Superstitians & Scary Halloween

Do you have a people job? Say, you work for the police or in a hospital. The following things make people crazy, scary, and make you eerily busy:

1. Full moon
2. Friday the 13th
3. If you drop something and don't pick it up
4. Saying, "Quiet."

Confidence

One of the biggest problems with the country right now, in my humble opinion, is lack of confidence that results from lack of honesty. We, as Americans, don't know who we can trust and who we can't trust. This has resulted in this long lasting recession.

Think about it. From 2002 to about 2008 the economy was growing relatively fast, and revenues to the government nearly doubled during that time. And while we were in a housing bubble, confidence was high.

Yet trust in our leaders was dim according to most polls, with Bush's popularity dropping year to year to as low as the high 30s, and the popularity of congress as low as 10%. In fact, a recent poll shows that 70% of us would just like to vote an entire new Congress into office.

Once housing bubble burst, and it was learned Congress forced banks to give loans to people who couldn't afford them so they could have a piece of the American dream. And then as time went by we learned that (ahem) the people who couldn't afford housing in the beginning couldn't afford their home mortgage payments. Surprising?

So now people cannot trust banks, and banks cannot trust people. So loans don't get made. Banks also don't trust businesses. They don't know if they will be a viable business in a few years, and therefore they aren't worth the investment.

Likewise, businessmen don't trust the market. They don't know if taxes are going to go up or down, so they wait to purchase new equipment. They wait to invest. They wait to build new buildings. They wait to create new jobs. They don't hire because they don't trust the market.

Yet while we look at banks as the blame, sometimes we fail to look at the actual Congressmen who created the problem in the first place. Who were the politicians who decided it was a good idea to give our home loans to people we knew couldn't otherwise afford them. What were they thinking?

The biggest problem with our country is not the fact that there are no jobs, because the reason there are no jobs is because we have little honesty in Washington. And I'm not just talking about democrats who control the executive, Congress and the Senate. I'm talking about Republicans too. Which of these guys to we trust? Which of these guys to we dare vote fore on November 2.

Lack of honesty results in lack of confidence. Do you have confidence in your local bank? Do the banks have confidence in you? Will Congress create an economically sound environment where we have an incentive to invest and save? Are our taxes going to go up? How is the healthcare program going to effect us? Will I have to increase the amount of money I spend on benefits? If so, I better wait before I invest in anything. All this results in no jobs. No confidence.

Look, the problem with America right now is confidence. Many run on principles we believe in and we vote for these people, and then once they get elected they run out of the pages of the same people they ran against. They increase the scope of government, and then they use those new programs to buy votes.

George W. Bush ran as a conservative, yet he gave us a prescription drug program many of us didn't want, and Obama ran on the platform that he was going to fundamentally transform America, and he gave us a healthcare program that most people don't want.

Right now we have no confidence in our leaders that they will do the right thing. Conservatives, moderate republicans, moderate democrats, liberals and circus clowns and the peanut butter fairy party are all running for offices on November 2. We must decide who are the honest folks, and vote for them.

Yet who are they? How are we to know? How do we know who we vote for isn't going to become another insider politician like John McCain and Joseph Lieberman who will do whatever they have to do to win votes and get elected, even if they have to set aside their principles -- the same principles they used to get elected (or to try to get re-elected).

Are you really a conservative? Are you really a liberal? Are you really a constitutionalist? Are you really a socialist? How are we to know? We don't trust you. We have been lied to so many times we don't know who to trust.

Yet we must still vote. We must still stay informed. We must read. We must think. We must make an informed decision, and vote for the best person. If we really want to fix this nation, and to restore confidence, it's up to good people like you and me.

Vote!!!! Vote on November 2. Yet don't just vote so you can say you voted and so you can get a sticker that says, "I voted!" Do your research. Read, not just today, but through the course of the year. Stay informed.

The more informed we as Americans are, the more honest our politicians will be forced to be. So in that sense, you have it in you the power to improve this country. So go out on Tuesday November 2nd and vote.

Tips for working as solo night shift RT

Since I worked as the lone shift RT for longer than anyone in Shoreline history, it only makes sense that I set the guidelines.

So, the basic rules and tips for working alone on nights are:

• Shift starts, so don’t forget to punch in!
• First thing you should do is compare the treatment orders in the computer charting with what is on your RT Treatment sheet. You'll want to make sure all ordered treatments are on your sheet.
• Prioritizing is the key to working alone at night. Most urgent therapies must be done first – use common sense.
• Check printers for new orders every hour
• All new orders must be signed and dated
• New oxygen orders must be checked and started immediately
• New treatment orders must be completed within 1 hours
• Respond to ER pages within 5 minutes, or call ER with a good reason why you are unable
• For respiratory arrest, chart the following:
  o Airway management
  o If intubated, chart intubation
  o If on vent, chart vent start
  o If on BiPAP, chart BiPAP Start
  o Chart # of hours on vent or BiPAP
• Do oxygen rounds early
• Do Q-shift vent assessments early. This includes:
  o Breath sounds
  o Lip-line
  o Cuff pressure
• Chart oxygen rounds anytime after midnight
• Be prepared for a morning rush and try to have all your charting done before 4:00 a.m. This includes:
  o All floor treatments
  o All ER treatments
  o PRN treatments
  o Vent checks and suctioning
  o Vent assessments
  o File all EKGs
• QID treatments can be started anytime after midnight. So if the patient is awake take advantage of this
• Make sure any airway boxes used are restocked
• Make sure any dirty vents are cleaned and put together
• If needed, make ABG kits and neb kits
• Before you go home, double check that all therapies are charted and charted correctly with proper meds.It’s now 7:30 a.m.
• Shift ends, don’t forget to punch out!
• Have a good sleep

Is the Job of RT recession proof

(Note: The following post was written last spring when work was slow)

Here is a good article I found in the May, 2010, issue of AARC Times, "Is Your Job Recession Proof?" by Sam P. Giordano. One would think any job in the medical field would be recession proof, what with the continued need for medical care and all. You're always going to have sick people.

Yet where I work the patient load is excessively low, and has been so for quite some time. It's been so low lately that few in my department have been able to get all their hours. While mostly we have two RTs during the day and one at night, recently one day person has had to stay home, or the three of us have had to split the day into 8 hour segments.

Actually, it's so bad right now that one of the RTs who's supposed to work tomorrow is going to work in another department doing a one-on-one. It's right now to the point that some of us are starting to worry if our jobs are safe. Is it time, perhaps, to budget one less person during the day? If that happens, this RT would be back on nights, if he didn't get laid off.

Other hospitals in this region, including the larger hospitals, are also facing a decreasing patient load. I think there are viable reasons for it, as with the recession fewer people are having elective procedures. And, I bet, that many are staying home with chest pains and abdominal pains. One can only think that while it's slow now, all these people might just decide to crash all at once, and we'll go from excessively slow to swamped.

Yet that is yet to be seen. The unpredictability of the medical field is being felt right now.

Yet, as Giordano notes, there are a lot of people losing their jobs, and with losing their jobs their health care coverage. This, coupled with increasing technology that is increasingly more expensive, and increasing health care wages, makes the burden of management tougher. Every department is being asked to make cuts.

So, increased cost, and decreased demand results in less profit. How long can the current level be maintained? Giordano writes, "Many persons concerned about keeping their head above water financially forgo both necessary and elected health care interventions. More still stop seeing their physicians. These dynamics create a ripple effect, and that effect has hit many a health care provider or institutions that were already on thin ice (financially speaking) and caused them to make immediate and profound cuts in their expenditures."

Actually, Giordano notes that most RT Caves do a great job of cutting costs and being efficient, especially those with RT Driven protocols, and efforts to cut back on nosocomial infections, such as VAP (Ventilator Acquired Pneumonia) to decrease length of stay and cut costs. So we're doing good there. VAP rates here at Shoreline are ZERO, and have been there for over five years in a row.

Another thing he writes about that might help us RTs is helping the AARC push for a Medicare Part B initiative that will allow RTs to be employed outside the hospital by physicians. He writes, "This will create new job opportunities and permit us to be more accessible to our patients while avoiding an expensive emergency department or hospital admission in order to do so."

By RTs being in touch with patients in doctors offices, we will be better able to prepare them about their illness and help educate them how they can stay healthy and at home instead of in the emergency room and admitted in the hospital all the time. He writes that respiratory conditions are in the top seven reasons why patients are readmitted to hosiptals. RT being involved with these patients can only make it better for them, and us to.

Bottom line: "Indeed, the healthcare sector is not as badly bruised as the rest of our economy. However," he writes, "over the last several decades we've adopted more business-like practices, which is a good thing in most respects. Just like businesses do, we as employees must not only contribute to the bottom line and ensure the financial success of our employers, but we must document how we do it and look for new ways to expand our value while working with our patient."

So this is an even greater reason to continue being professional, not complaining, going out of your way to find new ways to benefit your department and thus your patients, to improve outcomes, and improve costs. In the end, you might be saving your own job.

(Note: It is no longer slow at work. As of right now most hospitals in this region of Michigan are busy. Yet how long will it last?)

How to become the Best Respiratory Therapist

So you are seeking a job as an RT, or you want to improve your RT skills. The May, 2010, issue of AARC Times, "3 things you can do now to tune up your career skills" is a great article with some great tips for those aspiring to improve their career skills.

Many of these things I've discussed before on this blog, although it's always worth repeating. Many of you have written to me about your concerns about lack of respect for RTs. Although I've noted before that respect is not determined by the profession, but by you, because you are representing the profession (More detail about this here).

All it takes is for one person in your department to be a complainer, or lazy, or to portray an unprofessional manner, and respect for your department, and even you, takes a hit.

So, that in mind, here are some highlights of the tips from the AARC times:

1. Do not have the nurse convey concerns to doctors. Address doctors directly and make sure you are prepared with all the information you will need to speak knowledgeably about the situation.

2. Review patient records before treating them. This is one of the most important things you can do, especially if you want to move beyond the role of simply task doer or button pusher.

3. Attend rounds. This will give you a chance to communicate with the health care team. If you don't have rounds where you work, hang out around the doctors you will communicate with, and share your concerns, and ask questions.

4. Assess the patient. Do a really good assessment of the patient. This is very important to advancing above the task just being a treatment giver. Be part of the team, and relay any concerns you might have. This way if a doctor asks you a question, you'll have an intelligent answer.

5. Know lab values: I actually added this here myself. It's important that you know more than just respiratory stuff. You should be able to see the big picture regarding the patient. What lab values represent kidney failure? What lab values represent or can be indicative of heart failure? What are the signs of sepsis? What are the signs of DIC? What are the signs my patient is at high risk for ARDS? What are the signs of an acute episode CHF? What are the early signs of an asthma attack? What are the signs that you should call the doctor? What are critical values? All of these are things I've covered on this blog at one point or another (except ARDS, and that's coming soon). Don't just be a button pusher, know the big picture. For a list of all the lab values RTs need to know, click here.

6. Work with others. Be a part of the team. Share your concerns. Again, learn the big picture and coordinate your wisdom. This is the best way of becoming more than just an RT. Share your wisdom with the patient, the nurses and the doctors.

7. Stay calm. Another one I added here. Nothing shows respect to others, and shows that you know what you are doing more, than calmness during a stressful moment. If you are prepared, if you know your stuff, you will have no problem being calm. This shows you have confidence and confidence, and you are capable of doing your job. This shows the rest of the team you know what you're doing and they don't have to worry about the tasks you are performing. You will take care of your end.

8. Stay educated. I added this one too. Know your stuff. Practice working with neonatal ventilators often, especially if you don't have bad babies at your hospital much. If you don't do this, your skills may get rusty, and you will have a greater chance of looking rusty during a stressful moment.

9. Have cheat sheets. This is another one I added. I provide many cheat sheets on this blog (click here). You probably have some from when you were a student. While you are required to remember everything in school, it's not possible in real life. Have a cheat sheet, look at it when you are called stat, and have yourself prepared. This will keep you looking cool in a stressful moment. It will also give you the ability to have equipment ready, such as appropriate ETT size, tidal volume, and impress the physician and nurses in the process with your wisdom.

10. Be productive. Professionals get the job done effectively and efficiently. This doesn't mean you knock out as many treatments as you can during your shift. It does mean you don't waste time on the job. Prioritize. Get your work done. Don't leave things for others to clean up. Don't be late, and if you are going to be late call for help. Volunteer to help others. Participate in departmental events. Volunteer to write policies and procedures. Come up with new innovations to help your department. Write cheat sheets. Write a blog. Write a departmental website.

11. Be on time. If you tell a patient or co-worker you will be somewhere or do something, don't be late. If you are going to be late, make sure you notify the person. Yes, you are going to be called stat sometimes. If so, send a co-worker to notify the patient, otherwise he will be waiting for you. Show up on time for work too. Don't call in sick unless you absolutely have to. Volunteer to pick up hours. Be the RT who is always willing to go out of the way to help out a co-worker or, and especially, the RT boss or whomever is doing the scheduling.

12. Don't complain. Another I added. I wrote about this extensively awhile back on this blog. There is nothing worse than an RT complainer. It's easy to become one in this field, but it's important that you do not. Avoid the complainers. Once you complain, you are telling more about yourself than the person you're complaining about.

13. Don't gossip! Stay away from those folks however hard it may be. You don't want to be known as "that" person.

14. Look for useful innovations: Everything in the RT Cave has the potential to be better than it is now. Nurture new ideas and turn them into a game plan to help your organization streamline operations. Keep your eyes pealed for new ideas. Email other RT Caves to see what they are doing, what protocols they have, and how the incorporated them. This is a good thing to do instead of complaining or gossipping. It shows others -- especially the boss -- that you care.

15. Read literature. Read appropriate material on the Internet and magazines. Read medical blogs. Stay up to date on new equipment, ventilators, ABG machines, diseases such as asthma, CHF, COPD, CF and such. There are always new ideas and research, so it's important you stay up to date. When you share your wisdom, you will show the boss and coworkers you are professional and care. When you find some useful wisdom, print it off and leave it for others to read on the bulletin board or other appropriate place.

16. Dress for success. How you look reflects the image of your department. This goes along with not complaining. What you do, how you look, can show a negative or positive image.

17. Be easy to approach. This is mine. Be appreciative. Tell nurses and doctors they did a good job. Smile. Be honest. Be happy. Be appropriately humorous. Be positive.

18. Don't defend yourself. This is mine. Even if you are right, don't defend yourself. If there's one thing that can make an RT look like an idiot is when he goes on the defense. If you were wrong, apologize and take appropriate corrective action. If you were not wrong, take the hit and move on.

19. Don't lie. There's actually no better way of showing professionalism than being one of those coworkers and employers everyone can trust.

20. Be a champion of change. Actually, RTs are adaptable by nature. We have evolved coolly through the ages and, hopefully, and with your help and advice, will continue to evolve this profession into an even better one. Change can be good. Embrace it.

21. Expand your comfort zone. Don't be afraid to change the way you do something just because this is the way you've always done it. Your way may not always be the best way.

22. Know your role. Know where RTs fit into the big picture. So long as you keep up on your wisdom, and know more than just RT stuff (explained above) you should do just fine here.

23. Commit to the process. Don't give half hearted effort. If you commit to doing something for the department, give 110%. If you give less, you are not saying a lot about yourself, and you're definitely not helping the department. Don't let the complainers set you back. Go above and beyond and finish what you commit to. Better yet, commit yourself!!

24. Have a vision: Identify an objective and commit to achieving it.

25. Discipline yourself: A vision is one thing; carrying out all the steps to reach it is another. Discipline means sticking with the plan until it is done.

26. Ignore the negative voice in your head. A very important one here. Don't get sidetracked by thoughts that you can't achieve your goal or that what you would like to do is not something an RT can do.

27. Find a way to succeed: Know your limits. If you have an idea, and you have a protocol, and you are not a good salesperson, find a person to complete the task for you. Delegate. Get the job done. Make your department better.

Yes, I expounded on what the authors noted in the article. Pretty much, I believe if you follow the advice in this post you should be well on your way to becoming a professional in the RT cave, becoming a role model, and creating a positive image not only of yourself, but of your RT Cave and the profession as a whole.

Actually, if you follow following you'll be just fine:

• Franklin's 13 virtues
• 13 virtues of parenting
• 21 virtues of respiratory therapy
• How to be the best at everything you do

20 vices that might hold RTs back

Earlier I wrote about the 21 Virtues of respiratory therapy. In this post I will list the traits that might cause one to fail as a respiratory therapist.

The following traits might hold a respiratory therapist back

1. Ambition: There aren't many career advancement opportunities available
2. Melancholy: A gloomy state of mind usually doesn't fit in well with the medical profession
3. Choleric: Very irritable personality; easily upset; irascible; easily angered; RTs need to be cool and calm in stressful situations and in working with other people (See equanimity in the link above)
4. Controlling: Having power over other people and decision making; RTs need to be open minded and willing to accept that of which they have no control over. They need to be willing to complete doctor's orders they do not necessarily agree with.
5. Dogmatic: To be set in your way is the antithesis to success in the hospital setting, which is constantly changing.
6. Uncompassionate: If you hold a grudge, or are reluctant to forgive, you have no place working with people.
7. Undisciplined: If you are unable to act in accordance with the rules, especially rules you disagree with, you will fail as an RT.
8. Unconfident: This trait can actually grow in time, yet if you don't have confidence in your skills, or if you don't grow confident, or have the potential to grow, you will have a hard time succeeding.
9. Incompetence: Practice makes perfect. If you are incapable of growing as an RT, you will likely not succeed.
10 Unfriendly: You can be gauche (look it up), and you don't have to be social, yet you must be able to get along with others.
11. Materialistic: If your goal is to have everything, you may be very disappointed working in any field that involves helping people, as the reward of helping people usually comes at the expense of income. I'm sorry, that's just the way it is (exceptions for those who advance their careers by promotion, or sacrifice many years to advancing their education)
12. Unsympathetic: If you lack empathy, you better choose another path.
13. Filthy: Hey, if you can't keep yourself clean... get outa here!
14. Lazy: You might be able to get hired, but if you lack effort you'll lose favor with other RTs fast.
15. Listless: If you lack energy, you won't excel here.
16. Excuses: It doesn't matter if you're right or wrong, when you're accused of something, just keep your mouth shut and you'll be all right.
17. Complainers: You can probably still succeed as an RT, yet your department as a whole will not benefit if you choose to find fault. Read more about complainers here.

Keep in mind here that anybody can work in the medical field. All personalities have something to add to the mix.

Respiratory Therapists: There when you need us

We are your respiratory therapists, a part of a well-respected patient care team at a hospital near you. We are the experts when it comes to the heart and lungs, and we are always at your side when you need us.

You’ll see us everywhere in the hospital from the emergency room to obstetrics, from the patient floors to recovery. We evaluate and treat all types of patients from the tiniest newborn whose lungs are not quite ready to the elderly whose lungs are diseased.

We treat patients with respiratory ailments from COPD and asthma when they are having trouble breathing, to patients with heart failure and pneumonia. We do everything we can to help them breathe better from giving breathing treatments to offering our professional advice to nurses and physicians.

We work with patients that aren’t having trouble breathing too, as you’ll see us with any patient who can’t get out of bed or has recently had surgery. We encourage them to take deep breaths. We do this to prevent them from getting illnesses like pneumonia.

We love to educate. We work with smokers on how they can quit. We work with our COPD, asthma, heart failure and pneumonia patients and teach them what they need to do to avoid needing us again. Yet we assure them if they ever have trouble we are right here when they need us.

The procedures we perform are from the simplest breathing treatment to managing the most complicated breathing equipment, such as ventilators that keep people alive when their lungs aren’t working or simply need a rest. Likewise, we provide emergency services to any patients having respiratory distress, heart attacks, strokes, shock or who are involved in personal injury accidents.

Along with the nurses and physician, we work hard to make sure the patient is comfortable and breathing easy during difficult times, and we educate family members so they’re always aware of what’s going on and have all their questions answered.

You’ll see us in the respiratory therapy department performing outpatient tests such as pulmonary function testing that help physicians diagnose lung diseases, and we do tests that help physicians diagnose and rule out heart problems such as EKGs, Holter Monitors and Cardiac Stress Testing. Wedraw ABGs (a poke in the wrist) to see how well the lungs are working. Some of us do other procedures too, such as EEGs to rule out neurological problems, and even EMGs too.

We are your respiratory therapists: there when you need us.

How to survive halloween with asthma

Are you ready for Halloween? I suppose if you have normal lungs all you have to do to get ready is purchase or make a Halloween costume. For those of us with a lung disease, the preparation is a bit more complicated and time consuming.

Heed, for here I provide my advice to asthmatics on how to survive halloween without losing control of your asthma.

10 Tips to Help Asthmatics Survive the Halloween Fright
by Rick Frea Wednesday, October 14, 2009 @ MyAsthmaCentral.com

You might not think of Halloween as a trigger for asthma, but it can be. From my own personal experience, I can think of no holiday worse on asthma than Halloween.

In fact, my asthma acted up just about every Halloween that I participated in Trick-or-Treating until I was 11-years-old, at which time I vowed never to do it again. This, as you may imagine, was not easy to do.

When I was 24, I forgot my vow and each Halloween from 1990 to 1993 I went to a Halloween costume party and ended up in the Emergency room on -- ahem -- Halloween night.

In retrospect I've learned that I am not allergic to Halloween, but things I did on that night put me face to face with some of my most frightful asthma triggers.

Thankfully, you don't have to learn the hard way as I did, as I have come up a list of 10 tips to help you or your asthmatic child enjoy the Halloween fun.

1. Do not use recycled costumes that were stored in a box all year long. My parents were bent on saving money and kept old Halloween costumes in a box in the basement. While rummaging through them I was exposed to dust mites, a major asthma trigger.

2. Wear costumes that are new or recently washed. You'll want to make sure the costume is allergen-free. If you have latex allergies, make sure there is no latex in your costume!

3. Do not wear masks. Halloween masks can be full of dust mites, and when you have them over your face you are inhaling those dust mites with each breath. There may also be other asthma triggers in the mask too. Avoid them.

4. Do not enter homes while trick-or-treating. You never know what asthma triggers might be in someone else's home, including pet dander, dust, cockroaches, mold and fumes, so it is best to simply stay out of them. Have your kids say "Trick-or-treat," knock on the door, and stay on the porch.

5. Avoid smoky homes. If smoke is pouring from the door as it opens for other trick-or-treaters, avoid it at all costs. The last thing you want your asthmatic child to do is breathe cigarette smoke.

6. Stay home if you have a cold. If you or your child is congested or coughing he is more susceptible to having asthma symptoms and exposure to asthma triggers can make it all the worse.

7. Avoid inclement weather. Fall has a tendency to bring in some nasty weather. Cold air and humidity can be asthma triggers, and light rain can stir up allergens that were previously lying on the ground, such as ragweed pollen and dust. So if you want to risk the elements, make sure you dress yourself and your child appropriately for the weather, or avoid going out altogther if it's bad enough.

8. Don't forget about food allergies. Thankfully I never had to worry about this one, but many asthmatics have allergies to food, which you can read about here. Make sure your child isn't eating something he's allergic too. Common food allergies include nuts, eggs and milk products. Only take food with labels on them so you know exactly what the ingredients are before your child touches or consumes them. Sorry, that means avoiding homemade treats, no matter how healthy (or indulgent) they look!
Gina Clowes of Allergy Moms has great tips for allergy-free trick or treating here.

9. No playing with hay. Kids and adults alike love to use hay to stuff clothes to make scary characters or scarecrows. Not only is hay an allergy trigger, it is a breeding ground for dust mites and molds.

10. Be a gallant asthmatic. Make sure you keep in touch with your asthma doctor, have an asthma action plan, and take all your asthma meds exactly as prescribed. This way if you're exposed to asthma triggers you will be better prepared to deal with it. For some more helpful tips on surviving the season check out this great post.

Basically, don't take your asthma -- or your child's asthma -- for granted. If you regard the tips above, this Halloween should be fun and asthma free.

We must all be receptive to change

Opinion is opinion, yet facts are facts. You can debate an opinion, yet you can't debate facts. Opinions may change. Facts never change. That seems simple enough. Right?

A theory is an opinion. A hypothesis is an educated guess. Still, a fact is a fact, and that cannot and will not change.

Examples:

Opinion: The earth is made of green cheese.

Fact: Upon landing on the moon, Jack Armstrong confirmed the moon was not made of cheese, but of sand and rock just like the earth.

Opinion: Global warming is real.

Fact: The jury is still out, so debate away.

Opinion: Giving epinephrine at a code might help restart the heart

Fact: There is no evidence epinephrine will restart the heart.

Opinion: A high amount of oxygen (say 100%) with positive pressure breaths might instigate a baby to take its first breath.

Fact: After extensive studies on the subject, scientists now believe positive pressure breaths alone will instigate a baby to take its first breath, and oxygen is actually detrimental even to term babies and should not be used.

Opinion: Reverse facing car seats are good for babies, but stupid for a 2-year-old child.

Fact: Study after study has proven that reverse facing car seats are the safest way to secure a child into a car.

Opinion: If you give a COPD retainer who is in no respiratory distress oxygen he will stop breathing. This is called the hypoxic drive theory.

Fact: The hypoxic drive theory as applied by many physicians is a myth, and the evidence proves it.

Opinion: All Conservatives are liars.

Fact: To say all conservatives are liars is a generalization made by some liberals. Some conservatives probably are liars.

Opinion: All liberals are liars

Fact: Once again: a generalization.

Opinion: Conservatives are stupid

Fact: Many conservatives have well thought out opinions based on facts based on their goals for the country. I've had many intelligent discussions with my conservative friends.

Opinion: Liberals are stupid

Fact: Many liberals have well thought out opinions based on facts that support their goals for the country. I've had many intelligent discussions with my liberal friends.

Opinion: The best way to give breaths to a non-breathing neonate is with an AMBU-bag.

Fact: The AMBU-bag has been linked to hyline membrane disease and barotrauma, and the Neopuff is now the recommended mode of ventilation of neonates.

Opinion: Bronchodilators treat pneunonia and pulmonary edema.

Fact: Bronchodilators do not treat inflammation in the alveoli and do not rid the lungs of unwanted fluid caused by a failing heart.

Another term to throw into this discussion is dogma. What is dogma? According to Dictionary.com, it's "a settled or established opinion, belief, or principle."

I believe it was Socrates way back in Ancient Greece who was sentenced to death by a trial of his own peers because he dared question members of higher rank in society that they claimed to know what they really did not know.

Yet, from time to time, new evidence comes forward to prove our opinions either right or wrong. Yet we humans have a natural instinct to defend our old views, or the views we simply made up based on feelings. Yet, in fact, we have a natural tendency to be dogmatic.

Science, if scientists do their job, should never be wrong so long as the scientific process is used. A theory is devised and it must be observed as opinion. Yet we all know that some theories are considered fact by many, i.e. global warming, hypoxic drive theory. While others treat a theory as a theory.

Yet, once a person, or an group of people (say, the National Medical Association for example) decides that a theory is indeed a fact (the hypoxic drive theory for example), the view becomes dogmatic and it's nearly impossible (if not completely impossible) to get it's members to change and accept new fact.

I was faced with this problem today. In fact, I'm faced with it every day when doctors order bronchodilator breathing treatments for non bronchospasm disorders. Yet today I was teaching a neonatal resuscitation class, and some doctors winced when I said, "New evidence suggests we not use 100% oxygen anymore. It's hazardous even to newborns."

One doctor said, "Well, at least that's what the book says."

That was his opinion. He could be right, but the evidence is not actually pointing in his favor. Still, if he so chooses, he may give a newborn 100% oxygen. Yet, if he were taking care of MY baby, I certainly wouldn't want him doing so.

Yet since most people are ignorant of medicine, and leave it up to their well respected physician to make the right decision, you can see where dogma might cause a problem. We trust and believe the experts thinking they are doing what is right, or telling us to do what is right and best.

So what if the so called "experts" are wrong?

Some doctors, however, were more than open to this new theory, and have noted they will be more leery with oxygenating babies in the future.

The same happened when I mentioned about the Neopuff. One doctor said, "I'm not using that thing! You can't even tell if you're giving breaths."

"You can use your stethoscope," I said.

"I just feel better bagging," he said.

"Well that's fine," I said. And it is fine. Although, once again, the facts obtained from recent studies don't point in his direction. Still, a study is just a study.

The hypoxic drive theory. Well, I've discussed this recently with our medical director, and there's no budging there. I provided him with article after article, and he stands firm on his dogmatic view.

I also discussed global warming with him. I told him that I am neither a believer nor a disbeliever, as the facts are not all in yet. "After all," I said, "it is just a theory. I certainly wouldn't ignore it. I certainly would want to try to come up with better ways of running cars and heating homes. But I see no point in ruining the economy with regulation after regulation based on a theory."

"Bla bla bla bla!" He got all upset with me. No, actually, he was pretty cool. Yet he was not going to give up his belief that global warming is a fact. It is a fact. Period. No way to talk him out of it. No fact. No opinion. Period.

That's fine. Maybe he's right. Yet that's the kind of view I think is scary, and is the exact reason we have such a partisan divide now in Washington. That's exactly the reason we have some doctors not oxygenating some patients who need oxygen. That's exactly why we have a partisan Obamacare.

It's also why some kid somewhere will develop cancer in about 20 years because he was bagged with 100% oxygen. Yet no one will know he was bagged with 100% oxygen, because that fact will be forgotten, and the medical records destroyed long ago.

All I ask is that people be open minded. We all have our dogmatic views, and we all have our opinions, yet we should all be open to change. We should all do our research, and, as new evidence comes in, we ought to think better and do better.

As a wise person once said: "We do the best we can with the wisdom of today, and as we learn better we do better."

Mask new indication for bronchodilator

Perhaps you guys are tired of me complaining about useless breathing treatments in the hospital, but it's a fact that must be dealt with. Like tonight I was called to give a breathing treatment on an elderly lady who was in no respiratory distress.

However, I noted that she was wearing a mask which she required to maintain her sats, and the doctor decided that since she was wearing a mask, SOMETHING MUST BE WRONG WITH HER LUNGS, MEANING A BRONCHODILATOR IS INDICATED.

So, with all due respect, I added this to my list of indications for bronchodilators, and you can link to it here, or non-indications for bronchodilator here.

Mouth to mouth not indicated for adult CPR

Way back in 1995 I learned that chest compressions during Basic Life Support (BLS) were all that was needed to get CO2 to exit the lungs and the 21% Fraction of Inspired oxygen that's in the air we breath to enter the lungs.

The constant banging on the chest causes the CO2 to sort of vibrate out of the body, and air to vibrate into the body. It works similar to high frequency ventilation. During normal living this wouldn't be comfortable, but in emergency situations it works.

Way back then we learned that chest compressions were all that was needed during CPR, and breaths were not indicated and even harmful.

Since then more and more evidence has come out confirming the idea that chest compressions alone are more beneficial to a patient who is in cardiopulmonary arrest than wasting your time putting your less than 21% Fraction of Inspired Oxygen (FiO2) that's in expired breaths into a person. 15% FiO2 is simply not that beneficial to the patient.

New evidence also supports that the negative recoil of the chest that you create during good chest compressions are enough to keep air flowing into the lungs, and CO2 out of the lungs. It's simply more evidence to support that mouth to mouth breathing is a waste of time.

Not only that , but mouth to mouth breathing is considered to be gross, and it's probably the #1 reason why some people don't do CPR. Plus trying to remember guidelines that recommend 2 breaths to 30 chest compressions for adults, and 1 breath to 15 compressions for two person CPR on children is way to confusing even for the well trained medical professional.

What is more important is that you keep the person's heart pumping. A person can stop breathing for minutes at a time, yet the heart never stops beating. So the best chance that person has is for you to keep the heart beating, preferably at 100 beats per minute.

The Red Cross has finally realized this by setting an initiative to teach people about hands only CPR by 2011 (article here). They now recommend hands only CPR outside the hospital setting.

I actually think this should say, "in the absence of advanced medical equipment." I say this because most hospitals don't have AMBU bags in every room, and there are times CPR must begin before one is available. In these cases, chest compressions should be given until such advanced medical equipment is available.

I don't think that just because we are "trained professionals" we should be expected to put our mouths over another person's mouth.

The American Heart Association (AHA) has updated its guidelines, although, in my opinion, they have yet to go far enough. As you can see by this post, the AHA has changed the sequence of doing CPR. While it previously recommended ABC (Airway-Breathing-Compressions) it now recommends CAB (Compressions-Airway-Breathing).

The new changes are recommended for all patients except for newborns. This is good, because for adults who suddenly become unresponsive, the heart is the cause, and this is why chest compressions are so important.

For babies who suddenly stop breathing the cause is more likely respiratory related, and in this instance breaths are important. So for newborn babies it's important to give breaths first, especially if the heart rate is less than 100. (In babies, the heart rate starts to go down when breathing is slowed down).

I like the Red Cross recommendation to do chest compressions only because it will get more people doing CPR, and makes the efforts more beneficial (although statistics of success are still minute). Yet the AHA still refuses to get rid of opening the Airway and giving Breaths. A true sign the old fogies making these guidelines are overly willing to hang on to old fallacies.

(Note: Breaths are still indicated if a respiratory problem is the cause of failure. A good example is near drownings).

So while our BLS instructor was spending loads of time making sure we were giving breaths correctly, I couldn't help but to think I was wasting my time. I even said so this time around. Yet she gave your typical, "I'm just teaching it as I was instructed." And I respect that: she is just doing as she's taught.

I have respect for that. Which is exactly the reason those old fogies at the AMH update their guidelines to get rid of un-oxygenated breaths during CPR in the absence of advanced medical equipment. It's simply pointless.

I was told during a recent Advanced Cardiac Life Support (ACLS) class a few years back taught by an AMH instructor that a board of 10 or so doctors sets and updates the guidelines every few years. And the last vote you had something like 8 of the 10 experts voting against giving breaths. Those two said something like, "Well, it only makes sense we should be giving breaths."

Sure it does. Yet the evidence shows these breaths are pointless and even detrimental. It's hard to keep your chest compression rhythm when you keep stopping to give breaths. Plus these recommendations that you give cycles of two breaths for each 30 compressions are too complicated. In real life it's impossible to do that. In real life we never do it like THEY recommended.

Way back in 2000 I had a patient whose heart stopped, and I did CPR with chest compressions only. My coworkers frowned at what I was doing, "Well, I'm not putting my mouth on that," I said, looking at the patient.

I simply pounded on the chest, and within a minute the CODE team had arrived with advanced medical equipment, an AMBU bag was used to give 100% oxygenated breaths, and the patient was shocked. Plus, believe it or not, the patient survived.

So it's time the AHA join the Red Cross by stopping the complicated recommendations in their guidelines that breaths should be given. It's time to go to chest compressions only when advanced medical equipment is not available.

Stop Smoking Aids

This is part 2 of a series by Tim Frymyer from over at Stopsmokinghelper.org. To view part 1 in this series, click here. To view part 2 in the series click here.

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Today I thought I would talk about the world of stop smoking aids. You know, it still amazes me that smoking retains such widespread popularity in the United States despite all the Surgeon Generals warnings and tobacco company lawsuits. Roughly a quarter of all Americans are still smoking. As we all know, in many parts of the United States, smoking is as part of the mainstream culture as baseball and apple pie.

Currently, there are many stop smoking aids, methods or products on the market. Everything from electric cigarettes to lasers. But when you get past the hype and look at the science of smoking cessation, you are left with a very stark reality, low success rates. Let's look at the most popular methods for smoking cessation.

The first category can be called non-pharmacologic means. This includes quitting cold turkey, behavior modification, and support groups/counseling. Quitting cold turkey, although the preferred method of quitting by most smokers, offers the lowest success rate at around 3-5%. People seem to quit smoking cold turkey everyday. There is something in our DNA that takes pride in the idea of quitting without any help. Quitting cold turkey also gives the person a chance to "test the waters" of cessation without anyone else knowing about it. So if they fail or relapse, then their ego doesn't have to take a hit.

In contrast though, group counseling and behavior modification has the highest success rate, right around 20%. However, there is often a stigma associated with counseling in our society and so very few smokers will choose this option, despite the relatively high quit rates. This route to becoming smoke-free is wrought with lots of exposure and many don't want to admit they need help or are simply not that serious about quitting yet. So as a result, if I may borrow a poker term, they don't go "all-in".

The second category would then be pharmacological interventions. Here is where you see nicotine replacement therapy (NRT), like nicotine gum, the patch, the nasal spray, etc. You'll also find Zyban and Chantix in this category.

The success rate found with nicotine replacement is about equal to what is found with Zyban, which is basically double that of quitting cold turkey, right around 7-10%. NRT comes in a variety of forms, some expensive and some cheap. Some require a physician script, while others are OTC. I had one smoker tell me that he thought NRT was horrible because it didn't cure him of his smoking habit. After further questioning, he explained that he just wanted to "try" something different from cold turkey which had also failed him. So I believe smokers have this perception that you first try cold turkey, then NRT, then the next method and so on and so forth until you eventually quit.

Zyban is an anti-depressant which not only shows some smoking cessation properties, but also can help to treat some of the underlying depression associated with smoking. If smoking were a disease, which many feel it is, depression would be a primary co-morbidity. For many, Zyban is a good option because of the psych treatment component.

Chantix is a pill which boasts a success rate above 20%. However, Chantix has been required by the FDA to place a warning label on each box dispensed. The label warns the consumer that some who take Chantix, have experienced erratic and bazaar behavior. Many who want to quit smoking may not be willing to take that chance, in spite of the potential upside in success. But Chantix also utilizes a "program" for smoking cessation. They don't look at it as simple a “magic bullet“, but rather a piece in a complex support system to help smokers quit. There are some who believe that it is the support and not the pill that provides the high success rate seen with Chantix. Remember, counseling has a very high success rate by itself. So regardless of the method used, the addition of a counselor or behavior program will greatly increase the likelihood of cessation.

There is one more pharma category that many people like to use and that is what I call the placebo method - this group wouldn't be classified as front line though. This is where someone takes a legitimate medication with a very real medical use but offers it up as a stop smoking aid in an "off-label" manner. In other words, they may take some benign medication used to dry up secretions, and market it as a stop smoking shot. The consumer then receives this medication thinking they are getting some new smoking cure. This idea is so powerful, it creates a very real placebo effect in their mind. You’ll also find the “natural smoking remedies” in this category too. Various herbs mixed together to form a cessation cocktail of sorts. Again, it’s not so much the product that counts, but the advertising. The buyer needs to really believe the product will work. The success rates for placebo is thought to be about equal to that of quitting cold turkey, as you would expect.

The final category is what I label as alternative methods. This sort of catch-all group is where you find hypnosis and acupuncture (both traditional and laser). These methods might have a basis in non-traditional science and certainly have helped people to stop smoking. But there is sometimes no rhyme or reason as to whether it will or will not work; which, I suppose, doesn't make them much different than any other method. Like placebo meds, there are no studied success rates with these methods and there are no clinical studies to quote statistics from. But most agree, the success is equal to that of quitting cold turkey.

After looking at these success rates, it becomes easy to see why smoking is still so prevalent. Too often people buy into a product or method because it offers them the magic bullet. But in the end, they're just not mentally prepared for the grind. So how do we improve our results then? Many researchers and experts agree that education and information is what smokers need. Only then can they connect the dots between behavior, treatment and commitment.

As therapists, we need to help our patients set realistic expectation and help them select the best stop smoking aid that suits their personality and addiction. Simply put, knowledge has to be the driving force. The better informed someone becomes, the more sound their expectations will be and the more success they'll have.

This is one reason why I created a literature-based stop smoking website. I wanted it to be a resource for RTs and other healthcare professionals so they could talk intelligently about smoking cessation with their patients. I have a stop smoking aids page on my site that is a great resource for anyone who wants more information on the subject.

Thanks again to Rick for allowing me to share this information.

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Related links:

• Stop Smoking Help
  
• Smoking cessation program
• Smoke and have asthma: here's 20 incentives to quit
• More good reasons to quit smoking
• Stop smoking in front of your kids. Period!
  

Where to listen to lung sounds

A question I get quite a bit by nursing and respiratory students is where to listen to lung sounds. I have also learned that nursing schools and RT schools may teach a different method, depending on the experience of the teacher.

In this post, however, I will teach you the ideal way to listen to lung sounds. Note, however, that it is up to you to find the method that works best for you. As with anything in the medical field, it's an art based on a science, and therefore the final decision is up to the individual.

I notice a lot of nurses and doctors will tell you to take in a deep breath for each place the stethoscope is placed on your back. While this is a good method of hearing adventitious lung sounds, it's not the best way to listen.

Here is how I do it.

First, I tell the patient to breathe normal. This way you will hear how the lungs sound with normal breathing. Now you take your stethoscope and place it over the right base of the lung on the back of the patient. Then you listen to the left base. Then the right middle lobe. Then the right upper lobe, and then the left upper lobe. All of this while the patient is taking normal breaths.

Basically, all you want to do here is see if the lung sounds are equal on each side and if the air movement is normal, increased, or decreased.

Normal air movement: This is where you hear airflow throughout the lungs fields. If the patient is short of breath and you hear normal air flow, you can surmise there is a low chance of it being due to bronchospasm. However, you still cannot rule bronchospasm out.

Diminished lungsounds: If all the lungfields are diminished, this is often indicative of bronchospasm, loss of lung elasticity (emphysema) or other diseases that diminish air flow such as cystic fibrosis or pulmonary fibrosis. If in one lobe, it may be indicative of something blocking airflow in that lobe, such as pneumonia or lung cancer.

Increased air movement: Usually you will only hear increased air movement over one lobe of the lungs, and usually in the bases. This is indicative of fluid in that lobe. Note here that sound travels better through water, and sounds louder. This may be a sign of possible pneumonia or pleural effusion.

Equal air movement: If the air flow is the same on both sides of the lungs this is good. If airflow is diminished on the right and normal on the left, then you know you have some disease process going on and it's up to you and the doctor to determine what it is.

Bronchospasm: This is best heard during normal laminar flow, and this is why you will want the patient to breath normal. If you hear wheezes during normal breathing, chances are increased that it might be bronchospasm.

All of this should be done in only a few short moments.

Second you will want to place the stethescope back on the right base and tell the patient to take in a deep breath. During a deep breath you will hear other adventitious lung sounds, such as a cardiac wheeze, crackles, rhonchi and rhales. Or, better yet, the air movement will be good with no adventitious sounds.

Here you will hear any fine crackles you missed when the patient was taking in a normal respiration (alveoli popping open). You will also be more likely to hear rhonchi or secretions that are rolling around. This is because the deep breath causes more turbulence and this may knock secretions around.

Likewise, these secretions, or other fluid, are likely to cause a wheeze that is not a bronchospasm wheeze. This is where you will here your cardiac wheeze or your wheeze due to secretions sitting on the vocal cords. These wheezes are often audible.

If you hear a wheeze, particularly one that is audible or present with good air movement, you should then proceed to listen to the throat. If you hear a wheeze in the throat you do not have bronchospasm, but a throat wheeze (stridor) that is radiating throughout the lungfields.

You can work your way up the patients back by the standard stethoscope spots as shown in the picture. Yet, ideally, when you are having a patient take in deep breaths, all you have to do is listen to the bases. That's where you'll hear your crackles.

Hence, if you hear crackles during normal respirations, chances are you'll hear them during deep inspirations. And, if you hear crackles during normal respirations, chances are what you are hearing is secretions or fluid as opposed to fine inspiratory crackles.

Third, once you have listened to all the lung fields you will want to listen to the throat. If you hear a wheeze in the throat you know the wheeze is not bronchospasm. More than likely it's secretions sitting on or near the vocal cords. This often occurs with cardiac patients, such as CHF.

Likewise, many times if you hear a wheeze throughout the lungfields and you have good throat wheeze.

Fourth, use common sense. While good airmovement and a throat wheeze may increase the chance it's caused by secretions or fluid, it does not always rule out bronchospasm. I have heard COPD patients and asthma patients with a throat wheeze and good air movement.

Like I said, the medical field is an art based on a science.

Check out my lung lexicon for more on the lung sounds, or check out this post on how to listen to lung sounds. To learn how to hear bronchospasm, click here.

Why take away CFC inhalers and primitine mist?

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: Albuterol used to work much better, however the new propellant system has rendered it nearly useless. This is one case where the concern over the use of CFCs has gone to extremes with negative results. How much could I be depleting the ozone layer when I exhale from my inhaler? Didn't most of it go into my lungs? So why mandate a formula change? The new Albuterol inhalers are a joke, the delivery system is terrible.

Also; what happened to the over the counter Primatene Mist inhalers and the generic versions? I am convinced that the availability of these has saved my life in the past. They are no longer available, banned in fact (apparently a victim of the war on drugs - kids using them to get high - although for some reason computer cleaner sprays and other inhalents are still on the market). I suppose only rich people with health insurance are allowed have inhalers.

Us poor folks are expected to die of asthma in the street. Thanks for forcing regulations on my Walgreens. You folks at the FDA are making the world a better place.

My humble Answer: The primitine mist inhalers were sort of grandfathered into being a legal over the counter (OTC) medicine, yet the FDA has been trying to get them off the shelves because the medicine in them -- epinepherine -- has been linked some bad side effects. So when Congress decided to "force" the phase out of CFC inhalers the FDA used this as an excuse to finally pull the plug on OTC primitine mist.

However, while I believe there are some advantages to HFA inhalers, which I discuss here, I agree with you that outlawing CFC inhalers was a bit of a stretch, taking away options from us asthmatics. I think the choice -- CFC or HFA propellant -- should have been left to the free market. Yet that's just me.

To be honest with you, I think Albuterol should be available OTC. How's that for a controversial statement?

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

Asthma medicines: now they are ranked

Kind of in the fashion of a fun sports column, I recently had a little fun ranking asthma medicines.

The Top 10 Asthma Medicines

By Rick Frea, Wednesday August 4, 2010, @ MyAsthmaCentral.com

It would be neat if asthma was like a sport. Instead of writing dry, humorless posts, we could write exciting and entertaining posts about our theories and herald new inventions like the new vaccine that's supposed to cure allergies.

Another thing sports writers do that's fun is make fake rankings like this. They have fun writing these, and we have fun reading them. So I thought, for the fun of it, to rank 10 asthma medicines from worst to best (in my humble opinion of course).

So with sports on our minds, let's have a little fun with ranking common asthma medicines. How do your meds stack up?

10. Non-steroidal anti-inflammatory drugs (NSAIDS). Sorry to say it, but this one time classic team, which included Cromolyn and Tilade, has served its purpose and now finds its way in the trash heap of no-longer-used asthma medicines. If you find yourself on these medicines still, chances are you have been, or will soon be, forced to try more modern medicines. You may even find out the newer medicines allow you for even better asthma control.

9. Long-acting Beta Adrenergic (LABA): Powered by Serevent and Formoterol, these inhalers help asthmatics control bronchospasm long term and were one time top prospects in the asthma medicine farm system. Yet things just never panned out for LABAs, as most studies show while these inhalers treat the symptoms, they don't control the underlying chronic inflammation present in most asthmatic lungs. So asthma experts now contend if you need this medicine, you best be getting it in conjunction with an inhaled corticosteroid. Or, better yet, you should check out #1 on this list.

8. Oral steroids: Yes, prednisone and solumedrol hit homeruns in those desperate situations when you need to gain control of inflammation in your lungs. Yet, due to side effects, these meds are best avoided unless you really need them. The best way to avoid this team is by obtaining and maintaining good asthma control, which is best achieved by being compliant with meds one to three on this list.

7. Oral Bronchodilators: Fifteen years ago this was #2 on this list. It was a powerhouse team led by Theophylline that lead many asthmatics to improved asthma control. Yet now its usefulness has pretty much run out, and the old veteran was forced to retire. It was a great bronchodilator in its day, but the risks and side effects are far greater than newer medicines used to control asthma.

6. Immunomodulator: Here we have the latest trend in asthma medicines -- the young prospect like Xolair -- the IgE inhibitors. This is an expensive and one time injection that works to prevent asthma symptoms when you're exposed to your asthma triggers. This is basically only used for those with severe asthma not controlled with other meds on this list. Yet for some, I bet this medicine may be their #1 asthma medicines. Until further studies show better results, we had better subdue our expectations, hence the low ranking.

5. Xopenex: This Albuterol copycat was once believed to be stronger and have fewer side effects than Albuterol; yet new studies question that wisdom. Yes, it's now available in inhaler format, yet the added benefit to cost ratio may not make this medicine worth it (at least for the time being).

4. Albuterol: Ah, so you thought I'd rank this classic asthma medicine #1. After all, it's helped many an asthmatic breathe better on the spot. Perhaps that would have been the case, say, ten years ago. Today, however, chances are if you need this medicine often, your asthma is not under control. Every asthmatic should have this medicine on hand, yet it should be needed seldom. So there.

3. Inhaled Corticosteroids: This team is chock full of talent. We have Flovent, QVAR, Asthmanex and Pulmicort as the big boys hitting in the middle of the lineup, followed by some older veterans that appear to be mostly washed up. Use of one of these inhalers is the best proven method of treating chronic inflammation in your airways. Yet new research shows that if these don't work, #1 on this list may be better options.

2. Leukotriene modifiers: This team is closing in on the top spot, and includes some top hitters, such as Singulair and Accolate. This medicine works well on it's own for some patients by blocking the allergic response and controlling inflammation. Yet often it's used in conjunction with, ahem, the #1 asthma medicine on this list. Until I started taking this medicine spring hay fever season was miserable. Not anymore. For this reason alone, I have to rank this team near the top.

1. Combination inhalers: Ah, a rare leader at the top. The combination of Flovent and Serevent in one inhaler called Advair, and Formoterol and Pulmicort in another called Symbicort, creates a lineup like no other in the history of asthma medicine. Too many people are scared away from these meds because of FDA warnings and poor education. Yet I contend, and so does every study I've seen, that these combination inhalers greatly improve asthma control in most asthmatics that use them. If you have poorly controlled asthma, this team may be a big hit for you too.

With new wisdom, and the asthma and allergy genes isolated, newer medicines are just around the corner. In fact, just the other day we scouted the Lebron James of asthma medicine, the allergy vaccine that might just cure allergies.

For now it's in the farm system getting tested. So stay tuned: these power rankings may be set to change real soon.

Is cancer caused by modern way of life?

Cancer is a disease that is expected to cause 171,000 deaths in 2010 alone, and 1, 529,560 new cases are expected to be discovered, with an overall cost of $263 billion. As RTs we take care of many patients with cancer, and as humans just about all of us know of at least one person with some form of cancer. Yet new evidence shows that we humans might be the cause of our own cancers.

According to Fiona Macrae, "Cancer 'is purely man-made' say scientists after finding almost no trace of disease in Egyptian mummies," at dailymail.co.uk, scientists have been thinking this way for many years. Yet a new study of Egyptian mummies showed only one case of cancer out of all those studies.

According to the article:

Michael Zimmerman, a visiting professor at Manchester University, said: 'In an ancient society lacking surgical intervention, evidence of cancer should remain in all cases.

'The virtual absence of malignancies in mummies must be interpreted as indicating their rarity in antiquity, indicating that cancer-causing factors are limited to societies affected by modern industrialisation.'

The study went by the belief that tumors would be better preserved than normal human tissue, and would be present in mummies if they were present at the time of death.

However, researchers were also aware that Egyptians might not have lived long enough to develop age-related diseases such as cancer. However, there was evidence of other age related diseases, such as hardening of arteries and brittle bones.

Yet Egyptian texts do mention cancer as a possibly caused by leprosy or varicose veins. So we know it was still occurring in ancient times, yet not as much as it is today.

Samples of Netherland bones also showed up only one case where cancer was evident.

I wrote a while back (click here)how lung cancer rates were very low until people started becoming addicted to cigarette smoke during WWI. I wrote here how as the number of people becoming addicted to cigarette smoke rose, so to did the lung cancer rate rise. And as those who smoke is on the decline, so is the lung cancer rate.

So there is clear evidence that most cancers are caused by humans, although not all.

Possible carcinogens may include the following:

1. Radiation
2. Cigarette smoke
3. Asbestos
4. Hepatitis B Virus
5. Hepatitis C Virus
6. Solar radiation
7. Formaldehyde
8. Pesticides: Used to control bugs and vermin
   
9. Paradichlorobenzene: Found in toilet bowl cleaners
10. Perchloroethylene: Found in dry cleaning fluid, spot removers, and carpet cleaners.
11. Smog: The air we breath, especially in cities
12. Deoderant
13. Soap
14. Hair spray
15. Laundry detergent
16. Hotdogs with nitrates in them (such as Oscar Myer)
    
17. Zodiac Flea Collars
18. Carpets with petrolatum based chemicals

For more carcinogens click here.

For more information about cancer, with statistics, click here.

I also should mention here that modern society and improved technology has also improved the quality of human life, and has increased the human lifespan from near 35-45 at the beginning of the 20th century, to about 80 years today.

Macrae concludes her article by writing:

Dr Rachel Thompson, of World Cancer Research Fund, said: Scientists now say a healthy diet, regular physical activity and maintaining a healthy weight can prevent about a third of the most common cancers so perhaps our ancestors’ lifestyle reduced their risk from cancer.'

Of course we can't live in a bubble, yet we can be aware of what we put in our bodies, and we should do a better job of eating well and exercising regularly. Or, as my grandpa used to say, "Anything in moderation."

Vitamin E shown to reduce risk of COPD

Of all the patients we RTs care for in the hospital setting, a majority are COPD patients. That's not a coincidence, as in the year 2000 it was responsible for the deaths of 2.74 million people, and by the year 2020 the World Health Organization predicts COPD to be the leading cause of death in the World.

While smoking is a leading cause of COPD, many are being diagnosed with this disease, or asthma, due to the high amounts of air pollution, both man made and natural occurring. So while the number of people who smoke is declining, the number of those being diagnosed with some type of COPD is still increasing.

Yet new research shows that "supplementing" your diet with Vitamin E may reduce your risk of developing COPD or of your COPD worsening with time. In fact, a recent randomly controlled study showed this reduction was as much as 10%.

This article from NaturalNews.com, notes that it's not easy to get enough Vitamin E from our normal diet, so taking a Vitamin E supplement is essential. Likewise, the post notes you can get Vitamin E from the following food sources:

• Almonds
• Apples
• Broccoli
• Carrots
• Kiwi
• Peanuts
• Spinach
• Sunflower Seeds
• Vegetable and Seed/Nut Oils (sunflower oil, almond oil, olive oil, palm oil, peanut oil, etc.)

Vitamin E is essential to our bodies because free radicals get into our bodies via cigarette smoke and pollution in the air, such as "burning fuels in smokestacks, car exhaust pipes or house chimneys or from the formation of ground level ozone during hot weather," according to fellow asthma expert. Kathi MacNaughton in her post, "Are We at Risk From Free Radicals in Our Air?"

A free radical is any electron that has a single unpaired electron in its outer shell, and when it gets into our body it does whatever it needs to do to get what it needs. This can often result in disease formation in the human body, such as asthma or COPD.

Kathi notes our bodies don't have a defense mechanism against free radicals. Although antioxidents are known to interact safely with free radicals and "stop their action before vital cells are damaged." And, she notes a major source of antioxidents is vitamin E, C and beta carotene.

So while this new wisdom is still in the study phase, if you have a family history of lung disease, you may want to think about supplementing your diet with vitamin E.

An interview with myself

To commemorate the third anniversary of the Respiratory Therapy Cave, I recently sat down with myself in the comfy confines of my own mind and interviewed myself.

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(begin transcript)

Me: I'm honored to have this opportunity to interview you. I just want to start out by saying thanks for my allowing this time, and to congratulate you on three wonderful year at the RT Cave, as it was three years ago today you posted your first blog entry, The Beeper."

Myself: Wow! I completely forgot about that post.

Me: What were you thinking as you were writing it?

Myself: I was thinking, 'What am I going to write about? How am I going to come up with an idea every day.'

Me: How has your blog changed since that day?

Myself: Great question. I think back then I thought I was going to be writing about what I did every day on the job as a respiratory therapist. Since then it's evolved into a lot more than that.

Me: Like...

Myself: There's not enough excitement at a small town hospital to keep a blog afloat. And then there is this HIPPA thing. I can't write about certain cases I'd like to write about because being a small town it would be easy to trace back to who I was writing about. So out of respect for others I have to restrain myself. Plus I want to keep my job.

Me: Have you ever written anything you decided you can't publish but wish you could?

Myself: Yes. Real exciting cases only happen in a blue moon here at Shoreline Medical. Once I wrote about my experience taking care of a man who was shot in the chest... The premise of the post was not so much that we were doing CPR and such, but about the conversations that took place while this was going on, and how we discovered on our own what had probably happened. It was a great post idea, I thought. Yet after I wrote it I decided better of it.

Me: If you worked in Detroit where there's a murder every day you could probably get away with it.

Myself: Exactly. I have written many posts I simply cannot publish. Common sense aside, HIPPA had this unintended consequence of making people afraid to share information about patients, which is bad in that it stifles learning.

Me: I see.

Myself: Yet it also comes down to respect for people. I refuse to write what might come back to hurt someone, even if it would be a big hit on my blog. A part of being an RT is prioritizing, and part of being an RT blogger is also prioritizing. People come first. Plus I love my job and would like to keep it. So due respect is justified.

Me: Working for a small hospital, though, don't you have to be more well rounded as an RT. Didn't you say something about that once?

Myself: Yeah. I would say that's true. While 90% of our patients might be adults, we still have to be proficient at taking care of pediatrics and neonates. It's not like you can just become proficient in one population or one type of patient. RTs at small town hospitals have to KNOW IT ALL.

Me: So isn't that why you started this blog?

Myself: In a way I started this blog before I started this blog. I was simplifying complicated material for myself and my coworkers for several years before I started writing here. I started by working with my coworker Jane Sage on creating a cheat sheet for how to set up a vent on neonates. We don't set vents up on newborns very often, so when it does happen we need to know what to do, and we need to be cool and calm. That cheat sheet comes in handy.

Me: So you created a bunch of cheatsheats to make life less stressful for RTs in your department.

Myself: Yes. I created a bunch of RT cheatsheets. My coworkers and I also created some cool RT humor. I have since published both on the RT Cave. So the purpose of this blog is to have a little fun while sharing RT wisdom.

Me: What's the greatest challenge of writing at the RT Cave?

Myself: The greatest challenge is making sure I don't repeat what everyone else is doing. I want to make sure I write about facts, yet I have a personal, unique touch to all my posts -- or at least most of them. Or at least I try. I want people to know they are getting facts, and they are getting my honest opinions too. Wit and Wisdom.

Me: And what about...

Myself: Also I think I like to do on this blog is simplify complicated things. I mean, for new RTs, you can have a heart attack just trying to make sense of ABGs to the point just the thought of ABGs can give you the ABGBs.

Me: (laughter) Yeah. And that's the other unique touch you have, is the ability to find humor in something as dry as respiratory therapy.

Myself: Someone asked my coworker once what is the best part about doctors, and he said, 'Doctor's orders.' Then my coworker was asked what he liked least about doctors, and he said, 'Doctors orders.'

Me: (laughter)

Myself: Now he wasn't intending to be rude by any means, just stating the fact that doctor's orders save lives -- doctors save lives. Yet most of the time doctors write orders simply based on habit, or just to cover their bases, or just to make the patient think they are doing something, or just to make sure the patient meets intensity of service. Then since doctors are so well respected, few question them.

Myself: That's something you touch on a lot on your blog, is wasted medical care. You say that's what drives up the cost of healthcare.

Me: Yep. If more patients asked questions, doctors would be held up to accountability. What makes matters worse is government intensity of service and...

Me: Can you remind us what intensity of service is?

Myself: That's where the patient is sick enough to be admitted. Usually, Medicare will automatically view someone as sick enough if an IV is ordered, and that's why IVs are put in every patient who even goes to the Emergency room. I mean think about it, when do you ever get an IV put in you if you go to the doctor's office?

Me: Never.

Myself: When have you ever gotten an x-ray because you went to your doctor's office because you have nasal congestion and a cold and just wanted an antibiotic?

Me: Never.

Myself: That's because you don't need an IV most of the time. Yet if you have insurance, and you go to the emergency room because you have a simple cold, you're going to get labs drawn and you're going to get an IV, and you're going to get an x-ray. All those things aren't needed, yet the government or your HMO is going to have to pay for all those things. And then if you get admitted, you're going to have neuro checks every four hours, because neuro checks are one of the biggest indications -- according to the government anyway -- that a person needs to be in the hospital. Now you may not need neuro checks, but if you get them Uncle Sam says you probably needed to be admitted. So it's neuro checks on anyone.

Me: Do you think that's the biggest rip off in the health care industry?

Myself: It could be. Yet if people are admitted to the hospital and they have insurance, then the insurance company, or the government if they have Medicare or Medicaid, gets to pay a discounted price, which may be a 50% discount. They pay a flat fee regardless of how many services are rendered. Yet if you don't have insurance, you have to pay the full price, and pay the full price for every procedure. You don't get to pay a discounted flat fee. To me that's the biggest rip off.

Me: You make a good point.

Myself: Basically intensity of service is an excuse for hospitals to justify wasteful medicine, and offer unfair costs to people without insurance. I have a posts coming up about all these issues, so you'll hear more about this soon.

Me: You mentioned earlier that healthcare costs would be lower if the patient questioned doctor's orders more often instead of letting the doctor do whatever he or she wanted. How would questioning doctor's orders lower the cost of medicine? How can this be achieved?

Myself: It can be achieved by getting rid of the third payer. Since people don't see the bill, they never question a doctor. Say you had to pay your own bill, and your doctor ordered a breathing treatment on you. That treatment costs $100 a pop. You came into the ER for a cut on your foot. Would you not question whether that treatment was needed?

Me: I would.

Myself: Since most people don't pay for their own medicine, they just let the doctor do whatever. This increases demand. When demand for a product goes up, and the supply stays the same, the price goes up. So, demand for breathing treatments is high, and there's only so many RTs and so much Ventolin to go around. That means the price of a treatment will be high.

Me: So you mean if people paid for their own medicine the price would be low.

Myself: Right. Welfare had this same effect on the price of medicine. While it provides free or discounted medicine to the elderly and poor, it makes medicine cost more for everyone else. If you have to pay a co-pay, even $1, for medicine, you will be more likely to question, "Do I really need to go to the doctor for this cold?" Or, "Do I really need this, or do I really need that." Yet if medical care is free, then you'll be more likely to say, "It's free. I might as well just go see the doctor." So if you give away something for free, people flock to get it.

Me: And since many doctor's offices don't accept welfare, these people flock to emergency rooms with things that are not emergent. And since laws prohibit emergency rooms from turning patients away, this results in overcrowded ERs with long waiting lines.

Myself: Exactly. So then you have people waiting in the ER for three or four hours, and they are irate that they had to wait so long, yet they are the exact reason the wait is so long. If they really needed an ER, they wouldn't need to wait for four hours. People who really need an ER, real emergencies, get seen right away. If you have a heart attack, you aren't going to have to wait for four hours. Think about it. The next time you have to wait in an ER for four hours, chances are you could have gone to your doctor. If you have a wart
on your penis you've had for four years, you're going to have to wait, because in the ER we have to prioritize. We have to take care of real emergencies first.

Me: So lack of questioning on the part of patients, third party
payers, and even welfare, Medicaid and Medicare, have made it so medicine costs more, and results in overcrowded emergency rooms.

Myself: The price of medicine was low enough people could afford their own medicine until the 1960s when government got involved in medicine, and HMOs were started. It's my opinion anyway. Sure it's more complicated than that, and sure I could be wrong. I'm always open to any opinions here.

Me: No opinion is wrong, a wise man once said.

Myself: Yeah, but some say the opinions of common folks don't matter, that experts in Washington know what's best for us. You believe people are smart, and each individual should and is capable of deciding what's best for him or her self.

Me: We'll...

Myself: Well, let the readers decide what they think. That's what it's all about here at the RT Cave. Let the people decide. It's about thinking. It's about critical thinking.

Me: So do you...

Myself: I'm not saying we need to make all Americans fend for themselves either. I'm just saying that I think all the tinkering we've done with the Healthcare system has contributed to the unfordability of healthcare. I think we have gone in the wrong direction. I think we have the best healthcare system in the world, and according to polls so do most people. Yet when we open up a newspaper we read that we have one of the worse healthcare systems in the world. In this sense, the powers that be want to scare us into believing we need more government control of it all. Yet most of us don't want that. And that's why I think the recent healthcare reform package is so unpopular.

Me: Ah, I actually have a question about that healthcare reform bill -- Obamacare. But first, I want to talk about bronchodilator reform. You mentioned earlier about stupid doctor orders, and you often write about bronchodilator reform. What got you started on that tear?

Myself: Actually, that got started because I do have asthma, and I know when a person should have a breathing treatment because I know when I need one. And I know that nobody needs a Ventolin breathing treatment when they aren't short-of-breath, and I know nobody needs a Ventolin treatment when they are sound asleep in the middle of the night, and I know nobody needs a Ventolin treatment when they never have and still don't have respiratory distress. Yet due to ignorance we give any patient with a lung disease or annoying lung sounds on bronchodilators every 4 hours round the clock for the entire month they are admitted. It's poppycock. It's wasteful spending. It's a waste of resources, of your respiratory therapist's time. It's a perfect example of what's wrong with the medical field.

Me: Ah, so I got you going on that one. I don't want to spend any more time on bronchodilator reform.

Myself: Yeah. I've written about it ad nauseum.

Me: Yet since you mention wasteful spending, and to get back to what we were talking about a moment ago, what do you think of the healthcare reform package?

Myself: All I want to say about that is that too many people believe it's better to do something than to do nothing at all. One of my co-workers said that once at a meeting I attended, and I said, "It's better to do nothing than to do something stupid."

Me: What did you mean by that?

Myself: Well, once you make a law, or a new policy, it's nearly impossible to get rid of it if it's stupid and doesn't work. Yet if you try to make due with what you have, and try to make what works work better and to get rid of what doesn't work, that to me is the best strategy. A perfect example here is when Warren G. Harding died and Calvin Coolidge became President during a recession. Coolidge said he believed in holding back and shutting out. He conducted his official life according to his own version of the doctor's Hippocratic Oath -- first do no harm. It sounded easy, and many mocked Coolidge as being lazy in office -- the same people who made fun of him by calling him Silent Cal. And Coolidge's 'no harm' rule came out of strength of character. By holding back, Coolidge believed he sustained stability, so that citizens knew what to expect from their government. And, by holding back he allowed the country the opportunity to solve it's own problems.

Me: I see what you're saying.

Myself: If health care reform works, great. Yet if it doesn't, we're stuck with it forever. The same can be said of any time you add a new policy or order sheet or whatever in the hospital. If you're going to add something, you better be damn sure you know what you're doing. You better make sure you've tested it all the way through. And sometimes the best way to solve a problem is simply by keeping what you have right now and seeing if you can fix that first.

Me: So are you saying you aren't for breathing treatment protocols?

Myself: Treatment protocols, or RT Consults, or whatever you want to call them have been proven again and again to work. They improve the moral of RTs because RTs get to do what they are trained to do. And it makes a doctor's work easier because they don't have to be paged 20 times during the night. It makes the patient's life better because they can get what they need right when they need it. It makes the people paying the bills happy because it gets rid of frivolous procedures being done.

Me: So basically protocols allow for the medical professional at the bedside to decide what's best for the patient based on the patient's needs at that moment, rather than some doctor sitting in an office three miles away. It localizes health care.

Myself: Exactly. All problems are better solved locally. If you have pot hole in the road in front of your house. You can fix it by filling it in with dirt and be done with it. The cost will be very little. Yet if you have to wait for Washington to fix that hole, they will have to prioritize it, study it to make sure it needs to be fixed, and then what to do to fix it will have to be filtered through the bureaucratic system. When -- if -- it is ever fixed it will be a long time, and it will cost a ton more than if you fixed it yourself -- locally.

Me: Yet you wrote recently that the keystone project and core values make it so there might be a little overkill, but they work. You wrote that the pneumonia order sheet calls for Ventolin to be ordered every six hours, and while the treatment may not be needed, at least the RT is in the room every six hours assessing that patient. Did you not say that?

Myself: Well, yes I did. The keystone project injects what has been proven to work into the system. The Keystone Project and core values (an upcoming post) are based on things that have been scientifically proven to benefit a patient given a certain illness. Now I'm never a fan of doing something that is not needed, and that's where protocols come into play.

Me: So you still like protocols?

Myself: Man, I'm a protocol fan all the way. A doctor orders whatever he wants, yet it's up to the RT to decide if it's needed. It's not that RTs are smarter than doctors. I'm not saying that at all, because doctors know a whole lot more about fixing patients than we RTs. What I am saying is that we RTs, and RNs, are trained and skilled in taking care of patients at the bedside. Let us use our skills. Let us do what we are trained to do. And then, if the doctor so wants, he always has the right to overrule the RT at any time. That, to me, is the best policy. It's kind of a checks and balance system.

Me: I see.

Myself: Either that or you order scrubbin bubble therapy on everyone.

Me: (laughter) For... For (laughter) For those readers who aren't familiar... What is scrubbin bubble therapy.

Myself: Well, you know, many doctors think the ventolin particles act like that bathroom cleaner scubbing bubbles, and the ventolin particles get down into the lungs and sud up, and then they act like sponges and scrubbers and scrub out lung cancer, pneumonia, pulmonary embolisms and whatever happens to be in the lungs that doctors don't want.

Me: (laughter)

Myself: It also prevents bronchospasm. It makes a patient cough. It makes a patient stop coughing. It hydrates the lungs. It dehydrates the lungs. Basically, some doctors believe they can push whatever button they want and the Ventolin will do whatever they want. Or, to put it simply, all that wheezes is treated as asthma. It's that simple. That replaces thinking and common sense.

Mt: Interesting. Let me change the subject

Myself: Good.

Me: What to you think of overly critical doctors?

Myself: I think the more critical you are the less likely someone will want to talk to you.

Me: And that's bad how?

Myself: Well, say I know you're going to be rude to me if I call you at 2 in the morning because I have a concern about the patient. Say the patient has a very low blood pressure. Do you think it's better if I call the doctor, or that I don't call because I'm afraid the doctor will say something like, "So why are you calling me at 2 in the morning with this?"

Me: I see your point.

Myself: Doctors that are overly critical, as well as anyone who is overly critical, are basically telling other people they are useless dummies and don't want you thinking. Yet you have to think, because human beings think. And critical thinking is essential for good patient care. As nurses and RTs, we are at the patient's bedside, and we are taught to be proactive. Since we are at the bedside and the doctor is not, it's our jobs to do what's best for the patient. If we're concerned about a patient, we should call the doctor. And a good doctor doesn't have to be happy about getting a call at 2 in the morning, but if he's going to be grumpy and rude and cynical and overly critical, then he should get another job.

Me: True

Myself: It must be noted that most doctors aren't that way, thankfully.

Me: So are there any other types of doctors that aren't good in the hospital setting.

Myself: Any doctor is good for the hospital setting. Doctors are great. We could never function without doctors. Yet I also think the best doctors are those who appreciate the experts at the bedside -- the nurses and the RTs. I don't like any arrogant, all knowing doctors. Yet, if you are nice -- a downright pleasant doctor, chances are I'll like you even if I don't think you're the best doctor. Pleasantness goes a long way toward likability. I can get along with any doctor, or any co-worker who is nice.

Me: That makes sense.

Myself: I think it's easier to be rude when you're not working side by side with someone all night long. I think ER doctors who are right there with the nurses and RTs are more likely to be pleasant
than a doctor who gets a call at 2 in the morning. The ER doctor has to work with that person, and wants to maintain a good rapport. The further you get from the person, the further removed from the situation, the greater the likelihood your rudeness will stick out.

Me: Good point.

Myself: Thanks. Yet, allow me to add, even a doctor with poor bedside manners, and even a rude, irritable, intractable, ruthless, and arrogant doctor with the worse bedside manners can be a great doctor and good for your institution. In real life, you get all personalities. So sometimes we RTs and RNs and patients to some degree simply have to put up with a personality flaw because the doctor is so dog gone good at what he does.

Me: I know you're a busy person. With that son of yours striking out 17 of the 18 batters that got out the other night, and with those two girl's pretty eyes and vibrant personalities, it shows you spend more time with those kids than you do writing. You have your priorities straight. So I know you're busy, and I'd hate to take up any more of your valuable time. So just a few more questions.

Myself: Shoot.

Me: What's the most common diagnosis you see?

Myself: Pneumonia. I think it's the most common diagnosis because it provides to best reimbursement. The funny thing is that many times it's ordered, and I look at the chart, and I see no evidence of pneumonia. The x-ray is normal, labs are normal, yet here's a patient taking up space in a bed with no pneumonia. How's that for good medical service. Yet that's what the government has forced on us. They encourage doctors to lie.

Me: Do you ever lie?

Myself: I think sometimes you have to. I mean, if a patient asks me why he's getting a breathing treatment I don't think he even needs, it's sometimes easier to simply say: because it will help you breathe better. Yet I know I'm lying. Yet I also know that's why the doctor ordered it. It's idiocy, yet to keep my job I have to lie.

Me: Did you ever lie to benefit a patient? I mean, did you ever give Ventolin to a patient that wasn't ordered?

Myself: Consider the doctor who believes that every asthma patient should get three treatments 1 hour apart. Yet as an asthmatic yourself, you know the patient could better benefit from a back to back treatment. Would you slip in the extra ventolin and not tell the doctor?

Me: Are you pleading the fifth here?

Myself: If you had a CF patient ordered on Q4 breathing treatments and, when that first treatment was finished he said, "Can I have another treatment?" Would you not throw in another amp into the nebulizer?

Me: Have you?

Myself: I'm not saying I have, I'm just posing the question. It would be a great topic for an ethics class, hey?

Me: It would. You ever get caught in a lie?

Myself: Not really. Yet I did tell the truth once to a patient, that he didn't need the treatment, and then it came back to my boss what I said, and that when that patient told the next RT that I said the treatment wasn't needed, that this information put that RT on the spot. My boss told me then that I had to tell the patient the reason the doctor ordered the treatment, which, ahem, is based on either a lie or idiocy. So, in a way, I got caught telling the truth and was punished for it. Ironic, isn't it?

Me: That is pretty funny.

Myself: It's not funny. It's a perfect example of how bass ackwards the medical industry is sometimes, or too often. We are encouraged to lie. We are encouraged to do what we know is wasteful, and then to lie to the patient that it's needed.

Me: What's your favorite part about blogging.

Myself: Sharing facts. Creating humor.

Me: Why did you start blogging?

Myself: To share facts. To tell what it's really like being an RT.

Me: When will you have enough blogging?

Myself: When every bronchodilator loving doctor has conformed to the idea that all that causes annoying lung sounds does not benefit from a bronchodilator.

Me: Do you ever get hate email?

Myself: It's funny you say that. I get lots of emails from people telling me they love what I do. That motivates me to keep doing this. Yet from time to time I get someone who emails me and says something like, "I hate your opinion. Because you wrote that I'm never reading your blog again."

Me: Wow! That's harsh. Does it bother you? Does it slow you down?

Myself: No. It has no effect on me, because whether people like or don't like what I write is not why I write. I write to entertain myself first. I write because I love to write. I love doing this. I don't do it for money because there's no money in this. D don't do it for praise. I do it because I love it.

Me: So you think it's good to put your opinion in a blog, even if that will mean you will get fewer people reading your blog?

Myself: I think if I didn't put my opinion in my blog posts there would be no point to this blog. I think all blogs should be opinion orientated. In fact, I read the blog advice of a person once who said he made $1,000 a month on his blog. He said you can put your opinion in your blog all you want, and people will still read it. That's true, he said, so long as your blog has a useful purpose, and in his case he gave advice to bloggers on how to better their blogs. In my case, it's RT wit and wisdom.

Me: Where do you see the RT Cave in five years?

Myself: I see the RT cave making me a million dollars a day. (laughter)

Me: (laughter) If that happened, then we could quit our day job. (laughter)

Myself: (laughter) Sure thing. Then we wouldn't be able to continue blogging, would we?

Me: Probably not. But we still would. Writing is in my blood and I'm not very good at writing novels and short stories. So for now it's asthma and RT.

Myself: That's about it. Have a good day. Here's to another three years of RT Cave Success.

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