me.

Or, to achieve more tax funding, better asthma education among the greater population is a must.

My answers to your RT Querries

The following are all queries typed into search engines by inquiring minds and landed those individuals on my blog. Because I want to make sure everyone has his or her questions answers, I will provide my response right here

This week there were no questions sent to me by email. If you have a question you can sent it to me (anonymously if you want) at freadom1776@yahoo.com.

So, that in mind, here are today's queries and my responses.

1. singulair for dander: I'm sorry, but singulair will not stop, prevent, nor treat dander. I think what you are looking for is head 'n shoulders. You can buy it at any Pharmacy near you.

2. albuterol prevents pneumonia death: Albuterol prevents nothing. It does not prevent rickets, it does not prevent CHF, it does not even cure asthma. It also does not prevent these things. And while many doctors order it for pneumonia, it has no purpose being ordered for that diagnosis. Or, just because someone has pneumonia does not make Albuterol indicated. What it does is treats the SYMPTOM of bronchospasm only. So, if the patient is having underlying bronchospasms with the pneumonia, then it is justified.

3. steam for asthma, copd: Steam is not good for asthma. Check out this link.

4. am i smart enough to be a respiratory therapist: I asked myself that same question 13 years ago. Then I did my first tour of a hospital and saw some really dim witted people who were doing fine as RNs and RTs. Here is what I kept telling myself from then on as I worked my way through RT school: "If that person can do this job, so can I."

5. too much albuterol and impotence: I think you can take Viagronex or Screwtonix. See my list of 'olins at the bottom of this blog.

6. respiratory therapy vomit: RTs hate vomit pure and simple.

7. how do you fake pneumonia: I don't think a patient can fake it, but a doctor can make up the diagnosis because he thinks a patient should be admitted but can't think of any other diagnosis that would meets criteria for reimbursement. I wrote about this today over at Respiratory therapy 101. Click here and I will morph you on over there.

8. pulmonary edema and ventolin: Ventolin has no effect on anything but bronchospasm. Nothing else need be said.

9. how to prevent asthma shaking: I asked my doctor this once, and he said, "What's worse, shaking or suffering of an asthma attack? I'd take shaking anytime." I don't think there is a cure for shaking other than time. I think once your asthma gets better and you are able use ventolin less frequently, then you might shake less. Also, you should note that high doses of corticosteroids can make you shaky, so if you are on oral or IV steroids, you may stop shaking when your dose is cut down. Serevent can also make you feel shaky when you start taking it, but once your body gets used to it the shaking should go down.

10. do respitory therapist have to take people off life support?: Yes we do. We are responsible for extubating and turning off the vent. For some reason I think the person writing this question was thinking of a terminal wean. In rare instances we have to remove life support of a patient who might be brain dead or otherwise permanently comatose. In the majority of these instances the patient expires shortly after the removal of life support. If I have time I watch the cardiac rhythm strip on the monitor and watch as it transforms into a fatal rhythm. I know this sounds morbid, but we medical workers are all strange in that we enjoy weird things like this.

11. can albuterol cause pneumonia? No study has proven it. The side effects to Ventolin are relatively mild, and most doctors agree that you cannot overdose on the medicine either. The most common side effect is jitteriness, although it can cause hyper activeness in some children.

I hope my answers help.

If you have any further questions you may email me at freadom1776@yahoo.com

(Note #1: I had some technical difficulties with my email recently, so if you sent in question that wasn't answered, please send it again.)

(Note #2: I have a new policy for the way I answer questions here a the RT Cave. Any questions emailed to me at freadom1776@yahoo.com will be published and responded to in my weekly RT Queries post. When I answer your question I will send you a link to the post your question is published in. I will not answer your question in a private email unless a private response is requested or indicated).

Yes, there are benefits to having a disease

You might not think of it this way, but having a chronic illness like asthma does have it's benefits. It makes you take a second look at your life and put things you might otherwise take for granted in perspective.

You hear stories like this a lot, the guy who was 52 and all of a sudden was struck by cancer and he turned to God. The miser who was suddenly slammed in the face with his vulnerability and one day wakes up to donate half his money to some charitable cause.

A wile ago I wrote a post about the 5 different types of COPD patients, and one type was the loquacious COPD patient. He's the one who has realized that his lungs are disappearing and he wants to share all his experiences before he dies -- so he talks a lot.

Kids that grow up with chronic diseases have similar dispositions. Like the cystic fibrosis, and on a lighter scale the asthmatic, who learn at an earlier age that they are vulnerable.

A recent post I wrote for MyAsthmaCentral.com lists the seven benefits to having asthma. With all due respect, I think this list can equally be the benefits of any disease or illness.

Sure there is nothing particularly fun about having asthma attacks, or having to take medicine the rest of your life. But there are definitely humbly benefits.

To see what I'm referring to, click here and I'll morph you over to my Asthma Blog.

The seven benefits of having asthma
by Rick Frea Tuesday, January 20, 2009 @ MyAsthmaCentral.com

Living through an asthma attack is never fun. The good news is asthma can be controlled, and you can live a normal life with it. That in mind, and since we have to live with it anyway, no point in saying, "Why me?"

Based on my experience from being a lifelong asthmatic, I have discovered seven benefits of having asthma -- and no, I am not referring to using it to get out of gym class or work.

Here are the seven benefits to having asthma:

1. Perspective: When you have your breath taken away and then get it back, you never take breathing for granted again. At the same time you develop a view of life unique from people that have never had a health issue. You value every moment you are on this planet. You appreciate all the little things that others may take for granted, and that you may have taken for granted before you were diagnosed with asthma. In a sense, you have developed a new feeling of vulnerability that leads you to taking extra time to smell the roses.

2. Vulnerability: Anytime a person gets sick and has to spend time in a hospital he or she develops a sense that you are not invincible. You might not think of this as something good, but it is once you realize most people -- especially young people -- have no sense of vulnerability, they think they will live forever regardless of their actions.

Once you know you are capable of being knocked down by your actions, you learn to take care of your body in ways others do not. I know of many asthmatics who said, "I quit smoking the moment I was carted into the ER", or "I'm going to take my meds the way my doctor wants me to for now on."

This sense alone is the one reason, I think, that leads one to wanting to live a healthier life (a gallant asthmatic anyone?) and forming a closer bond with God perhaps.

3. Religiosity: Of course this doesn't always happen, but when a person is left breathless (helpless) for any amount of time a call to a greater power often occurs. Particularly when one's prayer is answered one participates in a form of retrospection that leads one to appreciate that life is not always in our own control. This tends to lead us to a greater sense of empathy.

4. Empathy: There is some truth to the statement that "Nobody has empathy for an asthmatic unless they have had an asthma attack or lived with someone who suffered with it." Well, since you have it and you have suffered once or twice with breathing trouble, you will forever have an understanding of any person who can't catch his or her breath. In a sense, you have doubled your asthma wisdom.

5. Intelligence: You were unable to spend time camping with your friends or family, or you were unable to visit yoru brother Bart because he has 21 cats and 17 dogs, and therefore were forced to stay inside your home and entertain yourself. You didn't pity yourself. You didn't say, "Why me?" Instead you entertained yourself by thinking, rationalizing, philosophising and, yes, reading.

First you become an asthma expert by reading about your illness (in the process of becoming a gallant asthmatic one would hope), then you morph into other areas of interest, like politics, history and sports.

Years later your best friend may jokingly note that you are the smartest of all his friends (and it will be true all because you had asthma). And you will have this desire to share your new wisdom too.

6. Sharing: Many people who feel vulnerable (see above), who have lived through a life threatening moment of which an asthma attack is, have this enduring desire to share their experience with others. They will also have a desire to share the wisdom they have learned as a result.

A perfect example of this is myself, hence my writings here at MyAsthmaCentral.com. One of the first things I ever learned about asthma is the importance of keeping your home clean and allergy free.

7. Cleanliness: You've learned what can cause an asthma attack, and now you have a desire to prevent that from happening again, so you take that extra step to keep your house clean from asthma irritents.

Many of you get rid of carpets, clean and vacuum your homes excessively, even under your beds and livingroom furniture. You get rid of plants and animals. And, definitely, you wash your own clothes and shower daily to get rid of irritants that might be lingering on your body at the end of the day. You may even place covers over your mattress and pillows.

You are not obsessed, but after a few allergic/asthma attacks you can sniff an allergen as soon as you walk into a house -- but not your own because it's allergy free (or am I the only asthmatic with that power?).

Well, there you have it. While you may not have thought asthma could improve your life, now you know it can. So long as you find a good doctor, educate yourself, and have a great asthma management plan, you too can reap the benefits of asthma.

RT Cave added to Alltop

The RT Cave is thrilled to announce it has recently been added to Alltop's "online magazine rack" of most popular asthma sites. I was actually added over a month ago, so to make up for my lateness this is the second day in a row I've mentioned Alltop on my blog.

So, if you're looking to further your asthma wisdom click here and I'll morph you over to Alltop.

Great Asthma Educational Links

So, you want to keep up to date on all the latest asthma wisdom, but you're not quite sure where to find it. I would like to help you.

What follows is a list of all my favorite links for obtaining asthma wisdom.

1. MyAsthmaCentral.com: Great asthma community that also provides a plethora of up to date asthma wisdom and advice. Plus they have asthma experts like me who write weekly columns.
2. National Jewish Health: The worlds foremost experts on asthma. They have an inpatient program for hard to manage asthma cases and also do extensive asthma research. They provide some easy to follow instructions regarding asthma for both child and adult asthma. I was a patient at this hospital as a kid and I learned a ton about asthma. From their website my asthma wisdom continues to grow.
3. American Lung Association: Any lung illness is covered here. They provide basic information about asthma and all the latest research.
4. American Academy of Allergy Asthma and Immunology: Another good site for basic asthma knowledge and some.
5. Asthma Mom: What better place to learn about asthma than from a mom of an asthmatic. She'll keep you up to date on all the latest asthma wisdom you may not find anyplace else, plus she adds the personal perspective you may get nowhere else.
6. Alltop: If I missed any good links this one pretty much should cover it. Alltop has a link to all the best asthma links. I'm sure if something is missing they'd be sure to add it.

There you have it. I'm sure there are more great asthma links out there on the world wide web, but these are the ones I reference the most. If you know of another great link let me know and I'll add it.

Vol. 1, # 1 of A Source of Inspiration is up

Well, it's finally up over at the Trauma Junkie's blog. It's the first ever issue of A source of Inspiration: Volume One Number 1. This is a new Respiratory Blog Carnival that is not meant to rival Grand Rounds and Change of Shift.

The topic for this first issue is surviving RT School. Future topics for future issues may be anything from respiratory therapy related topics to living with a particular RT disease to being a doctor and caring for stubborn COPD patients.

So, click here and I will morph you over to the first issue of A Source of Inspiration.

A case study: Does intervention worsen asthma?

I would like to discuss further today the topic of "Fatal Asthma" and the somewhat controversial theory -- although I don't think it is and aim to find proof -- that PURE asthma does not kill. (Actually, books have been published on this topic as you can see by the link above.)

When I first started out as the lone night shift RT a bad asthmatic walked through the doors of the ER. For the purpose of this post I'll refer to her as Cindy.

She walked into the ER one night in SEVERE respiratory distress. However she was awake, alert and orientated and perfectly able to GRASP at the table, hold her shoulders intentionally high, and suck a little bit of air in.

Fortunately for her, her Internist happened to be in the ER along with the ER Dr. While the ER physician proposed lying her flat and intubating her due to progressively worsening blood gas values (the CO2 was creeping up), the Internist decided to give this asthmatic more time.

"This is a risky move," he said to me, "but I'm sending her up to the CCU. If she is not better within a half hour we will have no choice but to Intubate our good friend here."

We were all worried for our asthmatic friend as she gasped and gagged and sucked wind or whatever you want to call it. However, being the consummate professional, THE DOCTOR DID NOT PANIC AND THUS OVER TREAT THE PATIENT. I think this is critical when it comes to treating asthma -- not over reacting and over treating.

I think the Internist gave her only one Epinephrine shot. Now, she did get a continuous breathing treatment with Ventolin, but this treatment has been since proven to be safe and effective. (The Epi, however, is not safe, and I will discuss that tomorrow.)

Yes, that's right, we need to be patient (no pun intended). So, with my ventilator all set up outside Cindy's room, and the Internist standing with me alongside her bed, she all of a sudden looked at me and said, "I think I'm better now."

She was better. I redrew the ABGs a half hour later and they were markedly improved. Thus, the Internist saved the asthmatics life. He did this by staying calm, cool, collective and not panicking.

Now, two weeks later Cindy returned to the ER in the same condition as she was the previous visit. She truly looked the picture of someone who should be intubated. This time the Internist was not in the room, and the ER Dr. decided to intubate.

I wanted SOOOO bad to say to the Dr., "She came in two weeks ago equally bad, and we waited, and she got better." Plus, being a fellow asthmatic, I knew that if I came in like this I certainly wouldn't want the ER Dr. to start thinking Intubation, especially considering I have turned my asthma around on a whim many times before (and of course sometimes with the help of ER docs).

That aside, I did not want to see this patient intubated out of panic. But the ER Dr. decided he wanted the head of the bed down so he could stick a breathing tube in the patients airway. I wanted so bad to say we should wait like the Internist waited, but since I was a new RT I didn't think I was in a spot to say anything (however I definitely should have spoken up).

As soon as the patient was lying flat her panic grew. She was given Succicholine to paralyze her, and she vomited under the mask that was on her face. It was the most disgusting thing. So now, on top of her asthma, she had developed aspiration pneumonia.

She was on the ventilator for over a month. The Internist I referred to earlier met me in CCU with the patient and he ordered a tidal volume of 700. Back then high tidal volumes were in. I swear that as soon as I hooked the vent up to the pt and set in this volume, the alarm went into a hissy fit. The high pressure alarm went off every split second. I had never seen anything like it.
I had no clue what to do, so I lowered the tidal volume WAY down, like say to 100. And, lo and behold, the alarm stopped. I also informed the Internist that he should paralyze this patient because otherwise ventilating her will be next to impossible. So he did. Granted I was a new RT here, so I was grasping at straws -- or, better yet, at the fresh RT wisdom stuck in the niches of my brain.

Of course now I'm sweaty and nervous myself thinking this Dr. thinks I'm an idiot. I'm pretty confident he thought how unlucky he was to have to work with such a fool of a green RT. So, I snuck away from the vent a moment, and nervously called a co-worker of mine to verify what I had done. She said, the way I explained it to her, that I had done all the right things. She said she would have done the same thing.

I said, "Well, the Internist is mad at me. He said he wants his 700 tidal volume, and he thinks the vent is not working."

So my co-worker friend came in to help. You'll never know how relieved I was that she came in. And she basically took over this patient for the rest of the night. This patient was now so sick, and so difficult to ventilate, that she was a one on one all the rest of that night.

At the end of the shift I discussed this case with my co-worker RT. I told her I felt stupid that I called her. She said, "Rick, the fact that you had the common sense to admit you didn't know everything and call me impressed me and the doctor immensely."

"Hugh!"

"Well," she said, "What you did for this patient is exactly what I would have done. Ventilating asthma patients can be very difficult. And that you sacrificed your pride and called me for my advice is proof that you are not over confident."

Well, I certainly wasn't over confident. I was still upset that this patient was intubated in the first place. I fear that we nearly killed her. Now, this case still bugs me to this very day. And this question still races around in my head for an answer: "If we had not intubated this patient, would she have turned around in the next half an hour or so?"

I will never know. We may never know. And this is why treating severe exacerbation's of asthma -- status asthmaticus -- is such a hard thing to do. Sometimes we think we are doing the right thing by helping them, and many times we do -- but sometimes we cause more harm.

Now I must add that all the Dr.s I mentioned in this post are among the greatest in the profession. I am not questioning their skill. What I am questioning is this: in the future, how should cases of status asthmaticus be treated in the ER? At what point do we take the invasive step and intubate?

Truly this patient had all the right indicators for intubation. She fit well inside all the guidelines. And, if nothing else, this case is a perfect example that perhaps sometimes -- as the Internist did the first time the patient was admitted -- it's important to resort to common sense over the guidelines of an era.

I will discuss this patient further and Fatal asthma further in the days to come.

Is it possible pure asthma is NOT a fatal disease?

When I was a child asthmatic rarely did I think of the disease as something that could kill me. Yes it can be a very stressful and hard to deal with at times, but even during the worse asthma attacks I never thought I would die.

My doctors, and my parents, on the other hand thought otherwise. They feared for my life so much that, on January 9, 1985, they had me admitted to an asthma hospital in Denver Colorado. While there I was faced with the notion that, if I don't take better care of myself, and if my doctors don't get my asthma under better control, I might of an asthma attack.

I even had a friend while there who was discharged to home and later died. I also met another boy while there who had a brother die of asthma just months before I met him. Since then, however, I have never heard of any asthmatic die from his disease. I work as an RT, and I have never had an asthmatic die while in my care nor in the care of my hospital.

I'm not saying that asthma doesn't present some serious complications, but I do wish to propose a theory by this post which may not be common but has been brought up by prominent physicians of the past: that pure asthma in itself is not a deadly disease.  Even prominent physicians such as Henry Hyde Salter and William Henry Osler made such an observation.

How shocking does that sound? Think of it this way. As postulated by Albert Sheffler in his book "Fatal Asthma," which was published around 1995, who explained that famous asthma physicians and authors starting throughout the 19th century wrote that pure asthma does not kill.  It may be extremely uncomfortable, but it doesn't (or rarely does) kill.  Various other authors have noted the same.

Sheffler explains in his book that Henry Hyde Salter, in his book, "On Asthma"that was first published in 1860, wrote, "Asthma never kills; at least I have never seen a case in which the paroxysm proved fatal." You have to note here that Salter was the prominent figure on asthma in the 19th century.

Yes it is true that the number of asthma related deaths had doubled since 1985 (to about 5,000 per year), however, upon further analysis, is it possible that those deaths were not caused by asthma per se, but the person taking care of the asthmatic or other ailments coupled with asthma, such as pneumonia or -- as might be caused by the unsteady and untrained eye -- a collapsed lung from artificial respiration.  Or perhaps the asthma was coupled with emphysema, bronchitis or heart failure, and it was this that caused the death and not asthma.

I have had many bad attacks. Fortunately I have never needed artificial respiration. However, I have taken care of a few asthmatics who required intubation and artificial respiration on a ventilator.  Yet all of those cases were complicated by a smoking history, obesity, pneumonia, or other such ailment.

And, as my colleague Jane Sage brought to my attention, an asthmatic kid she took care of before I became an RT died of asthma.  However, Jane told me, post mortem x-ay showed a massive pneumothorax (collapsed lung).  Jane believed that this asthmatic did not die of asthma more so than because the doctor tried to pump too much air into the patient's lungs. She said this may not have been so much panic, but a bad medical practice at that time.  If not for modern medical intervention, this asthmatic, Sage postulated, would have survived.

Modern intervention, panic, the feeling you have to do something right now may be the cause of many cases of asthma related death.   My theory is that a well trained and educated hand may save the asthmatic from dying an untimely death. In fact, I'm almost sure of this.  Plus patience is required.

Consider in the 1800s and all the way up to the 1960s books have been published where the authors, prominent physicians, wrote that asthma does not kill, as did Salter. Leffler writes that a textbook in 1935 wrote that "life of an asthmatic is not endangered."

Thus, wrote Lefler, , "In 1935 Dr. H. L. Alexander of St. Louis concluded that, prior to 1930, 'death during an asthma attack was almost unknown."

However, this wasn't always the case?  Epinephrine was discovered in 1900 and first used on an asthmatic in 1903.  After this time it became a readily available option to immediately end a fit of asthma.  Yet statistics show that asthma related deaths spiked at this time.

Another spike in asthma related deaths occured after the 1957 invention of the rescue inhaler.  This spike was determined to be caused by lack of education regarding the medicine, not so much that asthma got worse at this time.  This started a debate that continues to this day:

1. Are asthma related deaths caused by asthma rescue medicine?  
2. Are asthma related deaths caused due to poor education about asthma rescue medicines?

One the inhalers were made to not be so readily available to asthmatics, and once a warning label was placed on the boxes, asthma related deaths associated with the inhalers declined. This, in my opinion, shows the spike in asthma deaths following the introduction of epi and the epi inhalers was due to poor education.

It is my opinion that asthmatics are so happy to have the rescue medicine when they are having a fit of asthma, that they overuse it.  So, instead of seeking help, they stay home until it is too late.  Hence, they are found with the inhaler clutched in their grasp, and the blame for the death goes to the inhaler rather than the lack of patient education.

A similar event happened in 1976 when the long acting beta adrenergic Fenoterol was introduced to the market in New Zealand.  Deaths from asthma spiked, and this resulted in a panic that had experts wondering if the medicine was the cause.  Ultimately a warning was included with the product on how to properly use the mediicne, and the death rate declined.

A longer acting beta adrenergic called Salmeterol was introduced to the market in 1994, and has since been combined with the medicine fluticasone in Advair.  Yet Salmeterol was blamed for many asthma related deaths.  Once again the reason was credited to the inhaler and many experts tried to have the medicine removed from the shelves.

Yet, once again, asthmatics wanted the medicine to continue to be available because, like rescue inhalers, salmeterol helped many asthmatics control their asthma.

To encourage proper use of the medicine, the FDA now recommends serevent never be used by itself for asthmatics, and instead be given in combination with an inhaled corticosteroid to control the underlying inflammation of the air passages.  Advair has since become the most popular asthma controller medicine.  Advair also comes with a black box warning so patients know of the dangers of abusing this medicine.  I wrote about this in more detail here.

So while rescue medicine and LABAs can work to make life better for asthmatics, abuse of these medicine, which usually results from lack of education, can kill.  So this is just another long history of examples of why it's important for asthmatics to stay educated.  

Quote of the day

"Rick and I are intellectuals. We can't be bothered with any inane crap."

Make of that what you want.

The 3 different types of baby cries

With a 3 month old baby at home, I am now a baby expert. Which works very well for when I have to work with babies at work

You have a baby on q4 hour treatments. You walk into the room. He is bawling. What do you do? The answer is based on the type of cry

Here are the three types of cries:

1. Where the hell am I: This cry is often similar to the I'm hungry cry, except it calms down when you snuggle. It is an adamant, high pitched, prolonged expiratory short inspiratory gaspy cry. The decibel range can reach 300, so it cannot be mistaken. Once baby calms down you can do the treatment, but you may have to rock the baby.
2. I'm hungry: Similar to cry above, except the only thing to soothe it is yum yums. Don't you dare try the treatment before sleep.
3. I'm tired: More like a whiny, sniffly cry. Can be soothed by any of the following: num nums, nipple, booby, snuggling, blanky, etc. The treatment can be given once the baby is calmed or sleeping.

Well, there you have it. I hope this little lesson helps one or two of you RT Students out there.

"If THAT person can be an RT, so can I"

The first edition of the RT blog carnival "A Source of Inspiration" will be released today on the Surviving RT School Blog. As soon as it is released you can get to it by clicking here.

Since the theme was "Surviving RT School," it reminds me that there was a certain technique I used to survive RT school. Honestly, other than as a patient, I had never set foot in a hospital before. There were no doctors or RNs in my family. I only chose RT because of my past experience as an asthmatic.

There were many brilliant RTs and RNs I met while I was a student. And there were many brilliant RT Students I went to school with, but there were also a bunch of students in my class who were not so brilliant. And there were some RTs and RNs who seemed less than stellar.

So, as I started the RT program, I said this to myself often to motivate myself: "If THAT person can be an RN, I most certainly can be an RT."

Now, having been an RT for over a decade, I truly see the wisdom in that quote. There are definitely some RNs, as well as some Drs, and even some RTs, who tend to make the rest of us look good.

And, once you've been in the field long enough, you will know exactly what I'm referring to. Then again, I imagine you could adjust that quote to fit just about any career.

Some things should not be the job of the RT

I see the respiratory therapist as a member of the overall team of medical professionals who does his part in making a patient more comfortable or, if it comes to it, providing his expertise and skill in an attempt to save the life or improve the quality of a patent's life.

I suppose it's for that reason that I do not enjoy doing procedures just because a doctor orders it. I flinch when a bronchodilator breathing treatment is ordered on someone just because he or she is short of breath, or just out of a routine of the doctor -- or per his protocol.

Likewise, I flinch when I'm asked to do cord blood gases. The only reason this procedure is done is after a difficult birth because the doctor wants it documented that the gases were normal in case of a law suit. I do not see the RT as someone who does services just to prevent the doctor from being sued.

Thus, if a doctor wants a cord blood gas, he should draw it himself. After all, the RT had to be taken from the bedside of a person who was having difficulty breathing to draw the cord gas.

This is also why I'm anti doing EKGs on patients just because the doctor wants to make sure he covered all his grounds just in case the patient decides to sue.

That's also why I think doing Holter Monitors in the ER is not the job of the RT.

I'm not saying these things don't need to be done. What I'm saying is it should not be the job of the RT on duty.

Now, say, the doctor asked the RT kindly if he'd do these things, I'm sure he would oblige if he wasn't overly busy.

Yet, be it as it may, we do as we are told. We do things we do not approve and we do it with a smile. And then we blog about it in a wry or flippant way.

My common sense weight loss plan

Well, I imagine by now 90% of those people who made a New Year's Resolution to lose weight and get in shape have given up already. Hopefully you haven't. I'm chugging away.

I'm trying not to do anything crazy this time around. I'm trying to stick with a diet I think I can live with forever. It's what I call a common sense diet where you eat good but don't make yourself suffer.

I do weight training three days a week and aerobics four days a week and take one day off. However, if I don't choke myself if I miss a day, because Lord knows the wife and kids come first.

Every person, I think, must find a diet that works for him or her. What works for me may not work for you.

I'm not much of a reporter here because I can't remember the source of this information, but I was watching the Today Show this morning and there was a group of ladies talking about a study they did regarding a "sleep diet."

What they propose is simple: GET 7.5 HOURS OF SLEEP A NIGHT AND YOU WILL LOSE WEIGHT.

In the high tech world we live in most people get less than 7 hours sleep a night. This is much less than people used to get 100 years ago when there was little to do at night other than read stories and play the piano. So when the sun went down, people went to sleep.

Today, instead of going to sleep, people stay up to watch the last half hour of their favorite show, or finish a video game they started, or call a friend, or check their email. Of course as long as you are checking your email you might as well follow this link and that. Before you know it its midnight.

A study showed that people who have 5 hours or less sleep are 50% more likely to gain wait. The idea is that sleep deprivation increases the hormone Grehlin. Of course this also explains why people who work the night shift are more likely to gain weight.

Most of the people who participated in this study lost an average of 6 pounds in 10 weeks.

Likewise, when a person goes to sleep early, that is one less snack they eat.

I think this diet is very credible. Most of the diets I've read about say that not only is it important that you eat a good balanced diet low in carbs and fat, you should also drink 8-10 glasses of water to stay hydrated, and you should get at least 8 hours sleep at night. Or, they at least say to go to bed early.

That's hard to do when you work 3 nights a week like I do. But it explains why it is soooooo hard for me to stick to a diet. I'm doing it right now, but it's a major challenge.

Another good weight loss idea I got from Dr. Phil of all people. And I think this idea goes right along with the sleep loss diet. He said that one of the reasons its hard to stick to a diet is that people have week moments of the day, and it's in those moments you are most likely to eat bad things.

For example, I usually diet just fine during the day, but after dinner I have this undying urge to splurge. And then at about 9:00 I have this urge to have a beer. If I can somehow cut out that 150 calorie beer, and that after dinner splurge, that's 500 plus calories I could save (and an hour less on the treadmill).

What Dr. Phil proposes is to be observant of your week periods of the day (most people have at least 2), and find something else to do during those times. For instance, if you usually watch TV at 9:00 at night when you have the urge to have a beer, or to open a can of Pringles, schedule your workout at that time instead. Or find something else to do, like a hobby.

These are just some ideas. I'm not into anything wacko when I diet, just try to be sensible. I think it is dumb to give up everything you love. And I really See nothing wrong about having a beer a day, or a piece of chocolate.

In fact, the body for life for women has a diet where you eat one piece of chocolate per day. My wife read this book AFTER she lost 50 pounds while eating a piece of chocolate a day.

The idea is this, and it's not new wisdom either as my grandma used to say it: "Anything in moderation is good."

Which brings me to another idea. When I was a kid my mom limited what I ate. She never would let me eat 2 peanut butter and jelly sandwiches -- just one. She never let me eat a whole bag of chips -- just one. Yet she always let us have desserts, and we were never overweight growing up.

It wasn't until I turned 25 and decided I could eat anything I wanted now that I was an adult that I started to gain weight. Well, guess what, I have my kids on the same common sense diet my mom had me on when I was a kid. And, you guessed it, they are all in good physical shape -- for the most part.

However, kids are also a lot more physical than most adults. Which is why you need to incorporate at least some kind of physical activity, even if it's just a simple walk around the park.

Well, I'm no dietitian and no personal trainer, but I've succeeded at losing 40 pounds by dieting right and working out more than four times. Plus I try to keep up to date on all the latest tips. So you can say I'm an expert my default.

As I wrote earlier in the year I'm not a big fan of new years resolutions to lose weight and get in shape because I think you should have a lifetime resolution to do these things. Yet, if you made a resolution to do this this year, I certainly hope you are like me and are still at it -- chugging away one pound at a time.

Quote of the day

The patient was a sweet old lady who was a bit cantankerous and confused. She was also obsessed with her appearance. She said, "I look like a weirdo."

Instead of saying, "You don't look weird at all, you look just fine." What slipped out of the burned out RT was this: "That's okay, because I'm a weirdo too. In fact, we're all weirdos around here."

She was so obsessed with her hair I don't even think she even heard the quote of the day. However it provided us with a good laugh.

10 advantages to doing at least one clinical rotation at a small town hospital near you

So you live 60 minutes from where you are attending RT school, and 60-120 minutes from the closest big city hospital.

Your clinical adviser comes to you and says that if you want you can do your initial clinicals at your local small town hospital instead of driving.

What do you do? I say go for it.

Certainly you will want to gain some large hospital experience, especially in specialized areas such as critical care units, trauma centers, etc. But there is still of plethora of wisdom you can obtain from doing clinicals at a small town hospital.

What follows are the ten advantages of doing clinicals at a small town hospital:

1. Of course small town RTs get busy too, but there are more down times in smaller hospitals that will allow you to spend more quality time with your preceptor.

2. If you lack confidence in one particular area, a small town preceptor will have the time (and perhaps the patience) to work with you and allow you to harness your skills and confidence.

3. Even better, you will have quality time to pick the brains of experienced and seasoned respiratory therapists. Sometimes you can learn more from a simple RT discussion than from doing random procedures.

4. Instead of just doing breathing treatments and oxygen therapy, you will have the opportunity to do other things -- if you are ready -- such as suctioning, ABGs and EKGs. Many times we have students leaving here bragging to their fellow students.

5. No you will not get to work with trauma, neuro, or cardiac patients, but you will still get to work with ventilator patients. And since we usually only have one or two at a time, the RT will have plenty of time to work with you and prepare you in this area so when it's time for your ventilator rotation you will be ahead of the game.

6. You will have plenty of time to study.

7. You will still have quality time to do your case studies, and equally impressive patients to do them on. Plust you might even have time to spend with the patient so you can get to know him on a more personal level instead of just a number.

8. If you show your are a good worker willing to go out of your way to do things, you might even receive a job offer to work in the pool. Hey, you'll at least have your foot in the door at a hospital in your home town.

9. You won't have to worry about being thrown to the wolves.

10. You won't have to worry about becoming the third RT who so happens to work pro bono. You will actually have a great learning experience.

Well, there you have it. I imagine there are more, and if you can think of any please add to this list in the comments below.

A source of Inspiration coming soon

I just want to remind my fellow bloggers that the first issue of A Source of Inspiration -- an all new blog carnival just for respiratory therapy issues -- will be coming out next week, February, 13, 2009.

It's still not to late to write a post for this first issue. The theme for this issue is "Surviving RT School." However, I'm sure anything related would suffice.

If you have written an article, or are planning to do so, you can click here and submit it.

We RTs become humbled

When he got his job as an RT he had so many ideas to make it better. Yet when he came forward with his ideas he was screamed at and scolded by the RT Boss. Still he marched forward with new ideas, and each time he continued to be scolded.

Sometimes his ideas were approved. Once he asked for a new airway box, and the boss approved that idea. So, four years later when we still had the OLD airway box, he just figured the boss had lied -- In year #5 we actually got the box. Yep, it took five years.

Sometimes I'd listen on as he'd keep his mouth shut and listen to the lecture of why we as an RT department can't do this or that. I wondered why the boss didn't just tell him his ideas were great but he would have to go through the system the way he did with the airway box.

Of course any person who "goes through the system" (otherwise known as a bureaucracy) knows it can be extremely frustrating and extremely long. My friend once said to me, "If we were simply allowed to solve problems as they arose instead of going through the system, there would be no problem in the first place. It might even up morale."

And other times he'd make a gallant attempt to explain his position. And once or twice this resorted into a shouting match. And, of course, these little fights were always the fault of the person coming up with the new ideas, and not the RT Boss.

Perhaps he could have approached the boss in another way. But, instead of approaching the boss again, he came up with new ideas and has them stacked in a pile in his locker doing no one any good, except once in a while when he brings one of those papers to a meeting. And, hence, the bosses usually say, "That sounds like a great idea," and cast it aside.

So all the geniuses in our department were quashed. The one I'm referring to in this post nearly quit once or twice, but staying here is a lot more "convenient" than traveling two hours to the other hospital. He also decided the grass isn't always greener on the other side of the fence. Plus, other than this issue, he loves his job at Shoreline.

"It's frustrating when you have so many solutions yet nobody wants to hear them." He paused, then added, "When they do listen to an idea (a rarity), it's no longer your idea -- it's the admin's idea."

I haven't heard much from the one I'm referring to here in a long while. He has been totally shut up. One like him will never come about again -- too bad.

That is what I thought until recently, when we had a new hire who went through the same process. Recently he came to me and said, "I have come up with some great ideas, and what's the point."

She had many new ideas as new RTs often do. They have many ideas of new products or new RT wisdoms they picked up in RT school. Or something was done a better way at another hospital she worked for.

Yesterday she came to me and told me she was screamed at and scolded so many times that she has decided she will no longer go to the bosses with his ideas.

As he's saying this, I think to myself, "Hmmmmm, sounds familiar." I said to him, "Don't give up, because some day your hard work will pay off."

And so we become humbled as so many before us, yet we never give up.

8 theories why hospital census is low

I brought up a while back about how low our census has been. I'm talking extremely low. No one has been laid off yet that I know, but many have been losing hours.

It used to be that business would go in cycles. The ER would be busy during vacation season in the summer, yet we'd have fewer patients admitted.

In the winter it would be the opposite, with fewer ER visits and more elective surgeries and more critical patients being admitted.

Not anymore. I think we've been relatively slow for two straight years, and the past six months we've been so slow it's almost getting to the point we need to worry about losing more hours, and thus burning vacation hours when we don't want to.

So why is it that business is so slow lately. I have a few theories. Perhaps you can add to these:

1. It used to be that cardiac patients were given TPA and then they'd sit in our CCU beds for 4 days. Then they'd go for a cath. the new policy is for a cath to be done ASAP, so all cardiac patients are simply shipped right from the ER.

2. With the economy so bad, no patients are having elective surgeries.

3. With the economy so bad, many potential patients are without insurance. Since they have no insurance they are not coming into the hospital unless they are really sick.

4. Many ER docs are all relatively new to this hospital and may not fully comprehend that we are capable of taking some of the patients they are shipping out.

5. People going elsewhere for their care. People think there are better surgeons and nurses at other hospitals, when that's not necessarily the truth.

6. With the economy of Michigan being the 2nd worse in the U.S., people are moving out of this area. Thus, with a lower population, fewer patients can be expected.

7. DRs are simply not admitting for things they used to admit you for, especially when they know they aren't going to do anything here that you can't do at home.

8. We are doing such a great job with our medical wisdom and new medicines and education that patients stay healthier and don't need to visit us.

A great example of this is asthma. In the 1980s there were plenty of asthmatics to go around. Now we seem to have hardly any asthmatic patients.

As a former asthmatic kid myself, I thought it would be neat to be an RT and work with asthmatic kids. There simply aren't any kids with asthma being admitted.

So these are just some of my theories. I have no idea if it's just this hospital being hit with the low census, or all small town hospitals. I have no idea if larger hospitals have this issue, however I would like to say I doubt it.

If you guys have any theories you'd like to add here, please feel free to leave a comment because my curiosity is peaked.

Why do Drs get all the free stuff?

I walked into the doctor's lounge tonight and snooped through the drawers and the fridge down there. Hey, ain't no docs around this place at night -- too inconvenient.

They were chock full of goodies like poptarts, cookies, fruit and grain bars, cerial, V8 juice, pop, candy, donuts, bagels, beer...

Okay, so there really wasn't beer, but you'd be amazed at all the goodies down there. Oh, and I didn't mention that they get a fresh pot of coffee every hour or so from the cafeteria (although not at night.)

Yet the rest of the staff gets a big whopping handful of... you guessit it.... nothing.

Why is that? Doctors make 100 times more money than any of us RTs or RNs, and yet they are the one's the admins give all the free stuff to.

If anybody around here deserves free stuff it surely isn't a doctor who can afford to buy his own treats. And if they get free stuff, why not the people who are doing all the work?

Come on folks. Let's get with the program!

So, anyway, as I write this I'm enjoying my V8 juice, my poptart and my fruit and grain bar await.

The other 20 such objects I took I handed out to my coworkers.