What makes a good hospital

It's weird how one hospital can be bad and one be decent. I work at a really nice hospital, and I hardly ever heard complaints about it even before I worked here.

Over in the next town where I grew up there's a hospital many call Death Medical Center. And that's where I always went when I had bad asthma as a kid. I always thought I got good care. Although one of my coworkers who worked there back when I was a kid told me that even my doctor was a loopy one. Yet how was I to know? Well, I didn't care because I was just a kid, yet how were my parents to know? And even if they did know, what would my parents have done anyway? When I was having breathing trouble they certainly weren't going to drive me 20 miles to Shoreline Hospital when Death MC was five minutes away.

When I started as an RT, I thought where I worked had a nice down homey atmosphere, and all the people were great. We don't have the newest facility, but you know you're going to get the best care. Over at Death MC they have all the nicest rooms. They even have private rooms, and in their OB they have hot tubs. It's really nice. Yet the people are dip shoots. Well, not all of them, but the aura is different from where I work. I think the aura of a place comes down from the top, and here at Shoreline we have a nice aura.

I remember the first time I ever came into this place for my physical, a volunteer met me right at the front door and escorted me herself to where I needed to go. I had a good impression right off the bat. When I interviewed at Death MC the lady at the front desk "told" me how to get where I was going, and I never did quite find it. In fact, I'm still looking.

In fact, when I did work at Death MC 10 years ago, one of my friends who worked there said one day as we were walking into work, "I never met a bunch of a##holes all rolled in to one building in my life." I think she hit the nail on the head for dip shoot hospitals. It's weird how two hospitals so close can be so different in all regards.

Seriously, I think where I work, here at Shoreline Medical Center, there is an extra emphasis on public relations. When you say you're going to do something, you do it. When you see a patient looking lost, you walk them to their destination, and if you're too busy you at least stop and point them in the right direction. If a patient is sitting on a bed a long time, you go out of your way to at least make them aware that we didn't forget them. It's just that little extra effort can make a big difference in how people view your institution.

Yes we still do have our politics that irritate you from time to time. You have your occasional administrators who leave you notes every time you do something wrong, yet when you save a life nothing is said. Yet those events are normal, and to be expected. After all, the bottom line is making money.

Likewise, if I put myself in their shoes, I can't say I'd do it any different. In fact, I'm pretty sure I wouldn't. You do whatever it takes to keep your job, and to keep your institution in the black. And while the bosses don't mean to seem one sided, that's sometimes how they come across, especially to the complainers.

Yet a good pat on the back, a good comment, a smile, a nod of the head, or even just that little bit of going out of your way to make a difference can really help make an institution that much better.

It's true that I would like to see more protocols, and I would like to see administrators and doctors allow RTs like myself to share our opinions more, and have them listen and heed our advice. There is a process and we do get heard, yet sometimes it doesn't seem often enough nor fast enough nor efficient enough, and I think that's what's the most irritating.

Politics is irritating. And as much as I hate people in Washington deciding what pot holes in Shoreline to fill, I don't like Admins deciding how the nurses nursing station should be set up and arranged. Decisions should be made by local people who see the problems and know exactly what to do to fix them.

Our hospital has made progress in this ares with Keystone meetings, Huddles, and the like, and asking me and others in my department to participate by writing policy, creating protocols and working with admins and doctors and RT bosses to make our institution better.

Yet it's slow progress regardless. Like when you stare at a clock, it seems to be not moving at all. Daunting it is. That's just normal. You'll have your politics wherever you go. Yet, overall, I think Shoreline has a good, down home atmosphere filled with people who care. I think it starts at the top, and it starts with a smile.

Does warm water help an asthma attack?

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Your Question: My daughter woke up feeling congested and short of breath. I told her to drink a cup of hot water and that relieved her symptoms. Is that considered an asthma attack. She was recently diagnosed with mild asthma. I read about how hot drinks can relieve asthma symptoms.

My humble answer:That's possible. Some asthma attacks can come and go that quickly. It's great that you recognized the signs and knew your options. Make a note about this event in your daughters asthma diary, that warm water worked, the date, and discuss this with your child's pediatrician at your next vist.

Asthma is quite often known as a disease of the night, so it's not uncommon for a child with asthma to wake up congested, short of braeth, or coughing.

Your Question: Does warm water help an asthma attack?

My humble answer: The first thing you should do during an asthma attack is get away from whatever triggered your asthma and relax. Then many experts recommend drinking a warm glass of water to help thin secretions. Sometimes this alone works to stop an asthma attack. If it does not, then you should follow the rest of your asthma action plan (use rescue medicine and seek help if necessary). Cold water can actually make the spasms in your lungs worse, and milk products may thicken secretions.

Asthma hospitalizations on the decline?

For several years now we RTs have noticed a trend where asthma rates are climbing yet asthma patients are declining. What is the reason for these opposing trends?

This was the topic of my research the past several months, and the subject of my first post over at TherapyTimes.com, " Asthma on the Decline? Where today's statistics stand?" You can read the full article by clicking here.

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Growing up with uncontrolled asthma in the 1970s and 80s caused me to spend too many days in a hospital bed, getting to know many respiratory therapists. When the time came, it seemed a natural decision to become an RT myself. After all, I'd have empathy for all the asthmatic patients.

It sounded like a noble plan except for one thing: asthmatic patients are now few and far between. By the time I became an RT in 1996, there were few little kids, let alone adults, with asthma so bad they needed to visit the emergency room on a regular basis, let alone be admitted. At least this was the observation my co-workers and I have made for hospitals in the region where we live in West Michigan.

I work with two of the RTs who took care of me when I was a child asthmatic (I wrote about this here), and they both tell stories about asthmatics who were what we in the medical world like to refer to as regulars. Regulars, or in this case regular asthmatics, are those asthmatics who visit the hospital so often that RTs get to know them quite well.

Personally, in my 14 years as an RT, I can remember very few regular asthmatics, and only one of them had pure asthma. The rest were former or present smokers who were also diagnosed with COPD, so they probably don’t even count. Likewise, I have gotten to know zero, zilch, nada pediatric regular asthmatics, or those under the age of 18.

It appears that, except for a few exceptions, the regular asthmatic has been replaced by the spot asthmatic. Spot asthmatics are those asthmatics who come to the emergency room (occasionally being admitted), are treated, educated, and discharged. Most are never seen again for one or more of the reasons I list later in this article.

With few regular asthmatics, and a few spot asthmatics thrown in here and there for good measure, I’m still able to empathize with asthmatics, just not on the scale I imagined. And I figured I’d get to know at least a few pediatric regular asthmatics.

While we have plenty of COPD and pneumonia patients to empathize with, the classic asthmatic seems to be the patient of the past. Yet, while my co-workers and I observed the decline in the asthmatic patient, this was difficult to prove, as medical statistics aren’t always easy to come by, and even studies and statistics accumulated are often incomplete due to lack of data. Likewise, when I talk to my RT friends in Detroit, they say they have not noticed a decline in the asthmatic patient.

So would the stats confirm my observation?

According to this report by the Michigan Department of Community Health, the pediatric asthmatic hospitalization rate went from 33 out of every 10,000 residents in 1990 to 17.3 out of every 10,000 residents in 2000. Likewise, the same report notes, “Since 1990 there has been a significant overall decline in asthma hospitalization rates in Michigan for whites 0-4 years, 5-64 years, and 65 years and older.

So far so good. This statistic would explain our observation for the small town hospital we work for, considering the population where I live is mostly white. However, if you look at statistics for Saginaw and Detroit, the asthma hospitalization rate is significantly higher than the rest of the state.

In fact, according to this report with statistics from the Michigan Inpatient Database, “The rate of asthma hospitalizations in Detroit (in 2006) is three times higher than that of Michigan as a whole.” So this confirms what my Detroit friends have noted.

New York City asthma hospitalization rates actually increased from 1988 to 1997 according to this article from the Journal of Urban Health. Studies have similarly shown higher rates of asthma and higher rates of asthma hospitalizations among blacks and the underprivileged, which may help explain the higher rates for Detroit and New York City.

According to the same article, asthma rates overall have actually stabilized since 2000, with about 16-18 asthma hospitalizations of every 10,000 residents for the state of Michigan as a whole, and 51.2 asthma hospitalizations of every 10,000 residents for Detroit.

In the United States as a whole, the asthma hospitalization rate has declined, as you can see by this study originally published in the Journal of Asthma. The study “confirms that both asthma hospitalization and mortality rates decreased (from 1995 to 2002) and the black to white racial disparity in asthma hospitalization has narrowed for children younger than 10 years of age.”

Another report confirmed a decline in hospitalizations in Berkley, California, where the Health and Human Services noted that “over the entire 17 year period reviewed (from 1990 to 2006), asthma hospitalization rates declined an average of 2 percent per year.”

So, based on the statistics I have obtained, I think it’s safe to surmise that with the exception of some geographic regions, the overall asthma hospitalization rate in the U.S. has dropped since the mid 1980s. Yet, while we have made this observation, other statistics show the number of asthmatics is rising and will continue to rise.

According to the American Academy of Allergy, Asthma and Immunology (AAAAI.org), asthma rates increased 75 percent between 1980 and 1994. They also note, “It is estimated that the number of people with asthma will grow by more than 100 million by 2025."

Another interesting statistic of note is that up until about 1997, the asthma death rate in the U.S. steadily increased, and since then it has been steadily decreasing to it’s present level of less than 3,400. AAAAI statistics note there are about 34.1 million asthmatics in the U.S. Thus, the risk of someone dying from asthma is as low as 0.01 percent.

One would think more asthmatics would translate into more asthma hospitalizations as the statistics for Detroit and New York City confirm. Although that doesn't seem to be the case for the rest of the country, or at least the region of Michigan where I live. Obviously the asthma experts are doing something right – they are, after all, keeping an increasing number of asthmatics healthy and out of hospitals.

But How?

The truth is, nobody really knows for sure why asthma-related hospital visits are declining despite an increasing number of people diagnosed with the disease. I propose some viable theories.

1. Improved Asthma Wisdom: I remember my asthma doctor prescribing Vanceril when I was a regular asthmatic and then telling me to only use it when I was having trouble breathing. Any asthma expert today would wince at that prescription, but doctors didn't know any better back then. So instead of the Vanceril controlling my asthma, there were many hospital visits. This was the same for many asthmatics. Today, we know that inhaled corticosteroids are safe, and if used every day can actually prevent asthma from occurring.

Likewise, new asthma wisdom has proven there are two main components of asthma: bronchospasm that occurs during an acute attack, and chronic inflammation. This has lead to better ways of treating asthma.

2. Emphasis on Prevention: While the old emphasis was to treat acute asthma symptoms, the new emphasis is on preventing asthma attacks altogether. Asthma experts have learned that inhaled corticosteroids work best to control this inflammation, and are now a top line therapy for controlling asthma. The most common way of receiving inhaled steroids is in combination with long-acting beta agonists (LABAs) in medicines like Advair and Symbicort.

3. Better Asthma Medicines: Studies like this have proven medicines like Advair and Symbicort improve asthma and have reduced the need for ER visits and hospitalizations. These meds work best to control both components of asthma, and are therefore top of the line asthma medicines. Singulair is another medicine that has done wonders for asthmatics by controlling allergies and controlling exercise induced bronchospasm. While it may take some trial and error, with a good asthma doctor and good compliance by the patient, most asthmatics can easily prevent asthma from occurring altogether.

4. Improved Asthma Compliance: In 1985, I had to take some medicine about every two hours throughout the day. My Azmacort was four puffs four times a day, Theo-Dur one tablet every six hours, and throw in Q4 hour breathing treatments and I was inhaling asthma meds all day. Needless to say, there were many puffs, and many pills that were never taken.

Thank God for new medicines. Both Advair and Symbicort are only taken twice a day, and Singulair is a once a day pill. So, basically an asthmatic takes his medicine when he brushes his teeth in the morning, and again when he brushes his teeth in the evening. Since these meds work well to control asthma, bronchodilators are needed less often. The result here is much improved compliance with asthma medicines.

5. Better Educated Doctors: I had a good doctor when I was a child asthmatic, but there came a time when my asthma got so bad he didn't know what to do for me. So he had me shipped out to Denver to a hospital that specialized in asthma. That hospital, which is now known as National Jewish Health, did a great job of finally helping me to control my asthma not because it had better doctors, but because doctors that worked there had the advantage of access to the latest asthma wisdom.

Today all doctors are privy to the latest asthma wisdom. One reason is because asthma research centers like National Jewish hold annual seminars to educate regional asthma doctors. Another reason is because of the National Heart, Lung and Blood Institute's Asthma Guidelines.

6. The Asthma Guidelines: In the late 1980s, a group of the most renowned asthma experts in the world decided that with all the new asthma wisdom and medicines now available, most asthmatics should be able to gain control of their asthma and live normal lives. The catch is that every doctor needs to be up on the latest asthma wisdom, and be on the same page.

That's why in 1991, the Asthma Guidelines were released. These guidelines provide "guidance for selecting treatment based on a patient's individual needs and level of asthma control." Basically, every reason for better controlled asthma I mention in this article is in one way or another related to the asthma guidelines. It has resulted in better asthma wisdom, better educated doctors, better educated patients, and across the board better asthma control.

7. Better Patient Education: So not only do we have better educated asthma doctors we also have better educated asthma patients, asthma moms and dads, grandparents, teachers, day care providers, brothers and sisters, aunts and uncles. Asthmatics and those who take care of asthmatics are educated about asthma triggers and how to avoid them, about how to pick up on the early warning signs of asthma, and asthma action plans so the asthmatic (or those around the asthmatic) know when to take rescue medicine, when to call the doctor, and when to call an ambulance.

8. Asthma Action Plans: The asthma guidelines, along with most asthma experts, recommend the asthmatic (and/or the parents of the asthmatic) work together with the asthma doctor to create a plan so the patient knows exactly what to do when the signs and symptoms of asthma are observed. (To view a sample plan click here.) By observing the early signs of asthma and acting swiftly according to the asthma action plan, the asthmatic may prevent asthma from getting worse, thus eliminating the need for an unscheduled doctor’s office visit, emergency room visit, and hospitalization. Of course this has also helped to reduce the already low (although still too high) asthma death rate.

9. The Internet: I have to admit that since the advent of the Internet, my asthma wisdom has been magnified. Not only do we asthmatics get to share our asthma experiences via blogs and communities like these, we also have access to the latest asthma wisdom from Web sites like the one your on, or Google alerts, MyAsthmaCentral.com, or wherever else you prefer to obtain your wisdom.

10. All of the Above: Most of the studies you'll find on the Internet (such as this), will give credit for improved asthma control and decreased hospital visits to Advair, and occasionally Singulair. While it is true, these new asthma meds can work miracles for many asthmatics, no asthmatic can gain control of his or her asthma without all the other reasons listed above.

Studies show that both blacks and low-income individuals have a greater chance of having uncontrolled asthma, and a greater chance of being admitted for their asthma. One of the main reasons here is lack of access to quality healthcare, lack of education, and lack of opportunity to avoid asthma triggers, such as molds, cockroaches, cigarette smoke, air pollution, and dust mites. These individuals, as was noted in the Detroit study, are also less likely to visit their asthma doctor at least once a year, as the asthma guidelines recommend.

Efforts are ongoing to improve asthma control, and lower hospitalization rates, not just in Detroit and New York City, but across the country.

Thanks to smarter scientists, we have more information for the researchers to assimilate. And thanks to smarter researchers we have smarter asthma experts. Thanks to smarter asthma experts the asthma guidelines have been updated three times since 1991, and most recently in August of 2007. And thanks to the asthma guidelines we have smarter doctors, smarter patients, and so and so down the line.

Rarely do I ever look down at my clipboard and see the diagnosis of asthma listed there. When I do, it’s a spot asthmatic I’ll probably never see again. The reason is because most asthma cases are better controlled these days. And this, as I’m sure you’ll agree, is a good thing.

The forgotten Patient

I find I have no choice but to talk about the economy on this RT blog. I find I must do this considering we have been running on an extremely low census the past several months here at Shoreline. I'm talking half the hospital is closed kind of slow. I'm talking, like, 10 total patients kind of slow.

I'm talking many RTs and RNs who were living pay check to pay check before the recession hit are now finding themselves in a serious rough spot. Some are wondering if we will be able to pay our bills. Some are not paying them. Some of us have already become statistics.

Other hospitals in this area of Michigan are also experiencing a low census, although some of the larger hospitals have yet to get to the point where they have had to lay off RTs, some have been sent home early, and few hours are available for the pool RTs.

If you would have asked me two years ago how the recession would effect the medical profession, I would have predicted fewer elective surgical procedures, but I never would have predicted what is going on right now.

I think that not only are there fewer elective surgeries, I think there are a few people who require surgery who are staying home and suffering. In fact, I think there might be many people like this. I think there are many chest pain sufferers who are being modest and biting the bullet instead. I think there are COPD patients who are staying home until they can't stand the agony anymore.

Hence, I expect that some day soon we are going to be hit hard. The patients we get are going to be patients in critical condition; chronic lungers and asthmatics who have not taken their controller meds because they can't afford them, and chest pain folks who are coming in with the big one or a stroke because they ran out of their blood pressure medicine.

Sure, I bet, in this way, the recession may be responsible for many deaths this way. It will be slow, insidious, and agonizing. And yet it will not be seen, and therefore it will not be noticed, nor recorded in the annuls of history.

Yes, the recession is effecting the medical field. Since hospitals have little money, they are making do with what they have, and they are not expanding, not adding on, not making repairs, and not giving raises.

Actually, one hospital in my region is spending millions on room repairs, yet the money is from outside groups and donations. So, since no money is being spent this way, local contractors are not getting contracted out. They are -- the contractors -- having a lull time too.

And so they are losing jobs, and, with their jobs, they are losing their health insurances. And with no health insurance, they stay home when they get sick. Sometimes this is fine, yet sometimes this can increase morbidity and mortality.

So the lull has lasted a while now. Instead of having 2 RTs working during the day shift, we have been doing 8 hour shifts three days a week. Sure we have vacation hours we can use, yet those will die out some day. This cannot continue too much longer. Bills need to be paid.

Actually, I wrote before how those of us who live frugally as though we are always in a recession don't have to fret so much. Yet look around at all the people who have 2 cars that are rented, a camper that is rented, a house that is too extravagant for their income. These folks have been living above their means, check to check, assuming the recession would never come.

Those folks are the ones being the hardest hit. Those folks did not prepare. Those folks are the ones who bought houses they couldn't afford and are thus going to have no choice but to file for bankruptcy.

Temporary jobs can keep an economy going for a while, yet will it pull us out of the recession altogether? What happens when those bridges are done? What happens when those dams are built? What happens when roads are repaired? What happens when that shrimp farm research in Florida is finished? (These are all things in the Obama Stimulus Plan).

And what happens when the Bush Tax cuts expire? Some economists write that some business people will continue to spend until those tax cuts expire, because they expect the economy will hit the skids at that time. And then the economy will slip into a prolonged recession or even a depression as they make cuts and further stop spending.

Yet some predict the Obama stimulus will eventually pull us out. What we do know is the business cycle history proves that the economic lull will end at some point. What we don't know is how long it will last. The Great Depression was the longest economic lull in history. Some say FDR got us out of it. Yet some say he prolonged it. Yet FDR was popular, and Obama is copying his economic strategy.

One of the neatest things about an economy is that most people only look at what they see. The job of the economist is to look at what is not seen as well as what is seen. For example, say you have three men. Man A is the owner of a shoe business. Man B just filed for unemployment. Man C sells suit coats for $100.

Man A is planning to buy a new suit coat. He has the $100. The public has empathy for Man B, so they encourage their Senators to sign a bill raising man As taxes by $100 so they can help out Man B. Since man A has to pay $100 in taxes, he can no longer afford to buy a new suit coat. While the unemployed man is being helped with that $100 and we are all happy about that, Man C is actually the forgotten man here. He will lose business, because during a recession people find better ways to spend money than buying things like suit coats and entertainment and other such things.

I imagine many medical care workers are forgotten men and women. Yes it's true many are still working, yet we are not getting raises to keep up with inflation, and we are not getting all our hours. So we cannot spend money on things like, say, suit coats. So man C suffers even more. He cannot pay for his hernia repair.

And, another forgotten man is the RT Student who has a family and bills to pay and just spent $100,000 to get through RT school and now he can't find a job. What is he to do? He in essence becomes man D. So, if man D has asthma, and he has an asthma attack, he might stay home because he can't afford the $50 nebulizer treatment, or the $100 mandatory ER Room fee, or the $500 for a chest x-ray.

He thus becomes the forgotten patient. We do not see him, yet he exists He is in agony. He is suffering. Yet he does not become a statistic because we do not see him. Some day, though, he will enter the doors of some ER room. The question is: in what condition will he enter this door when we finally do see man D.

It is the job of economists to see man A through D. It is the job of those in Washington to heed the advice of the true economists, and not make rash decisions based on sympathy for the men who are suffering that we do see.

Lest the recession will continue, and we RTs will continue to work during lull times, and one day all those forgotten man Ds will come strolling through those ER doors and it won't be pretty.

10 changes I'd make to Major League Baseball

As a lifelong Detroit Tiger and baseball fan, I have some humble advice for the league:

1. Allow Pete Rose into the Hall of Fame. He's the MLB leader in total hits, and all those hits were obtained before he did something stupid. He should be in unanimously.

2. Allow instant replay. Each manager should get three opportunities each game to question a call, including balls and strikes. And the review should be automatic in the 9th inning or later.

3. Get rid of the designated hitter (DH). I think the game would be more interesting, and probably even more fun for the players and managers, if pitchers were allowed to hit.

4. Shorten the season by 20 games and start the post season earlier so the World Series can be played the first week of October when the weather is still nice.

5. Get rid of inter-league play as it currently stands. The way which teams are chosen to play each year creates too much imbalance. Inter-league play is no longer exciting and must be eliminated. Besides, accomplishing this will help balance the divisions.

6. Balance the divisions. Five teams in the National League Central have to vie for one a playoff spot, and only four in the American League West. The Angels get to the playoffs every year by beating 3 easy teams. This is not fair. CBSSports, in this post, has a good idea to balance the divisions:

There would be four 15 league divisions, and each team plays each team at least once. If MLB wanted, it could always have at least one inter-league series going on. As noted:

"14 of the AL teams would face each other, 14 of the NL teams would face each other, and then one AL team and one NL team would face off in the one inter league series.... That way, every team is playing two series every week, and every team has an equal chance at the playoffs."

Of course this would mean one National League team would have to move to the American League, and I think the easy favorite would be Milwaukee which already jumped leagues for no apparent reason twice. Although there could be some sort of lottery or something to decide which team has to switch leagues.

7. Fix the voting system for the All Star Game. I think voting should be done 70% by the fans, and 30% by sports reporters, players, managers and baseball administrators. This would assure only the best players get to the game, and not some old washed up superstar.

8. Change the rule that says one player from each team has to be on the All Star Game. Only the best should make it to the All Star Game.

9. The rule that the winner of the All Star Game game gets home field advantage in the World Series should end too. This game should be for fun only.

10. The team with the best record should get home field advantage in the playoffs. This can be done because you don't have to worry about one team having the best record because it has only easy teams in its division: the divisions will be balanced.

Is respiratory therapy a dying field? If I can't find a job as an RT, what can I do?

I occasionally check my statcounter to see what Google inquiries or searches lead someone to the RT Cave. If I think the landing page did not answer the question, I humbly try to provide the answer in this post.

So, here are Your RT Queries:

1. Should children use a face mask for a a breathing treatment? I think most studies recommend a mask is the best method to get the most medicine into a child's lungs. A mouthpiece is the best method, yet many children can't use a mouthpiece. Check out this link and this link for more detail.

2. Do I need a respiratory therapist for a Cpap? If you are in a hospital and need a CPAP you will inevitably have to deal with the CPAP experts. However, outside the hospital you can obtain a CPAP from your home care establishment, or may run into a CPAP machine if you have a sleep study. I guess the answer to your question is yes and no but not necessarily so.

3. How do you write prvc settings? Where I work PRVC is the default mode per our ventilator protocol, where if there is no order we automatically use PRVC. In fact, if PRVC is available, I see no reason to use any other mode unless you have a greater objective.

4. Respiratory therapist dying field: I do not believe RT is a dying field. In fact, there is no evidence of such. Respiratory therapists are an essential part of the patient care team. They are the lung experts, and rather than being utilized less in the future, I think they will be utilized more.

5. Why elevate hob for patient with COPD? Because it helps them to expand their lungs so they can get more air in. It helps relieve the feeling of dyspnea, or air hunger. Try slouching forward in your chair. Now try to take in a deep breath. Now sit straight up as you can, and try to take in a deep breath. It is much easier when you are in a high position. When you're not short-of-breath you don't think of things like this, yet when your short-of-breath you quickly learn it's easier to breath sitting high, or even standing.

6. I can't find a job in respiratory therapy, so what should I do? I know there is a squeeze on hiring at most hospitals. Your best bet might be to spread your application around and be willing to move if necessary. Chances are the jobs available will be pool positions. Another thing you might want to try is another job in the hospital, such as a nurses assistant or a tech. Sure these might not be the ideal jobs, but at least it would help pay the bills while helping you get your foot in the door. Good luck.

7. Are crackles found at the base of the lungs in chf patients? While the CHF patient is having an episode of acute heart failure, yes there will be crackles. This is the sound of fluid in the lungs. Between acute episodes, there ideally should not be crackles. However, this will also depend on the overall health of the patient too. End stage COPD patients have a tendency to CHF, yet many COPD patients have crackles all the time in the bases. This isn't so much fluid, but the air sacs opening and closing with inspiration. Yet, during acute CHF episodes, the crackles will be more prominent, may fill the lungs about half way up, and sound like water in the lungs. Stay tuned, because on 9-1-2010 I will publish a post everything you need to know about CHF.

8. Wet lung sounds: See #7 above. Also see the lung sound lexicon.

9. DNR full code definition: This refers to do not resuscitate. According to Wikipedia: "document is a binding legal document that states resuscitation should not be attempted if a person suffers cardiac or respiratory arrest. Abbreviated DNR, such an order may be instituted on the basis of an advance directive from a person, or from someone entitled to make decisions on their behalf, such as a health care proxy." I believe (as I wrote here) that DNR orders can be a good thing, especially if you have a patient who is chronically ill or at an elevated age. I believe there comes a point where it's better to let nature take its course. Not only is this better on the patient, but on the family. So, it's a good idea to plan ahead.

10. Why don't we give 100% oxygen to patients on ventilators?: Because oxygen is a drug, it should be utilized as a drug. New studies (like this one) show that even being on oxygen greater than 60% for as little as three hours can do damage to the lungs. So it is essential that if a patient require oxygen at greater than 60%, that he is weaned off as soon as possible. Stay tuned, because I have more research coming up in an upcoming post.

CTs may lead to early diagnosis of COPD

As I wrote here, there are many COPD patients who go undiagnosed. Early diagnosis may lead to education and treatment that can slow the progression of the disease. As you can read here, a CT scan may be the newest trend in diagnosing COPD.

According to this article, "The study indicates that smokers, who suffer from slight emphysema, but have normal lung function, have a distinct blood flow pattern in their lungs as compared to non-smokers and smokers without emphysema

. This distinction may be used to identify smokers who are at a higher risk of emphysema, and prepare them for early intervention."

Of course this early testing isn't something we'll see regularly in the hospital, as usually we see patients with further progression of the disease. Although, as America stops smoking, this test may help reduce the number of RT patients in the future.

Ventilator Bundle

Patients used to be left on ventilators too long. If the attending had the day off, the covering doctor was often leery of extubating. The RT on duty wasn't encouraged to "think wean" because there were no protocols. Procedures performed, and sedation, was essentially left to the covering physician, and often varied from patient to patient.

This policy lead to long ventilator stays, increased chance of getting ventilator acquired pneumonia (VAP), and, thus, increased time in hospital, too many poor outcomes, and all this resulting in increased cost to both the patient (or his insurance, or the government) and the hospital.

Studies were done that showed VAP was very high. In fact, every day on the ventilator increased the risk of VAP by 1 percent. Once a patient has VAP, this increases the days on the vent by 4-6 days on average, which increases hospital stays by 4-9 days.

Likewise, fatality rate for VAP is 20-50%, and ultimately costs the hospital an average of $15,000 to $40,000 per patient. Something needed to be done to improve outcomes. The focus was on reducing VAP, and the emphasis was getting all those who cared for the patient on the same page, and thinking the same things.

And if something was missing, or done wrong, others caring for the patient were encouraged to speak up. Studies (like this one) performed showed the following were the best ways to reduce VAP:

1. Good hand washing
2. Ventilator Weaning or extubation Protocols
3. Decrease Ventilator Circuit Contamination:

• use inline suction catheters
• change inline suction catheter every 7 days
• change vent circuit every 30 days (max)

4. Oral Intubations: Studies (as you can see here at Medscapes.com) show that the risk for acquiring VAP is 75% for nasal intubation as opposed to 29% for orally intubated patients.

5. Patient positioning: Keep HOB 30 degrees or greater to decrease risk of aspiration, and lowers diaphragm to improve ventilation, reducing risk of VAP.

6. ETT cuff pressure 20 or greater (a change from what we learned in RT school)

7. Proper Yankauer care, and replace daily. Contamination can potentially cause VAP.

8. Oral intubation: Studies show the best way to intubate patient s is oral intubation, as orally intubated patients had a 34% chance of developing VAP as opposed to 73% of nasally intubated patients.

9. Swabbing the mouth: Studies show swabbing mouth with chlorhexidine gel 3 times a day reduced the risk of VAP from 66% to 29%.

10. Feedings by gastrostromy or jujunostomy: These have the lowest infection rate according to studies. Long term feedings should be done by these methods. Short term feedings should be done by oral gastric tubes as opposed to nasal gastric tubes.

These have all been proven to greatly reduce the risk of VAP. Poor oral care increases the risk of colonization of the mouth, and this can work it's way to the lungs via secretions. An inflated ETT cuff does not prevent germs from reaching the lungs and cause inflammation and pneumonia.

As you can see from the graph above from the MAYO Clinic, from April through December 2003 there were between 6 and 9 cases of VAP per month. Then, almost by miracle, the number dipped to zero, where it has stayed ever since. So what happened?

In January 2004 the MAYO clinic started what is called the ventilator bundle. This is basically an order form that shows the doctor, nurse and RT what needs to be done to prevent VAP The following are the recommendations for a Ventilator Bundle:

• Elevation of head 30-40 degrees unless medically contraindicated


• Continuous removal of subglottic secretions


• Change ventilator circuit no more often than every 48 hours


• Washing of hands before and after contact with each patient


• Daily Sedation Vacation to assess for weaning daily


• Ventilator Weaning or extubation Protocol (always be thinking wean)


• Prophylaxis for DVT


• Prophylaxis for Peptic Ulcer

Here's a copy of our Ventilator Bundle order form from Shoreline Medical. This is a standard sheet that goes in the doctor's orders section for each patient placed on a ventilator:

• Ventilator Protocol Initiated


• Sedation Protocol Initiated


• Peptic Ulcer Protocol Initiated


• DVT Prophylaxis Protocol Initiated


• Glucose Control Protocol Initiated


• Hold Sedation once per day to assess for weanability per ventilator protocol


• Elevate HOB 30-45 degrees unless contraindicated


• Chest X-Ray daily


• ABG daily


• Sputum C&S ASAP after initiation of vent to rule out colonization at time of vent start


• Bronchodilator therapy if indicated (MDI only)


• Dietitian consult if pt. on vent longer than 24 hours to maintain proper nutrition


• Foley catheter


• Oral care TID to QID and prn


• Suction as indicated, or at least once per shift, preferably with inline suction catheter


• Restraints if approved by physician


• ISOPTO tears 1-2 drops as needed

Since the MAYO Clinic initiated its Ventilator Bundle, they have had one reported case of VAP. Likewise, since we initiated ours, we have had only one case of VAP.

It's kind of nice, because it pretty much puts the RNs, doctors and RTs on the same page, and it makes sure that every thing that can possibly be done to improve outcomes, and speed up time from intubation to extubation is done.

About five years ago Shoreline Medical established what it calls the Keystone Committee designed to establish protocols and policy to improve patient care and reduce costs. This committe consists of a champion physician and members from each department within the hospital, including critical care, respiratory therapy, surgery, emergency, administration, and quality assessment.

Quality improvement, and new research, is duscussed on a monthly bases, and the ventilator is updated accordingly. And Ventilator Bundle Core measures are assessed to make sure all procedures are being completed and charted accordingly.

An example of a core measures analysis for the Bundle can be seen in the picture. The goal is to obtain 90% or better in each area, and this is indicated by the green. Green ultimately means the goal has been met.

The areas marked by red indicate the goal has not been met, and something needs to be done to make sure the measure is improved. Ovarall, based on this data, the problem area is oral care. So the team would look at why we are only at 85%.

Is this because the nurse or RT forgot to chart? Was it because the procedure is ordered every 2 hours and this is not possible when the patient needs to sleep? What can be done to correct the problem?

These are all things we think of at our Keystone meetings, and then the bundle is changed if needed.

For examle, our initial bundle changes our practice of lavage and suctioning, and we not have inline suction catheters to reduce the risk of infections. We also give Ventolin MDIs to vent patients instead of breathing treatments.

For us RTs, we are thinking wean as soon as the patient is intubated. Length of time on vents has greatly diminished as well. If we notice the HOB is not elevated 30 degrees, we move it up. If the patient is not receiving feedings, we notify the nurse. Vice versal when it comes to clean suction equipment, and assuring that a sputum sample is obtained to make sure the patient didn't have pneumonia at the time of admission. We work together.

So, ultimately the goal of the Ventilator Bundle is to:

• Reduce VAP


• Reduce time from intubation to extubation


• Reduce costs


• Improve outcomes

Ventilator Bundles work, and one should be initiated at your hospital too.
This topic was also recently discussed at rtmagazine.com

For studies that show what should be done to reduce VAP check out this post at Critical Care Nurse

Moving make asthma worse? What can I do?

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Your Question: My daughter just moved to San Antonio, Texas and now she and her daughers have trouble with allergies and asthma. Her doctor says this has to do with the molds and mountain cedar here. What remedies can you suggest?

My Humble Answer: Asthma experts no longer recommend moving to another location to control your asthma, as new medicines work wonders for controlling asthma. Ideally you should be able to work with your physician to determine what you are allergic (or what she's allergic to), and then her physician will have an appropriate recommendation. Obviously, if you know what you're allergic to and can avoid it, then do it. But, otherwise, there are some options. One is allergy shots. Another is asthma controller medicines such as Advair or Symbicort. Another great medicine for asthma and allergies is Singulair. I personally am taking Advair and it works wonders to control my asthma. And Singulair is actually the first medicine to really control my allergies. Yet, your daughter will want to work with her asthma doctor to determine which therapy regimine works best for her. The same for her children.

Your Question: What causes asthma more, running or allergies?

My Humble Answer: About 90% of asthmatics have exercise induced asthma, and about 75% of asthmatics have allergies.

Even so, I think every asthmatic is unique. So there really is no true answer to your question. And, with good control, most asthmatics should be able to live a normal life regardless of allergies or exercise induced asthma.

If you have any further questions email me, or Visit MyAsthmaCentral.com's" Q&A section.

Exercises all asthmatics can do

Time and again you'll hear asthma experts hailing that you need to exercise whether you have asthma or not. It makes your lungs and heart stronger, and gives you an overall better disposition of life. Yet there are exercises some asthmatics simply cannot do.

Some asthmatics, like many Winter Olympians during the 2010 Winter Olympicis, can exercise even under the coolest, and harshest conditions. Yet most of us need to pace ourselves in onw way or another.

That in mind, a recent post I wrote over at MyAsthmaCentral.com lists 7 exercises all asthmatics should be able to participate in, regardless of how bad your asthma is.

The Seven Best Exercises for Asthmatics

by Rick Frea, April 12, 2010, @MyAsthmaCentral.com

So you've come to grips you have asthma, and now you've decided to heed the advice of the "asthma experts" and get your body in shape. Now you're wondering, "What are the best exercises for people with asthma?"

Exercise is essential. Along with improving your health, the Mayo Clinic notes here that exercise also improves your mood, gives you more energy, helps you sleep better, and can be fun too.

If you have asthma, exercise is even more important. It strengthens your lung muscles, which improves lung function. It strengthens your heart which makes you less winded with exertion. Over time, the more you exercise the more tolerant your heart and lungs become to the effects of exertion.

However, it's tough sometimes for asthmatics to exercise. Since 80 percent of us also have exercise- induced asthma (EIA), sledding out in the cold, dry air can instigate a dreaded asthma attack and set you back. Cross country skiing and ice skating may pose similar problems.

And too often, strenuous exercise, like you get while rushing back and forth on the basketball court, hockey rink or soccer field, can trigger asthma. Sometimes during the high pollen season (which is just around the corner) exercising outdoors can also trigger asthma.

Still, by working with your doctor, and obtaining good asthma control, many asthmatics can do any exercise, anywhere and any time. For example, Olympians with EIA were able to participate in the cold weather Winter Olympics in Vancouver, which I wrote about here.

However, many of us have our limitations. We have to pick exercises that work best for people with asthma. So, listed here are seven exercises that all asthmatics can participate in?

1. Swimming: Way back in the 1980s I was told this was the best exercise for asthmatics. It's good because the air around pools is moist and warm, and less likely to trigger asthma. You also get a good amount of physical activity.

Since EIA is triggered after running for six or more minutes of continuous movement, you may want to try things that let you move in short bursts, such as:

2. Team sports: This would include activities such as Baseball, Football or Vollyball. You'll only need to run while the ball is in play, yet you can still get a good workout.

3. Martial Arts : This activity is generally done indoors, and the short movements are enough to get you in good shape, build muscle tone, and may also help you develop a sound mind and body.

4. Yoga : Another activity that is generally done indoors, and also helps to relax your mind.

5. Biking : If the weather is right, this is a great way to get in shape. You can also get a stationary bike for your home.

6. Walking : This is safe in any environment.

7. Jogging or running : I list this here tentatively. If you have controlled asthma, you should be able to do this as I noted above. Ideally, this should be done when the weather is warm, or on a treadmill. Pace yourself though. Pacing is key.

I wrote here how I am now able to run with asthma. I wrote here how even someone with Hardluck Asthma can finish a marathon.

8. Weight training: This is a good way to build strength, improve muscle tone, and lose weight. You can do simple workouts with a five pound dumbell, or you can do something like this intense Body-for-Life workout that I do.You'll get results regardless, although don't expect to look like Arnold, which these before and after pictures suggest. I work out in my own basement, but you can also join a club. For some more tips, you can check out this site.

I find if I go a long time without exercising my asthma gets worse. Of course anyone who's sedentary will get winded eventually, although I find this to be accentuated when you have asthma. So asthma kind of gives you an added incentive to start moving as I wrote about here.

So don't let the fact you have asthma stop you from exercising. Work with your doctor to gain control of your asthma, and then find an exercise program that works best for you.

Make a difference

The nice thing about America is that even stupid people get to vote. Even the stupid get to have an opinion or not have an opinion at all. In fact, even smart people can have an opinion or not have one at all. Yet, in the end, we all need to be careful what we do with our opinion.

One of my friends wore a McCain/Palin sticker to school during the last election cycle, and one student came up to her and said, "I'm voting for Obama."

"Why are you voting for Obama?" My friend said to the kid.

"Because my dad said he wanted to make a difference."

Of course some of you could turn this around and wear republican for President sticker on your coat, and you'd think the opposite. My point is the same.

I get tired of hearing people say "I want to make a difference."

I watched the Mrs. U.S.A. pageant once, and about half the women on stage said, "I want to make a difference."

Well, Hitler and Stalin both made a difference. They created fascist governments and social reform that many here in the U.S., even our own Presidents, were envious of until they learned what Hitler and Stalin were really up to.

FDR made a difference. Conservatives say that difference was to create a more socialistic America. Liberals say that difference was to create a more just society. Conservatives think the liberal view is stupid. Liberals think the Conservative view is stupid and should be shut up.

Many doctors believe in the hypoxic drive theory. I would say that 8 out of every 10 doctor who works at Shoreline Medical won't give a patient enough oxygen just based on that theory alone. Yet, I bet 8 of every 10 respiratory therapist have become aware, or will become aware, that the hypoxic drive theory is a hoax.

So are we RTs stupid, or are all those doctors stupid. Hitler had good intentions in that he wanted to create a more just society, and so did Stalin. FDR had the same good intentions, and so does Barack Obama when he decided to create his health care program. Although he probably thinks I'm stupid in that I call it stupid, yet that's beside the point.

George W. Bush had good intentions when he opted to call terrorists on their bid for war. Yet he was called stupid by many in the media and Washington, just like those who supported Bush called those who spoke out bad about the War were anti-American and, well, stupid.

So, what are good intentions then?. First of all, if you create a program or a policy or a belief based on good intentions, then you are assuming you have the right answers based on the facts. If you have the wrong answers, then you are doing something that will not benefit anyone. In this way, you are creating a stupid program or belief. Does that make you stupid?

Good intentions do not always create good results. As we saw with FDRs National Recovery Act and his high taxes (which were up to 80% on the upper class), which actually made the great depression last longer than any depression in the history of the U.S. He had good intentions just like Bush had good intentions when he took us to War with Iraq.

Doctors want to make a difference too, as did Dr. Marsha the other day. The patient was awake and alert and oriented and chomping at the bit to come off the ventilator. She passed her weaning screen with flying colors. Yet, because her heart rate spiked when the doctor came in to see her, the doctor decided to keep this poor patient on a vent for another day.

Too me this doctor's decision was stupid, because I believe the patient's heart rate spiked because she was pissed at the doctor and the nurse, and not because she was "failing the wean," as Dr. Marsha told me. Well, I actually KNOW the patient was pissed, because she told me so.

I begged the doctor to extubate the patient. The doctor said, "Rick! I am not extubating today!"

So am I stupid, or is she? One of us is.

My good intentions made me spend extra time with that patient to make her look good for the doctor so the doctor wouldn't make a "stupid" decision based on some "stupid" dogmatic protocol she has set in her head. Yet I failed the patient.

I wanted to get a job as an RT so that I could support myself and my family. I write because I want to make a difference. Although I don't just say, "I want to make a difference." I believe that making a difference is knowing that if you work hard and become good at what you do, making a difference will come naturally.

So when I hear a kid say, "I want to make a difference," I just think that if he keeps doing what he's doing he'll definitely make a difference. He might go home and throw a brick through a window and make a difference all right. Or he could become President some day and make a difference too, and if he's stupid it might not be good.

That's the neat thing about our country is you can vote for whomever you want, and you can believe in any theory, or you can do whatever you want. You do not need to have any measure of logic or intelligence or reasoning or goodness behind your decision either.

I come from the school of thought - or the hope -- that the best way to move forward as a nation or as an institution or whatever you're referring to, or to sustain the greatness, is a massively informed public. That is why I blog. And I bet I'm making a difference with one or two of you.

And, if we had a massively informed public, we would not have a nationalized health care program, and we wouldn't have all these entitlement programs that we can't afford, and that actually make health care more expensive, and add to unemployment.

If we had a massively informed public, people wouldn't do things just because "that's what my doctor said." Because they would reason.

I had a patient the other day who was going to a nursing home. I said, "Why are you going to the nursing home." She said, smiling, "Because my doctor said so."

You see, to me, that's not good reasoning. I get the same response when I ask the patient, "Why do you think you're getting a breathing treatment if you're not having trouble breathing?"

Do you ever twist reality in this way? Turn a question back on the patient. Make them think. Well, I did this, and my patient said, "Because my doctor says I need one."

To me that's not good reasoning. One of the reasons we have stupid doctor orders is because the public is not informed. One reason we have high health care prices is because the public is misinformed.

If we had a well informed public, politicians who ignore our Constitution and create laws telling you and I what we "have to do" for the better of society wouldn't have a chance. Also, misinformed doctors would be forced to better educate themselves, and politicians too.

As I wrote a while back, going to school does not make you smart. There are people in Washington who went to the best schools in the world, like Harvard or Yale, and they continue to create laws that are not the the benefit of you and me or America or our hospitals or whatever. So schools do not make smarts. What makes smarts is effort and logic and facts and the ability to listen, to read, and to understand facts.

Because for every one of you who are informed and enlightened and smart who "make a difference," remember: The ignorant can make a difference, too -- and when they do, it ain't good.

A report about day shift

So after working 10 years as a night shift RT I've finally graduated to days. I've now been on days for the past four months. It was actually a tough transition at first. It was hard getting used to all the people being around, and the LIGHT.

Yes, that's right, after working the graveyard shift pretty much on a regular basis since 1991, I feared the sunlight might make me melt. However, that has yet to happen. I'm still in tact.

When I started this blog I had the following in my banner: " I work solo nights and prefer it that way. The dragons are sleeping at night, if you know what I mean."

Ah, the dragons. You know who they are. They are the bosses who scream every time a dot isn't crossed or t dotted. They are the ones who are more concerned over paper work than saving lives. They, as you may know, are perhaps former RTs and RNs who have morphed into intractable dragons.

So now I work with the dragons. I wasn't sure how this would go, but I've learned as long as you say what they want to hear you're all right. So long as you understand their way of thinking, you're all right. You can question them, but you better watch your step or.... ROOOOAAAAAAAAAR!!!!!

Trust me when I say this, when you work for a small hospital, and every dime counts, the roar is a lot louder than it is at bigger hospitals, or hospitals that are merged. I know this because I work with RTs and RNs who have also worked at large hospitals.

So, now here's the big difference I've observed working days versus working nights. On nights, I grumbled and griped about doing useless breathing treatments. On nights, however, I worked by myself, and I had to do all the useless breathing treatments on the floors AND all the useless breathing treatments and EKGs and Holters and etc. in the emergency room and everywhere else in the hospital.

Thus, if I didn't have to do all the useless treatments, I might have a good night. So I was more likely to complain. Although, be it said, my complaining more or less came out in the form of humor as you can tell from this blog. "Allbetterol Anyone?"

On nights, when there are very few procedures, I didn't have anything to do and could just sit around and blog or gossip or whatever I wanted to do. And there were no bosses to tell me what to do. And, no matter how slow it got, I never lost hours because nobody wants to work nights.

On days things are different. On days, if it's slow, one of us goes home. So, since it's slow around here quite a bit lately, I've lost at least 8 hours a week. That's not good. So, I find that when I work days I actually want useless treatments.

I'll repeat that last sentence: On days I find that I actually get happy when a doctor orders a useless treatment. I want them because it means I will not have to be sent home. I will not lose hours.

On nights I didn't care how many patients there were. On days I want at least 10 patients so both of us day RTs can get our hours.

Other than that, all the expected changes have occurred in me. Yep, I'm not so exhausted every day. After about 1.5 months of being on days I started to feel like a different person. "Gosh," I said to my wife one morning, "Is this what it's like to feel normal."

So, now that I work days, I'm less grumpy (to be expected), am more wide awake, get much more sleep, don't complain (as much) about useless treatments (just tolerate them), have learned that the dragons are tolerable to work with (so long as you say and do what they want), and the light doesn't make me melt.

Mask or mouthpiece

I asked the 80 Year Old retired philosophy teacher patient if he wanted to take his breathing treatment with a mouthpiece or a mask.

He said, "Mouthpiece. I can use the mask to rob banks."

"That's a good business," I said.

He said, "I live a block from a bank, and the tunnel is halfway there."

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Word of the day: Colloquial: Conversational, common, casual, idiomatic, dialectical, vernacular; appropriate to, used in, or characteristic of spoken language or of writing that is used to create the effect of conversation; characteristic of informal spoken language or conversation.

Hospital workers use hospital abbreviations as though they were colloquial.

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How heart failure is treated

Heart failure is what happens when the heart becomes a weaker pump, and thus fluid backs up into the lungs and the rest of the body. Often the ankles become swelled, and breathing becomes difficult.

This can occur as a result of a variety of ailments from a heart attack to lung disease such as severe COPD. The good thing about heart disease is it can be managed, although it may entail some lifestyle changes, and managing some new medicines.

Heart failure may may refer to congested heart failure (CHF), which is when the left heart fails, or it may refer to left heart failure secondary to right heart failure.

Methods of improving heart function include anything that reduces afterload. This is anything that forces the heart to use a more forceful contraction, such as systemic hypertension, or pulmonary hypertension caused by pulmonary disease, or coronary artery disease. Another way to improve heart function are medicines that increase that make the heart a better pump.

Note that any blood used to decrease afterload must be titrated to make sure blood pressure is not decreased too much. Individual response to such medicines vary from person to person.

According to the American Heart Association, Medicines used to treat heart failure are:
1. Ace inhibitors: They are a type of vasodilator, which are medications that cause the blood vessels to expand, lowering blood pressure and reducing the heart's workload (reduce afterload). Medical billing employees in cardiac offices are familiar with these drug names.
Common brand names are: Capoten, Vasotec, Altace, Prinivil, Zestril, Accupril, Monopril, Lotensin, Univasc, Mavik, and Aceon

2. Diruetics: Diuretics are prescribed for almost all patients who have fluid buildup in the body and swelling in the tissues. A diuretic causes the kidneys to remove more sodium and water from the bloodstream than usual and convert it into urine. This actually reduced preload (the amount of fluid that arrives in the heart that it has to pump to the system), and thus helps to relieve the heart's workload, since there's less fluid to pump throughout the body. It also decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs. Different diuretics remove fluid at varied rates and through different methods. Diuretics are usually given in high doses when symptoms are more severe, and tapered off as as the patient gets better. Note here that diuretics make you pee (coffee isalso a diuretic, as you may have noticed you pee more after drinking several cups. Theophylline used to treat asthma and COPD is also a diuretic).

Of course your doctor will need to find a good balance of diuretics, as too much will cause your kidney's too pump out too many electrolytes such as potassium (see below), which isn't good either. Often times, a potassium supplement may me necessary.

Common brand names: Bumex and Lasix. Others include: Hydrodirul, Diuril, Aldactone, Dyrenium, Zaroxolyn, Lozol, Midamo and Dyazide

3. Vasodilators: Vasodilators cause the blood vessel walls to widen or relax, allowing blood to flow more easily. These are used for people who can't tolerate ACE inhibitors. Some, such as Nitro, are used in the emergency room to control angina (chest pain) due to cardiac disease or mycardial ischemia (heart attack).

Common brand names: Isordil, Apresoline, Loniten, Natrecor, nitroglycerin, nitropress (nitroprusside), Nitrogard (Nitroglycerin pills), Nitro-Bid (Nitroglycerin patch), Hydralazine,

4. Inatropic drugs: Increase the force of the heart's contractions, which can be beneficial in heart failure. This relieves heart failure symptoms, especially when the patient isn't responding to ACE inhibitors and diuretics. Most people continue taking the drug even after they feel well, to keep the heart working effectively.

In the hospital setting the nurse will often have to work to find the right dose of the inatropic drug to increase the force of the heart (to increase blood pressure) and the anit-hypertensive agent (like Nitroprusside) to maintain the target blood pressure.
It also slows certain types of irregular heartbeats (arrhythmia), such as atrial fibrillation. This is the rapid, irregular beating of the heart muscle that's present in some people with heart failure. When used by someone who has atrial fibrillation, digoxin prevents the ventricles (the lower, more powerful chambers of the heart) from beating too rapidly.

A patient on Digitalis will need to have his level checked often for dig toxicity, which will result in nausea, insomnia, vomiting, altered color vision, and irregular heart beat such as preventricular contractions (PVC). This shows up on the EKG as large t-waves.

Common brand names: Lanoxin (Digoxin), Dobutamine, amrinome

5. Beta blockers: The failing heart tries to compensate for its weakened pumping action by beating faster, which puts more strain on it. Beta blockers reduce the heart's tendency to beat faster. The drugs block specific receptors ("beta receptors") on the cells that make up the heart, reducing the effects of chemical messengers that increase heart rate. This allows the heart to maintain a slower rate and lowers blood pressure. Beta blockers are used for mild to moderate heart failure and often with other drugs such as diuretics, ACE inhibitors and digoxin.

Note: Beta blockers block the effects of beta adrenergic medicines such as Albuterol and Xopenex. They also can cause bronchodilation. So they should be used with caution in patients with COPD and asthma.

Common generic and brand names: carvedilol (Coreg), metoprolol (Lopressor & Toprol XL), atenolol (Tenormin), bisoprolol (Zebeta), labatelol, propranolol (Inderal), sotalol (Betapace), pindolol, penbutolol, acebutolol (Sectral), timolol (Blocadren), nadolol (Corgard), betaxolol (Kerlone).

6. Blood thinners: People with heart failure are at risk of developing blood clots, usually in the blood vessels of the legs, lungs and heart. The last type can occur in cases of a condition called atrial fibrillation, which happens when the heart's upper chambers (atria) contract rapidly and without coordination. This causes the blood to pool in the atria, where it can form clots. These clots can be carried into the blood vessels that supply the brain. If one gets stuck in a vessel, blood flow to the brain is cut off and a stroke results. Doctors prevent strokes by prescribing blood thinners for patients who have a history of clots in the lungs or legs, atrial fibrillation or stroke.

Common blood thinners: 1) heparin. It can only be taken by injection, and usually in the hospital 2) warfarin (Coumadin) It can be taken long term at home.

6. Angiotensin II Receptor Blockers (ARBs): ACE inhibitors, the cornerstone of heart failure drug therapy, prevent the formation of a chemical called angiotensin II. This chemical causes the small blood vessels to constrict, which raises blood pressure and places more stress on the heart. However, even when a patient is using an ACE inhibitor, some angiotensin II may still be formed. Rather than lowering levels of angiotensin II (as ACE inhibitors do), angiotensin II receptor blockers (ARBs) prevent this chemical from having any effects on the heart and blood vessels. This keeps blood pressure from rising.

Common meds available: Losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro), candesartan (Atacand), telmisartan (Micardis), leprosaria (Teveten), olmesartan.

7. Calcium Channel Blockers: Muscles of the heart and blood vessels need calcium to contract. Calcium channel blockers may be used to treat the high blood pressure often associated with heart failure. These drugs interfere with calcium's role in the contraction of these muscles, which causes the muscles to relax. This lowers blood pressure and can improve the blood circulation in the heart.

Common meds available: Amlodipine (Norvasc), Verapamil

8. Potassium: Potassium helps control heart rhythm and is essential for the normal work of the nervous system and muscles. It's important to have just the right amount of potassium in the body, especially for the heart. The kidneys control the amount of potassium in the bloodstream and eliminate any excess through the urine.

Since most diuretics remove potassium from the body, heart failure patients who use them are at risk of losing too much potassium. Some patients need to take potassium supplements or pills to compensate for the amount they're losing. Sometimes all they need to do is eat foods high in potassium, such as bananas. However, ACE inhibitors can cause the body to retain potassium, so this needs to be taken into account too.

The doctor will do blood tests to check on potassium level and kidney function. Kidney function can change over time in people with heart failure, which can result in potassium level changes. Patients should check with their doctors to determine their potassium needs.

8. Sedatives: These are used sometimes to reduce anxiety and agitation, and reduce autonomic (neurological) stimulation on the heart (prevent rapid heart rate and increased force and contractility of the heart due to outside stimulants, such as stress and anxiety).

Examples of this include morphine and Versed.

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Word of the day: Cognizant: To be aware, fully informed, or conscious
It's good to be cognizant of the latest wisdom.

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21 Virtues of Respiratory Therapy

So I wrote earlier about Ben Franklin's 13 Virtues to his success, and how he believed anyone who followed these virtues would be bound to successful lives. That in mind, I've created a list of 21 virtues to becoming a respiratory therapist.

The following virtues, or personality traits, are required of all respiratory therapists.:

1. empathy: You have to show some sort of understanding of what the pt is going through
2. priority: You have to be good at arranging tasks by priority
3. acceptance: you have to be able to accept that of which you have no control over
4. punctual: You have to pay strict attention to time, and never be late without good reason (yet you must never make excuses).
   
5. honesty: You have to prove to others that you can be trusted
6. transcendence : Going above and beyond the call of duty. Exceeding expectations
7. political: Know when to speak and when to keep quiet and bite your tongue
8. candid: You have to be open honest and straightforward with patients, doctors and nurses. This has to be balanced with political.
9. cooperation: You have to be able to work with a team to attain a greater purpose
10. perseverance: Regardless of setbacks you trudge forward, even if your boss or a doctor scolds you, you don't let that set you back
11. decisive: Coming to a quick resolution, answer or solution
12. Friendly: Get along well with people
13. Reliable: You are dependable to get your stuff done.
14. Confident: Knowing what you know and not hesitating to do it or say it
15. Competent: Being efficient at the few tasks you're expected to perform
16. Creative: Ability to fix equipment problems in unique ways
17. Insightful: Ability to see the unseen
18. Proactive: Ability to use unsightliness to solve a problem before it occurs
19. Observant: Ability to see what is obvious.
20. Communicator: Ability to share what you know, learn and think.
21. Listener: Ability to comprehend what other speak
22. Equanimity: You must be the calmest one in the room

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Word of the day: Pertinacious: Persistent, tenacious, unflagging and assiduous commitment; holding tenaciously to a purpose, course of action, or opinion

A pertinacious respiratory therapist is the one who gains the most respect.

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Q&A: I smoke and have asthma

Question: I smoke and have asthma. I wheeze after smoking, but the wheeze goes away. I rarely use my rescue inhaler when this happens. I was wondering how bad is this. Even in the morning I wheeze a little but after a while it goes away. Am I doing my lung more harm by not using the inhaler.

My humble answer: This is something you really should discuss with your physician. However, in my opinion, you really shouldn't use any medicine unless you absolutely need to. If you aren't feeling short of breath, and if the wheezes go away, there really should be no need to use a rescue inhaler like Albuterol.

The fact that you smoke, and have asthma, should be an added incentive for you to rush to quit smoking. Smoking is the #1 cause of severe asthma. However, if you stop smoking right now, you will stop any further damage, and your lungs will begin to heal.

I actually have plans to write more about this in an upcoming post, so stay tuned. In the meantime, I will link to one of the best brochures I have ever seen on this topic. It has some great information. To view it click here.

How good is your asthma doctor?

So how do you know your doctor is doing a good job. I provide some good tips in a recent post at MyAsthmaCentral.com.

Is Your Asthma Doctor Doing a good job?
by Rick Frea , Monday, March 22, 2010 @MyAsthmaCentral.com

How do you -- the asthma patient -- know if your asthma doctor is doing a good job? While there is no ideal way to compare doctors, there is a certain criteria you should expect your doctor to live up to. After all, you'll want to get the best care possible.

Even as a teenager I'd often wonder if my doctor was any good. I suspected he was a good doctor, but how was I to know?

Now, as a respiratory therapist who works with most of the doctors in my area, I know which ones are the best and, needless to say, I chose the best one for myself. Together we have forged a good patient/ doctor relationship.

That's the funny thing about medicine: we have a lot of faith in our doctors. We trust they are doing the right thing, yet how are we to know?

Well, one way is to keep up on your asthma wisdom which you are doing by hanging out here. With the advent of the Internet, and the recent emphasis by asthma experts on educating patients, I observe that patients are becoming wiser.

Still, how do you know your doctor is worth trusting? How do you know he or she is keeping up his or her end of the bargain?

One way you can tell if you have a good asthma doctor is that he or she answers your questions, and you don't leave an appointment unsatisfied. Yet, an even better way is by the questions your doctor asks you.

That in mind, in my review of the National Heart, Blood and Lung Institutes's Asthma Guidelines, I have found a list of questions you should be asked at every appointment:

• How has your asthma been the past two weeks?
• Have you missed any school or work since your last visit?
• Have you had any episodes of worsening asthma symptoms since your last visit? If yes, What do you think caused the worsening symptoms? What did you do to control the episode?
• How satisfied are you with your asthma care?
• How can we improve your asthma care?
• Do you have any concerns about your asthma action plan?
• How can we improve your asthma care?
• Have your asthma meds caused you any problems?
• Have you been compliant with your medicine regime?
• How many puffs of your bronchodilator (Albuterol) have you taken in the past two weeks?
• Do you feel your asthma is managed well on the meds you are presently on?
• What is the highest and lowest your peak flow has been the past two weeks?

The above questions were created based on the latest research that shows you better remember how your asthma has been the past two weeks, as opposed to, "Well, how has your asthma been the past year?"

That's a good point, considering I remember my doctor asking me how my asthma was the past year and me saying something along the lines of, "Um, well, I don't know."

"Well, did you get worse around spring? Were you worse in the fall?"

"Um, I don't know. Yeah, I was bad at times, but I don't remember exactly when."

Modern research proves that if a doctor wants to know how your asthma is doing in the spring, he should have you see him in the spring. If he wants to know how your asthma is doing in the fall, he should see you in the fall.

Likewise, missing school and taking more than the recommended puffs of your rescue inhaler can be signs your asthma is not well controlled. In this case, your doctor may need to alter your medicine regimen. He may also ask you the following:

• Please show me how you measure your peak flow
• When do you usually monitor your peak flow?
• Do you know your early and late signs of asthma?
• Do you feel confident with your asthma action plan?
• Please show me how you use your inhaler
• Have the costs of your asthma treatment interfered with your ability to get asthma care?

A good doctor is one who has you on all the best asthma medicines , makes sure you're being a gallant asthmatic , works with you on creating and adjusting an asthma action plan, reinforces what works, educates, listens, and knows the boundaries of his wisdom.

Well, you can't expect all asthma doctors to have patience, and to have good bedside manners -- although most do right? -- you should expect your doctor to fulfill his part of the asthma/ asthma patient team.

Of course there are all different types of asthma doctors , yet no matter what kind of doctor you have, you'll need to know he (or she) is one you can trust, and that he really, truly is doing a good job.