MCAT Question #43

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

You are a surgeon and you performed an outpatient procedure on Jane Patient. During the procedure the anesthesiologist gives 1800cc of fluid to hydrate the patient.  Two hours after the surgery the patient is AAOX3 and ready to go home.  But the nurse calls you saying the patient's SPO2 is only 84% on room air.  On 2lpm her SpO2 is 90%.  You order for RT to do an ABG on room air that shows the following results:  pH 7.33, CO2 33, PO2 50.  You order an EKG and an x-ray.  The EKG shows normal and the x-ray shows new onset infiltrates in the bases.  Which of the following would be the most appropriate next action?

• a.  Think fluid overload and order 40mg of Furosimide followed by an ABG 30 minutes later
• b.  Think cardiac and order a second EKG
• c.  Think bronchospasm and order 2.5mg of Albuterol nebulizer followed by an ABG 30 minutes later
• d.  Send the patient home.  She's fine.  

Why do I do this blog solo?

A random person emailed the following question:

I'm an avid reader and always will.  But I have a question:  Why do you do your blog solo?  It would appear to me if you had more guest bloggers, if you did more interviews, your blog would be more credible.  I'm not saying your blog is not credible, but I am saying it would be better.  What do you think?

This is kind of an interesting question, but a good friend of mine, a friend I will not name, asked me a similar question:  "Why do you do your blog solo?  Why don't you have more guests writers on your blog?"

I do have guest writers on this blog.  At one time I tried to get a bunch of respiratory therapists to submit posts on a regular basis on this blog.  Yet then I decided this is my blog. People come here because they want to know what I think.

So I decided I'm no longer going to allow guest writers on my blog unless something I think is important and beyond the scope of my knowledge needs to be written about.  Yet more often than not, I make myself an expert on such topics.  I report on it and give my opinion.  That's what people want in a blog: an opinion.  More often, they want an opinion they agree with.

Generally, this blog is a marketplace where ignorance is reported on.  I write about all the myths of the medical industry as they pertain to respiratory therapy.  If I simply came on here and championed for breathing treatments and justified all of them based on breathing treatments are good for all lung ailments, my blog would have few readers. I'd simply be rehashing the myths most doctors and nurses and RT bosses already believe.

The reason I go solo is because I'm the world's foremost authority on respiratory therapy. I read all the studies, I read all the peer reviewed material (and I think my blog is peer reviewed), and then I tell you what you think about it.  If it's good material I say that.  If it's poppycock I say that.  Generally, I don't write anything new.  

What I don't know I research until I am an expert.  I never guess.  I never make stuff up. I never write an opinion because that's the safe opinion, or because it's the accepted opinion.  I never or rarely tell you what a doctor will tell you, because doctors have to play it safe due to liabilities.  Because I'm a writer not a doctor, I can write the truth.  I can tell you a breathing treatment is a waste of time for pneumonia, while a doctor has to order it because that's what they were taught in medical school.  For liability reasons, they have to do what everyone else does; what's accepted practice.  

I do read and listen to information that pours in every day.  Yet when it comes to my opinions, I ask nobody what they think.  I'm not big on interviews because I don't care what anybody else thinks.  That's why I don't have guests.  Really.  Why pussyfoot around that.  People have asked me oftentimes, "Why don't you have guests on your blog?"  Well, there's a whole bunch of format  reasons.  One is, everybody else does.  There's no way to be different.  But, secondly, I'd rather find out myself and become the expert rather than turn it over to people plugging this and plugging that.  

You know, behave and conduct a blog according to formula.  And then I finally one day, in a shocking realization, I admitted to myself, I don't care what anybody else thinks.  It's not gonna change my mind.

It's work to sit here and ask people questions that I don't care about.  I'm not much for small talk.  I'm not gonna subject myself to that.  That turns this into a job.  But I'm gonna make a departure from that this week.  This week I asked you a question, let you write the blog post.  I want to know what you think of.  You can email me by clicking on the "contact me" icon in the right hand column.

You must be prepared to give a short -- and you can say you have no idea.  That's fine, too.  You can say you don't know.  You can say what you hope.  No, I know what you hope.  So don't give me that.  I know what you're saying.  I know what you're thinking, "What are you asking us for, Rick? You are the master at reading the tea leaves.

No I'm not the master of anything.  I'm not even a good respiratory therapist.  I know respiratory therapy better than most people, but that doesn't mean I'm good at it.  I might be, but I can't judge myself.  I can only judge other people, and I don't even like to do that.  I don't like small talk.  I don't like to talk.

So how the heck do I come up with ideas to blog about?  Well, I do that by observing and by thinking.  I do it the same way my readers come up with the same ideas I've already written about.  In this way we are all smart if we think outside the box instead of inside it.  If we think inside the box we're just going to continue making the same mistakes over and over again.  And I know my readers know what I mean when I say that.

The best opinions come from thinking outside the box, and that's what I want from you.  So email me with your opinions.  Let me know what you think.  Be honest.  The topic this week is healthcare reform.  I know most of you are hot on this topic, and you know what I mean by that to.  So you don't have to be an activist to email me, all you have to do is care.


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What do you think of the Obamacare ruling?

Since the Supreme Court Ruled today on Obamacare, your humble blogger here finds himself in a state of......?  Well, I guess it doesn't matter how he feels.  Today I want to know how YOU feel.  I'm going to let YOU write the post.  Please email me with YOUR thoughts on the Obamacare ruling.  You can email me by clicking on the "Contact me" tab to the right.  Please do not leave a comment, for my comments section is broken.  We'll share thoughts tomorrow and have a nice discussion in this arena of ideas.  Thanks  Rick.


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How will Supreme Court rule on Obamacare?

Many people are asking me how I think the Supreme Court will rule on Obamacare.  My answer every time is that I cannot and do not make predictions.  I do not even like to write about things that have yet to happen, yet I am making an exception here because of all the questions and the importance of this issue.

The democrats in the House and Congress, and the President, believe Obamacare is necessary.  They believe a mandate to force every American to buy health insurance is necessary.  They believe the young and healthy should pay more for their health insurance to take the burden off the sick and elderly who canot pay as much, if at all.  They believe Insurance companies should accept people with pre-existing conditions.  They believe all of this stuff is needed, even if it's not Constitutional. Yet they beleive it is Constitutional. Either that or they don't care, as some people contend.

I'm not telling you how I think on this issue.  If you want to know what I think you can go back and read some of my archives.  I'm just writing here what other people say.  The democrates believe it's constitutional because of the commerce clause.  They believe people need healthcare, it's commerce, and therefore it can be regulated.  They believe everyone will need healthcare at some point, so they should all "pay their fair share."

Republicans believe the whole thing is unconstitutional because the 10th ammendment states that anything not mentioned in this here Constitution is left to the states and the people to decide.  They believe that no matter if Obamacare is needed, or wanted, or whatever, that it doesn't matter because it's unconstitutional.  They believe that no matter what the opinion is of the Supreme Court justices they should rule that it is unconstitutional becasue that is their job -- to rule based on the laws that exist on the books, with the U.S. Constitution beging the supreme law of the land; the superior law.

I would like to note here that what makes the U.S. Constitution so great, what made it last this long, what makes our Constitution older than any other, is that it does not tell the government what it can do, it tells the government what it can't do.  It limits the scope of government.  It prevents the government from making any law that takes away our natural rights.  So if Obamacare does that, if it takes away our natural rights, it should be ruled unconstitutional and shot down.

Some, those opposed to Obamacare, say it does take away natural rights.  They say that it will take away our right to choose where we buy something.  It will force you to buy something if you want to be an American.  It will force health insurance companies to accept people with pre-existing conditions even though that would be the equivelent of a farmer buying a barn full of dead cows: it would cause him to go out of business.  Some say Obama and the democrats want insurance companies to go out of business becasue then people would beg for a solution, i.e. a single payer government run healthcare system. 

Most of the opinions, the guesses, I've read say at a minimum the Court will shoot down the part that forces people to buy healthcare -- the individual mandate.  Yet if this happens, it may have to shoot down the rest of the law because without forcing healthy young people to buy healthcare and subsidize those who can't pay, there's no way to offset the cost of forcing health insurance companies to accept patients with pre-existing conditions.

So it's a complicated task set upon the Supreme Court Justices.  It's a task I wouldn't want to take up. Regardless, most Americans, according to Scott Rasmussen, as many as 54%, would like to see the law repealed.  An Associated Press poll shows that if the bill is shot down 77% want Congress and the President to work on a new healthcare bill.  The Supreme Court may shoot it down, by a 5-4 vote, and simply tell Congress to start over if it wants healthcare reform; to start over and obide by the Constitution.

Regardless, the U.S. Supreme Court is expected to make the much anticipated ruling today.  So by sunset tonight we'll be discussing the possible repercussions of whatever ruling is made.

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Pulm. fibrosis patients can tolerate low PO2s

So recently we had an end stage pulmonary fibrosis patient in respiratory distress and with an SpO2 of 77.  The blood gas revealed a PO2 of 47, and it was determined by the respiratory therapist that this patient needed oxygen or she was going to die.

Her doctor wrote an order to never exceed 4lpm by nasal cannula.  This meant that my hands were tied, and there was nothing I could do without calling the doctor.  So I did, and he said, "Draw an ABG and call me with the results."

It should be noted here the patient was a DNR patient and was a hospice patient.  Yet by no means are those abbreviations indications for not treating the patient. 

So I called the doctor back with the results, and he said, "Good.  I'm satisfied with those numbers."

Why was he satisfied with these numbers?  Every ounce of common wisdom in my head told me this patient needed oxygen.  My coworkers thought the same. 

 An RT student of mine took up the task of writing a report on this patient.  She discussed it with her RT teacher, who said, "So if a hospice patient had a pillow over his head, does that mean you don't make an effort to remove the pillow?"

The student later approached the patient's doctor to get an explaination of why he decided a PO2 of 77 was adequate for this patient.

The doctor said, "We are not trying to cure the patient.  We just want to make her comfortable."

To me that was an unsatisfactory answer.  It reminded me once again of the pillow analogy.  Yet I explained to the student that in medicine there are usually more than one option for one situation, and in many cases both options are correct.  The doctor is not necessarily wrong here, it's more that we RTs would give her oxygen.

My initial thought was he didn't want to oxygenate because the patient smoked 30 years ago.  I thought perhaps he was afraid more oxygen would cause her to stop breathing.  Yet during previous visits she was on an NRB for several days and never stopped breathing. 

So I discussed this with the sagatious Jane Sage.  She provides us with the following explaination for the doctor's behavior:

Most people with end stage pulmonary fibrosis are used to a low oxygen level.  In fact, it may surprise you to learn that pulmonary fibrosis is not an oxygenation problem.  Most of these patients are used to running around with PO2s in the 40s and even 30s.  Their oxygen levels dropped gradually so such PO2s are normal for them.  If you or me had a PO2 that low we'd be in severe respiratory distress.

Yet since their PO2 levels dropped so gradually, their bodies produced lots of extra red blood cells to search for more oxygen.  So checking a sat on these patients isn't even going to do any good.  With so many RBCs, there's going to be many hemoglobin molecules that are not carrying an oxygen molecule.  It will be normal for an SpO2 to be in the 80s, or even 70s.  That's nothing to panic about with these patients.

Yes oxygen might make these patients more comfortable, and personally I'd oxygenate this patient.  I hope this helps.  Jane Sage.

Thanks Jane.  Once again we appreciate your wisdom.

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Deflatolin

Symptom:  High Blood pressure, wet?

Diagnosis:  High Blood pressure, possible pulmonary edema

Frequency:  Maintenence dose and then Q6

Effect:  Albuterol works to deflate the lung to decrease blood pressure.  Medicine should be maintained in teh system with a series of Q6 hour treatments. 

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ASID-uterol

Symptoms:  Shortness of breath, rapid deep breathing,

Diagnosis:  Metabolic Acidosis

Frequency:  Q4

Effect:  All metabolic acidosis conditions must be treated with ASID (Albuterol Solves Increment Disorders).

What did you do prior to becoming an RT?

The interesting thing about the profession of RT is few enter this field right out of high school.  Usually people work hard in another career before jumping into this one.  So, that said, what were you before you became an RT? 

Usually poeple choose the profession of RT because the one they are in now is too arduous, dangerous, and doesn't pay well.  So they switch to this one.  They appreciate the ups and downs of this profession because we work in air conditioning, work with wonderful people, are guaranteed a job, and can take the job anywhere.  It's good, fair work -- if  you want to work that is.

Many of them -- expecially those who worked in construction -- contend if you hate the profession of RT you should try working on a black top on a 100 degree day during a dust storm.  Sure this profession isn't ideal, yet what job is.  Work is work; work is pay.  That's usually why people choose this profession.

Here's a list of some jobs of those I've had contact with:

• House wife
• House dad
• Construction worker
• Painter
• Journalist
• Hair dresser/ barber
• Food service
• Pilot
• Factory worker
• Nurse
• Salesperson
• Telephone/ cable company
• Manager of small business
• Military

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Comorbidities complicate care

People in developed societies today are living longer than ever.  Generally, we are seeing most people living in good health until the age of 75, and even 80.  Yet at some point a person will develop comorbidities, and it's this that often makes the patient hard to treat.

This was the topic discussed by Helen M. Sorenson in the May 2012 issue of "AARC Times," in her article, "Common Comorbidities, Complications, and Consequences in the Elderly." 

Usually a person can make it through an entire life with one ailment.  As we know, there are many asthmatics, and many COPD, arthritis, osteoporosis and hypertension patients out there.

Yet when a person develops more than one disease, this is referred to as a comorbidity. In most cases, this occurs as a person ages, or as a disease progresses.  The following are common comorbidities listed by Sorenson:

1. Past heart attack
2. Hypertension
3. Congested Heart Failure
4. Atrial Fibrilation
5. Ventricular dysthrymias
6. Aortic or Mitral Valve Dysfunction
7. Diabetes
8. Renal Disease
9. Asthma
10. Urinary Tract Infection
11. Depression
12. Osteoporosis
13. Gastrointestinal Reflux (GERD)
14. Osteoarthritis

You can easily see how treating one may exacerbate or even cause the other.  If you're short of breath you'll probably require steroids, which can lead to diabetes.  Treatment for heart failure may lead to electrolyte imbalances that cause heart dysthrythmias.  Treatment for some dysthrythmias may trigger asthma.

So the patient, thus, becomes an enigma; a conundrum.  Sometimes we refer to these patients as a train wreck. 

Related links:

• Comorbidities complicate COPD care

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Does supplemental oxygen help with a heart attack?

Your question:  The ACLS protocol recommends giving any patient with chest pain or a suspected (or actual) heart attack 2-4lpm of oxygen to ease the oxygen demands of the heart.  If the oxygen saturation is already 96 percent or greater, what use is this suplemental oxygen?  Or is it a simple waste of money?

My humble answer:  This is a great question.  If the patient's spo2 (oxygen saturation) is already 96 percent or greater, that means the blood has an ample supply of oxygen, and the tissues have an ample supply of oxygen.  To put it in simple terms, if 100 percent of hemoglobin are carrying an oxygen molecule, then there are no more empty trains in the station.  Every seat is occupied.  You can put all the oxygen molecules you want into that person's lungs, it will have no place to go but back out into the atmosphere.  So supplemental oxygen in this case is frivolous and a waste of money.  I agree with you.

Yet some will say that even if the oxygen saturation is normal the patient's heart might have infarcted and is not getting good oxygen supply.  Yet with a sat of 96 percent on room air, you know this was not caused as a result of hypoxia (lack of oxygen to the tissues).  It was caused by a blockage in the heart.  You can add all the supplemental oxygen you want, no oxygen is going to get past the blockage.  So, once again, we have shown that you are right and that supplemental oxygen will not benefit the patient in this case.

However, if the heart attack was caused by lack of oxygen in the blood that results in tissue hypoxia, then definitely supplemental oxygen is essential.  Yet so long as you have a good oxygen saturation (or more specifically, a healthy PO2), there is no added benefit to supplemental oxygen.

So pretty much the only reason for giving supplemental oxygen is so you can say you used it in the case of a malpractice suit.  If we got rid of malpractice suits doctors could spare the supplemental oxygen and save a billion dollars a year on just that alone. 

However, medical schools have taught for years that people with chest pain must have oxygen.  This is a myth that may take a while to rid the medical industry of even thought the ACLS recommends not placing ANY patient on supplemental oxygen who has an SpO2 94% or greater.  

Last fall the instructor told our class this, and one old-time doctor said, "I'm still going to put my patient's with chest pain on oxygen, it only makes sense."  The ACLS instructor said, "Not if Medicaid doesn't pay for it you won't."  This is one of the few times Medicaid got something right and the doctors are wrong.

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Why are we superstitious?

It's amazing how things that happened to humans thousands of years ago still influence people today whether we are aware of it or not.  Perhaps the best examples of this are the superstitions many of us believe in.

Wade Boggs was one of the best baseball players of all time, and he attributed his success to eating chicken every day.  The days when I'm not busy I attribute to my lucky parking spot. Everyone knows when there's a full moon it's going to be crazy busy.  Likewise, if you say the word Q-U-I-E-T it's gonna be busy.

Yes, these are superstitions.  Yet 30,000 years ago they weren't superstitions at all but facts: they were omens.  Primitive people believed health and fortune were determined by the spirits, demons, dead, and gods that live among us.

They believed these transcendental forces were ubiquitous: seeming to be everywhere at once.  To make a comparison, our world is filled with bacteria and viruses that can cause us harm, and yet we live in peace among them.  In the same way, people 30,000 years ago lived in peace among the transcendental.

The way they did it was by omens, amulets, talisman, incantations and prayers.  Amulets are objects that ward off evil spirits.  Perhaps it's a bone taken from prey or loved one lost in battle, or  knife or sword or a rabbits foot. It was a bracelet or necklace.  Talisman is a similar object, yet it's objection is to bring good luck.

An omen, however, is a projection of the future.  It can be both good and bad.  A word in our language derived from "omen" is "ominous."  However, the ancient view of omen wasn't necessarily bad: it was good or bad.

One way the Babylonians sought omens was to open an animal and inspect the liver. To them the liver was the essence of life. They viewed the liver the way other societies viewed the heart, or how today we view the brain or the mind.  Priests examined the liver for signs they were trained to interpret.  For example, an abnormality on the left side of the liver may mean the enemy will be defeated, and a deformity on the right side may mean defeat.

Surely we see such omens -- superstitions if you will -- as goofy, they saw them as real as the chair you're sitting on.  Yet in a time when the only medicine was an incantation or prayer, omens were actually a good thing.

Consider the following quote from Henry E. Sigerist in his book, "A History of Medicine (Vol. II, page 455):

"We must keep in mind... that the most abstruse omens do exert an influence on people as soon s they believe in them.  If somebody is convinced that a black cat crossing his path brings bad luck, he will feel uncertain and will be inclined to make mistakes.  The general who in the past went to battle knowing that the stars were against him had a good chance of losing it, because he was bound to feel that it was a vain undertaking to fight against destiny, when he thought that the odds were against him and all in favor of his adversary."

So superstitions -- omens -- aren't so bad.  On the days Wade Boggs ate chicken he put himself in a relaxed state of mind because he just knew he was going to have a good day.  On the days my parking spot is available I do the same because I just know I was going to have a good day.

On those full moon nights, many of which are not busy at all, we medical care workers just put ourselves in a mood where if it's busy it must be because of the full moon.  The same with the recitation of the word quiet. Yet we owe it all to the first form of medicine: the magico-religious.

In a sense the magico-religious is ingrained in our blood.

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Useless breathing treatments may never end

I've decided that the people who have the power to improve the profession of respiratory therapy are the same people who have an incentive to keep it as it is.  So while many RTs have made the observation most of what they do is a waste of time or delays time, nothing will change in the near future.

UNLESS...  unless something like what happened during the 1950s happens again.

You see, why would the bosses of the RT cave want to add protocols and educate doctors to get rid of procedures that aren't needed?  You have to realize these are the same folks who have petitioned to get order sets that have breathing treatments automatically ordered for a given diagnosis, as opposed to doing therapies for scientifically proven reasons.

They won't make the needed changes because.... THEY WOULD BE OUT OF A JOB.

The proof is in the pudding that RT Driven protocols reduce unnecessary procedures and reduce hospital costs, yet many small town hospitals don't want them because they fear -- as they say -- they will reduce procedure counts and we would all be out of a job.  Most evidence shows this is not true. No matter what happens, RTs will always be needed.

However, a more confined RT department would quite possibly means RT bosses WOULD BE OUT OF A JOB.  So this is the very reason they don't want to get rid of unnecessary procedures.  They are selfish.  They are afraid an improved RT department would result in them being squeezed out.

That is why when you approach an RT boss they blow off any wines of RT apathy due to useless breathing treatment orders.  Many times my boss has nodded his head in agreement, says changes are coming, and then.... nothing.  Silence.

It's not a coincidence.  It's not because he tried.  It's simply because he doesn't want to make changes.  He's telling you what you want to hear and that's that.

However, in the 1950s and 1960s doctors were ordering IPPB treatments for just about any lung patient.  They were doing this based on some unproven belief the IPPB would force medicine deeper into the lungs and make the medicine work better, and the fake study it would open atelectic lungs.

Yet insurance companies in the 1970s cried foul. They argued that such treatments were expensive.  And back then they paid for every procedure unlike today when they simply pay a flat fee (no thanks to HMOs).  In this way, IPPB therapy became the laughing stock of respiratory therapy.

And it was partially for all the IPPB therapies being ordered just so RT departments could make money that HMOs were created.  Yet instead of getting rid of stupidity it simply exacerbated it.  Surely studies proved IPPB gave 35% less medicine to patients, and IS was better to treat and prevent atelectasis, yet now doctors -- instead of using science, order breathing treatments for any annoying lung sound or lung ailment.

It's to the point it's ridiculous.  Nobody wants to be an RT because of stupid doctor orders.  In the past two days alone I had two different doctors explain to me, using the x-ray, why a patients needed breathing treatments based on infiltrates on the x-ray.  Now how a breathing treatment is going to help this is beyond me.  Yet for some silly made up reason they think it will.

Yet I don't see another 1970 happening mainly because insurance companies aren't paying for these wasted breathing treatments.  And RT bosses don't want to protocol themselves out of work.  So nobody will call doctors on their idiocy.  Hospitals will simply continue to eat up the costs, probably with administrators not even knowing it.

The only hope is the hospital itself, tired of flipping the bill for a department that makes no money, who might step up and end such frivolous therapy.  However, at the same time, HMOs and government agencies only pay for hospital visits when criteria is met.  And, in many cases, breathing treatments are believed -- based on fake science -- to be necessary in order to justify admission to the hospital.  Thus, the hospital won't step in and do anything either.

So we are stuck doing useless breathing treatments for a while.  This will continue until someone comes up and gets the government out of the healthcare business.  It will continue until some smart legislature comes along and decides that doctors and nurses and RTs are better capable of caring for patients at the bedside, rather than old doctors and legislatures sitting around in suits on leather chairs around a table in Washington or Lansing.

In the meantime, the morale of RTs will continue to sink, and bosses will continue to blow them off.

Thoughts?

See bronchodilator reform

Are Respiratory Therapists rewarded for their knowledge?

Your RT question:  Are RTs rewarded for their knowledge.  I know RTs go to school for two years and learn a ton.  Plus you guys have some good experience you learn from.  Do you get rewarded for your wisdom?

My humble answer:  Wow.  You got me there.  Great question.  We do learn a lot in this profession. We learn a lot about the lungs in school.  There's no one on the planet who knows how to diagnose and treat lung diseases than we do.  Your questions is, do we get rewarded for our wisdom.  Honestly, I'd have to say no we don't.  I know many of you were hoping I'd give a positive, optimistic answer to this question, yet I can't.  We are a young profession and growing, yet we still have a ways to go.  I think there are many times I make recommendations to doctors in nurses as to whether or not a treatment is indicated more often than not I'm told to do the treatment anyway.  So based on these experiences, I'd have to say that we are not rewarded for our wisdom, or any new wisdom we acrue.  We might win some friends, save lives and may impress some of our coworkers, yet we will not be paid extra for this added wisdom.  I'm assuming that by reward you're referring to pay.  Usually we RTs get pay raises at the end of the year equal to inflation, and our raises are not due to what we know.  Most raises are across the board or performance bsed, but not based on wisdom.  If we were paid based on our knowledge and not so much on performance, I think I'd be worth twice what I'm paid just for all the time and energy I spend bloggin here at the RT Cave. 

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Will LABAS end useless breathing treatments?

For the past several years one doctor orders Pulmicort BID instead the patient use his Qvar QID.  We RTs have hated it, because it makesk treatments last longer.  Now I'm wondering if this is the wave of the future, and that it's for the best.

Hear me out, folks, because Pulmicort BID treatments may be good for us.

Last fall I gave my first Brovana breathing treatment.  I had no idea what this medicine was, so I did a Google search.  After doing this I realized I had heard of Brovana before: it's Foracort.  This is a LABA: a long acting broncho dilator.

Think of this:  Both Brovana and Pulmicort only need to be taken twice a day!


You heard it here first, folks.  Remember a few years back I wrote about a talk I had with a doctor (you can view it here).  I asked her why she orders Q4 Ventolin treatments when the patient is not short of breath.  She said, "Because we want to prevent bronchospasm."  I said, "Then why don't you prescribe Serevent?"  She gave me a wry expression, hissed, and left the room.

That was ten years ago.  Yesterday a homecare representative visited me in the RT Cave, and he told me most of his patients now get Brovana and Pulmicort.  He said it's great because it improves compliance.  "Think of how much easier it is for patients to only take two breathing treatments a day, with Ventolin only if needed?" he said.  "Our doctors are buying it."

He convinced me.  If doctors truly believe all these patients need a bronchodilator, and all these procedures are burning us RTs out, and doing nothing for the patient, then why not at least try BID Brovana and Pulmicort with prn Ventolin or Xopenex?

Surely we can have further debates, such as will this put us out of a job?  Yet we'll delve into that in a later post.  Or, better yet, I'll leave it to you guys.  I just wanted to bring this subject up and let you know it's a possibility for the future.

This may be the RT Revolution we need?

How to get a job as a Respiratory Therepist?

For those seeking advice on how to get a job as an RT, you have come to the right place.  Keep in mind, however,  I can't guarantee the job you want will be available, and I can't guarantee you won't be up against more qualified candidates.  Yet what I offer here are simple tips to help you stand out to a prospective RT boss, and ultimately -- you hope -- make your file stand out upon his desk.

So, what can you do to be hired as an RT?  Here are some simple tips:

1. Study hard in school and work your butt off to learn as much as you can during clinicals
2. Create a simple one page resume
3. Send in your application and resume.  Most are available now online.
4. Wait about a week and call the hospital to get the RT Bosses phone number at work
5. Call the RT boss and say something like, "Hi, I'm Bob lookingforwork.  I put my application for a job as an RT a week ago and am wondering if you got it."  The conversation should take off from there.  If he has a lot of applications this will put yours at the top.  He will know you're interested and serious.  Do not make your initial contact by email unless that person has already contacted you.  You may contact this person once a week until you get an interview or a flat out no.
6. Be prepared. Learn as much as you can about the hospital you are applying to.  If you worked clinicals at this hospital that helps. 
7. Dress nice for the interview (but don't over dress), and bring a copy of your resume. Do not overdue the makeup, perfume, aftershave, etc.  You don't have to wear a suit.
8. Answer questions honestly. 
9. Ask questions.
10. Make nice comments about the hospital or department, such as, "I like the down home feel of your hospital."  Again, don't over do it.   
11. Know your weaknesses.  If you're a new RT, this is your weakness.  
12. Do not bring up pay at the initial interview. If you are asked, be reasonable
13. After the interview, make sure the RT Boss knows how much you want to work for him, say something like, (shake hands) "I look forward to working with you in the future."
14. If you don't get a call within a week after the interview, call the RT boss and say something like, "Hi Mr. RT Boss, this is Bob lookingforwork and I'm curious if you made a decision about your RT position."  You may also use email if you have the person's email. You should make sure you continue to make contact every 1-2 weeks until you are hired or hear otherwise.  
15. Spread yourself out if you want.  You can do this for as many hospitals as you want at the same time.  Just make sure you don't schedule two interviews at the same time.  Good luck. 

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Asthma symptoms in infants

The following post was originally published at healthcentral.com/asthma on June 3, 2011:



"What are the signs of asthma attack in infants?"

Although it's difficult to diagnose, kids can get asthma too.  Since infants can't communicate they are having trouble breathing, it's up to you to spot an attack and know what to do about it.


The most common signs of asthma in infants are: 

• Coughing, especially at night: This is actually a classic sign of asthma.  It's often the only sign.
• Night time wakenings: May be due to coughing and/or chest tightness
• Wheezing: May be audible or silent

The following are signs your child's asthma might be getting worse, and immediate attention is necessary: 

• Rapid respiratory rate: Breathing is faster than normal
• Trouble feeding:  Or lack of desire to eat
• Agitation/ crying: When babies can't breathe they get restless
• Retractions: One great way to tell babies are having trouble breathing is if his chest is being sucked in with each inspiration.
• Nasal flaring: This is the flaring out of the nares upon inspiration. It is done in an attempt to suck in extra air. A classic sign of air hunger in babies.
• Grunting on expiration: This is the baby's natural attempt to keep his lungs open. Another classic sign of air hunger.
• Cyanosis: This is the blue discoloration of skin caused by lack of oxygen to that area. Usually it's around the mouth, nose and fingertips. This is a sign the baby is not getting enough oxygen.

Your asthmatic may display one or a combination of any of the above signs.  Each child is unique, and this is why it's important for you to be vigilant to the specific signs your child displays.

Once diagnosed with asthma, you and your child's pediatrician will want to create an asthma action plan tailored just for your child.  This plan will help you monitor your child's asthma, and know what to do in the event you see the above signs.

Most asthma experts recommend all asthmatics have a rescue medicine called Albuterol or Xopenex on hand at all times.  These are bronchodilators.  They relax the muscles surrounding the air passages in your asthmatic child's lungs, and can rapidly make breathing easier. 

This medicine can be given to your child using a nebulizer with a mask or an inhaler with a spacer and a mask.  While a nebulizer is the most common method, more recent studies actually show an inhaler is the best method to use.  However, the truly best method is whichever one your child accepts (to learn more click here).

Usually two puffs of the medicine are given if an inhaler is used.  These puffs should be spaced one to two minutes apart.  If a nebulizer is used, the treatment usually lasts about 10 minutes. 


Of course this depends on the severity and control level of your child's asthma, yet if your child's need for his rescue medicine is greater than normal, then you should notify his pediatrician or take him to the emergency room.  Increased use of rescue medicine likewise a common sign of uncontrolled or worsening asthma.


If the signs of asthma go away after using the rescue medicine, you can simply monitor your child at home.  If the signs don't go away, you should call your child's doctor or take your child to a local emergency room.


Again, you should follow whatever guidelines written down when you and our child's doctor created an asthma action plan. 


However, if your child is not yet diagnosed with asthma, you do not have an asthma action plan, and you observe any of the above signs, you should call your child's pediatrician or take him to the emergency room right away.


Since your infant doesn't have a voice, it's up to you to observe the signs of trouble breathing.  By being vigilant in this way you can make sure your child is always breathing easy, and you might even save his life.

The benefits of staying positive.

Every study I've ever read on the subject shows that people will like you better, and you'll like yourself better, if you are positive.  Studies also show it makes you live longer, and even have a greater chance at career advancement.

I remember following my dad to work one day when I was a kid.  My dad went out drinking the night before, and stayed up late.  He was not his usual self. Yet once he got to work, a coworker said, "Hey, Bob!  How's it going today?"  My dad smiled and said, "I feel great!"

I asked him later why he said that, and he said, "Because it makes you look good and feel good."  I didn't understand until I had a full time job as an RT where I work with people day in and day out. The people I like to associate with are those who are positive and happy.

A few years ago I started an experiment with myself.  I decided I would say nothing but happy, positive things.  When someone asked me how I was doing I'd say, "Great!"  When the bosses made an unpopular change, I'd say something like, "It will all work out in the end."

I think people like it when I work.  My coworkers like me and so do my bosses.  My bosses particularly like me because they know I won't complain about decisions they had to make, especially ones that are not popular.

When I do complain, they the bosses take me seriously.  That's a major advantage in itself. I recently had a run in with a coworker, and even though this wasn't what I expected, my bosses and my coworkers boss kowtowed to every wish I had.

This is a major advantage.  After doing some research on the Internet I've learned there are other advantages of staying positive, such as...

1. People like you better, even when they disagree with you
2. Your positive attitude spreads to your coworkers, and this improves morale
3. You make better decisions under pressure
4. You have a greater chance at promotion
5. Your marriage is more likely to succeed (by a 5-1 ratio)
6. You will be more resilient to stress 
7. Make you feel better (Saying "I feel Great!" counters any feeling of stress)
8. Positive people have more friends
9. Positive people live longer

Reference:

1. Jon Gordon Blog
2. The Mayo Clinic, "Positive Thinking: Reduce stress by eliminating self-talk,"  http://www.mayoclinic.com/health/positive-thinking/SR00009
3. Smith, Jenn M, "The Benefits of Being Positive," ezinearticles.com,  http://ezinearticles.com/?The-Benefits-of-Being-Positive&id=5031933, viewed 6-6-12

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MCAT question # 42

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

The phrase "cover your bases" refers to which of the following:

• a. Wrapping a towel around your ass when you get out of the shower.
• b. Ordering procedures that aren't needed so you don't get sued
• c. Ordering every procedure you can think of to make sure CMS doesn't come up with some stupid excuse for not reimbursing you for that patient.
• d.  Both b and c
• e.  All of a, b, and c

Respiratory Therapy is a low stress job?

Some of my coworkers will debate me on this, yet I have and always will contend that the profession of RT is a low stress job .

Okay, allow me to add at least where I work.  And allow me to add this other little statement:  and most of the time.

Surely you're going to have your newborn baby who isn't breathing.  You're going to have a kid come in after an auto wreck.  You're going to have a relative come in some day in severe respiratory distress.  You're going to have your moments.

Some of you who work for trauma hospitals may see that stuff every day.  Yet usually you either see adults or kids, not both.  So after you do this for a while doing CPR will become as easy and nonchalant as picking up a tissue when your nose is dripping and wiping it off and tossing that dirty tissue in the trash. 

Seriously folks.  With the exception of the asthmatics who truly needs a breathing treatment, no one is going to drop dead if they don't get one on time.  Most patients won't even know you didn't show up if you were busy. 

ABGs are nice, but they are just procedures.  EKGs are nice, but they too are just procedures.  When it comes down to it you treat the patient, you don't wait to get a procedure.  You do what you were trained to do.  You think. 

Now, is thinking stressful?  It can be for some people.  It can be when the patient is a wreck or a conundrum.  Yet it shouldn't be.  If you studied in school.  If you paid attention.  If you still know your stuff.  If you read RT magazines and keep up to date on your RT wisdom, thinking shouldn't be a big stressor for you.  If anything it should be challenging and fun.

I like my job.  I like being an RT.  Yes there are stressful moments.  Yes there are days when I'd like to kick my boss in the butt for not wanting to make waves or for telling me what he thinks I want to hear rather than dog gone truth.

The pay could be a stressor too for some.  While there are some who say RTs are paid well, I beg to differ.  Yet no one ever died saying they wished they made more money.  Your money goes as far as you wisely spend it.  You can make $40,000 a year and be richer than a man who makes $70,000 a year and spends it unwisely.  So stresses over money are unfounded.

Yet this is a good job and a relatively stress-less job.  Plus where I work I get to do this (blog) and this is a major stress reliever for me.  What do you think?  Is your job stressful?

Note:  The comments section below is temporarily broken, so send comments via the email (contact me) in the right column. 

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Indications for intubation of the critically ill

When it comes right down to it, the decision to Intubate a patient is a difficult one, and generally involves all a combination of many of the following:

1. An assessment of the patient
2. Interview with friends and family
3. Knowledge of the history of patient and recent history
4. Analysis of data if available (EKG, lab results)
5. How critical is the patient?
6. Is there a sense of impending doom?
7. Past experience of the clinicians at bedside (doctor, RN, RT)
8. Education of clinicians at bedside
9. Common sense

Rarely is the decision an easy one.  Often do I find that both I and the doctors involved wonder whether intubation was indicated.  "Could we have done something different?" and "Did we make the right choice?" are common questions. 

The answers are never obvious, and stem to an array of ethical discussions that have no answers either, such as:  "Are we just delaying the inevitable?"  The ultimate goal, however, is always the same:  To prevent the patient from dying due to hypoxemia or hypoventilation.

The task of listing such indications is compounded by modern wisdom and technology.  For instance, we used to list intubation as indicated anytime positive pressure ventilation was required, although today not even that is true as I note below.  

Still, most RTs should be able to know what patients are candidates for intubation.  Yet to write the indications down into a guideline and suggest to intubate a patient any time they fall into such a category would be both frivolous and dangerous.  

Likewise, I have found by my experience that modern wisdom and technology (like BiPAP) has decreased the number of patients who are intubated.  Still, there will come a time when you will have no choice but to intubate.  

That said, the following are the basic indications for intubation as best as they can be written down:

1. Relieve airway obstruction:  Severe bronchospasm (asthma, COPD), laryngeal edema (burns, epiglotitis)
2. Facilitate removal of secretions:  Chronic bronchitis, cystic fibrosis, asthma, pneumonia, pulmonary toilet
3. Protect airway from aspiration:  Anything that causes lack of gag reflex, such as neuromuscular disorders, drug overdose
4. Hypoxemia:  If the patient is not oxygenating, and other means of supplying supplemental oxygen fail (NRB, BiPAP).  May include pneumonia, CHF, CF, COPD
5. Ancicipated loss of control of airway:  Anesthesia use (as in surgery), paralytic use, trauma, increasing laryngeal edema as in from burns, worsening stridor (suspected bronchiolitis),  cardiopulmonary arrest, respiratory failure, impending loss of consciousness

The following I have removed from the list for said reason:

1. Facilitate application of positive pressure ventilation:  In many cases of respiratory failure, BiPAP may be trialed first, and this often eliminates the need for intubation. This is particularly true for cases of COPD and heart failure. This is true so long as these patients are consciously breathing. If a patient is unconscious, or is otherwise unable to take the mask off, intubation should always be considered. 

So how long do you wait to intubate?  Do you try BiPAP first?  Did we make the right decision?  These are questions often left to the best judgement of those caring for the patient. 

References:

1. Egans:  Fundamentals of Respiratory Care
2. Critical Care Medicine Tutorials

Tips for drawing ABGs

Your question:   i'm a 1st year student and I was wondering if you could give me a few tips on drawing ABG's. I went 0-3 on drawing ABG'sduring clinicals thus far, putting the patients in pain with no results was pretty discouraging for me. Any tips/advice is appreciated, maybe teach me

different techniques that you've heard of if you can, thanks. 

My humble answer:  Okay, I'll give you the same tips someone gave me when I was in your shoes, having missed my first several ABGs.  I'm going to describe a radial artery poke, although drawing from the brachial and femeral arteries is relatively the same.  I give these same tips to every student I have to supervise with their first pokes.  

1. Have your syringe, bandaide, gauze pad and everything you need to use ready before you ever walk into the patients room.  When doing this make sure you set the syringe to 1cc because most new ones fill automatically once you hit the artery.  Also make sure the cap comes off easily.  If not, loosen it slightly.  Label the syringe. Have a rolled up towel ready too.  
2. Walk into the room and say, "Hi, I'm (your name)  from respiratory therapy.  I'm here to draw some blood from you."  Do not give out any further information. Do not say you have never succeeded before.  Do not say "It's going to hurt." Do not say, "It's going to be a big poke."  Do not say anything unless the patient asks a question, and answer it as briefly as you can.  I know this goes against contrary wisdom, but I find it works best this way, especially for students.  Don't say you are a student. If they figure it out, that's fine, but don't jump out and say it.  And don't lie, either.  That comes without saying, though.  Just be pithy in what you say is my point here.  
3. Put on gloves.  Make sure the rubber is very tight over the right pointer finger.  I usually rip off the rubber over this finger so I can feel the artery better, but your student policy may not allow this.  
4. Prepare the skin with betadine and alcohol.  (make sure to ask the patient if he's allergic to betadine.  I think newer studies say skip the betadine, but you have to follow your hospital policy). 
5. Get comfortable (sit, stand, kneel, or whatever) facing the patient.  
6. Feel for a pulse on the radial artery, as 90% of your ABGs will come from this spot.  If the pulse is week feel the pulse on the other hand.  Pick the one that is best.  If you're right handed you may want to choose the right radial artery if possible.  Once you gain confidence it won't matter which side you poke from. 
7. Either on the side of the bed next to the patient, or preferably on a table,  place a towel or pillow under the patient's wrist so that the wrist is cocked and the artery is easily accessible
8. Perform your Allen's Test if appropriate
9. Carefully uncap the syringe.  I'm right handed, so I hold the syringe like a pencil in my right hand and use my left hand to prep the artery
10. Feel the pulse again.  Choose a good spot to poke where the artery is most stable.  I preferably go as close to the fingers as I can because the artery is more stable here.  But use common sense.  
11. Use a two finger technique. Using the middle finger of my left hand, I tighten any loose skin over the groove the radial artery usually sits in.   This is especially important for elderly people who have loose saggy skin.  Of course you don't want to press down too hard as to cut off circulation. And you technically don't want to feel the pulse with this finger if you can help it.  
12. With my pointer finger of my left hand I feel for a pulse.  If the pulse is strong you should feel it easily. If you don't feel it, make sure you're not pressing too hard with your middle finger
13. If possible, arrange the needle so the bevel (opening at the tip of the syringe) is up.  I'm told this make the blood flow more easily into the syringe.  I'm not sure if this is true, yet I don't like to risk it. 
14. Insert the syringe at a 30 degree angle right under your pointer finger (do not go at a 90 degree angle). This was a key tip for me.  I usually get as close to my finger with the tip of the needle as I can over the bounding pulse.  Do not insert the syringe to the right or left of your finger, but right under it where you feel the pulse.  Some people do it other ways, but I find this works great. You should succeed 90% of the time.  Most students I recommend this to succeed their first time. (When you enter the syringe it should be at a 30 degree angle toward the patient, not away from the patient or toward you) 
15. Insert the syringe slowly until you get blood return.  Sometimes the artery is right at the surface and fills right away, sometimes it's deep (especially on overweight folks).  YOU MUST BE PATIENT.  
16. If you don't hit blood right away don't give up. Pull the needle back as far as you can without exiting the skin, and reinsert by aiming the needle to the right or left, wherever you think the pulse is strongest.  Insert the needle very slowly.  If you still don't hit blood, pull back and do the same in the other direction.  I know rules say you can only re-position the needle once, but I think it's okay to do this twice or even three times because you should go right and then left if needed.  However, use common sense. Actually, if you're a student you should follow whatever rules you were taught.  
17. DO NOT MOVE THE SYRINGE OR YOUR FINGERS THAT ARE SUPPORTING THE ARTERY UNTIL THE SYRINGE IS FILLED WITH BLOOD, OR THE FLOW OF BLOOD STOPS.  However, if you get a flash and flow stops, you may try slightly adjusting the tip of the needle a little deeper or out a little.  You may also try lifting up your fingers to see if your pressure was blocking blood flow.  This sometimes helps.  
18. Hold gauze over needle, pull out syringe, hold pressure until bleeding stops.  If person on blood thinner like coumadin you may have to hold up to five minutes.  If in DNC (clotting disorder) you may have to hold longer.  Some hospital policies state you should hold for five minutes, but I don't find this necessary for most people.  Usually 1-2 minutes will suffice.  However, use your better judgement here.  Sometimes other people can hold for you if you're in a hurry.
19. Place the Bandaide right over the balled up gauze.  
20. 13.  If you do not get blood, do not give up or feel discouraged.  Every person misses, and every person even goes into slumps.  So keep trying and you'll eventually be a pro at it.  
21. 14.  Do not place the ABG on ice unless you think it's going to be more than a half hour for it to be run.  I don't care what anyone says, ice dilutes the sample, especially in the newer plastic syringes.  

I'll see if I can find a video on you tube.  I think it would be better to see what I'm describing.  

Anyway, let me know if this helps.

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3 types of respiratory therapists

After 16 years of doing this I've decided there are three types of respiratory therapists. 

1.  Neb Jockeys
2.  Respiratory Therapists
3.  Yearning

A neb jockey is a person who is just a task doers:

• Does what the nurse or doctor says just to keep the peace
• Uses politics to smile and keep the patient happy
• Travels room to room in the hospital setting doing tasks, such as EKGs and nebulizer treatments. 
• Once he's finished he travels back to the RT cave and continues reading his novel or blogging, blogging on the Internet, or some other similar activity
• He finds it easier just to do the treatment than to challenge himself or the doctor or nurse
• They might recommend no treatment be given and be called a half hour later to do one anyway
• They are treated as ancillary staff

A respiratory therapists is what we read about at AARC.org. They are actual therapists and not just doers

• They work with doctors and nurses in making decisions to benefit the patient. 
• Diagnose and make treatment decisions for breathing disorders
• Interview and exam patients and relay our opinions to physicians and nurses
• Analyze lung sounds and ABGs and EKGs and make recommendations to the benefit of the patient
• Managing ventilators and other airway equipment
• Educating patients and families about lung disease\
• Their recommendations are respected
• They are treated as professionals

I find that most respiratory therapists are treated as neb jockey respiratory therapists as opposed to the ideal respiratory therapist respiratory therapist (if you get my drift).

Contrary to popular belief, here at the Respiratory Cave we're neb jockeys.  I'd like to say it's not by our personal choice nor due to educational restraints on our part, yet part of me wants to say it is our fault.  Think about it:  it's easier to just do the treatment than to think; it's easier to just do it and be done than to assess, talk to the doctor, fill out paper work, and reassess after the treatment and then reassess again.  Can you see?  It's easier to just do it.

Plus there are those among us who are afraid if we move into the future it would result in protocols (more work and more thinking) and this might result in fewer treatments (the fear of layoffs).  Yet by the evidence of those who currently have protocols, that rarely ever happens.  The work will remain there.

There are a few RTs like myself who are neb jockeys respiratory therapists who try to be respiratory therapist respiratory therapist.  And this brings me to the 3rd type of respiratory therapist:

Yearning Respiratory Therapists:  These are neb jockeys not by choice but because their bosses and coworkers don't want to make waves.  They are neb jockeys who pretend to be respiratory therapists.  They tend to be among your more frustrated bunch because they expected the profession to be as the AART described, yet realize at some point the ideal world is, well, not so ideal after all.  The picture painted by the AARC is not the real world.  They are neb jockeys not by choice but because their department made them that way.  When they are young and fresh they try to change things, and when they fail (90 percent do fail -- at change I mean), they give up and decide it's easier to just do the treatment.  Then they reserve themselves to silly blogs and making RT humor .

So you have your three types of RTs:

1. Respiratory Therapist Respiratory Therapists (ideal)
2. Neb Jockey Respiratory Therapist (real)
3. Yearning Respiratory Therapist (dreamers of the idea)

What kind of RT are you?  Are you that way by choice, or because your department has made you that way?  Are you a fighter for change, or have you given up? 

Also read:  The six different types of respiratory therapists

Note:  The comment section on my blog is broken, so you'll have to send me an email.

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Is a humidifier beneficial if you have COPD?

Your question:  Does a humidifier help with chronic bronchitis, emphysema, or pneumonia? 

My answer:  I would not recommend a humidifier for any person who has a lung disorder, especially if you have asthma, chronic bronchitis, emphysema, cystic fibrosis, or any similar disorder.  Why?  To learn more you can check out this post. 

Note:  the post is written for asthmatics, but the information also applies for the other diseases mentioned. 

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Expired Asthma Meds: Can you use them?

The following was originally published at MyAsthmaCentral.com/asthma on May 23, 2011:

"Is it okay to use expired asthma meds?"

You found your asthma medicine sitting at the bottom of your sock drawer and now you're wondering:  Can I still use it?  Is it safe?  Will it still work?  Is it okay to use expired asthma medicines?

Asthma medicine has a tendency to be expensive. One Advair Discus costs over $100 just for one month.  Even with good health insurance, I pay about $1 for each Singulair pill.  The cost of other asthma medicines can add up to.

If you're normal like me, you lose your inhalers.  I just opened three brand new Ventolin inhalers in the past week, and I already can't find two of them.  I did find one when I cleaned under the bed, yet it was dated January 2009.

While it's recommended every asthmatic have a rescue inhaler like Ventolin on hand at all times, and that we replace it every year, I know of many of you guys who have one yet it's done nothing but sit at the bottom of your sock drawer.  Now you're short of breathe and wondering, can I still use it?

More recently I received a question about how long Advair is good for.  This person had no insurance and wanted to know if it was safe to use an Advair that was opened but expired four months ago.  She also had one Advair that was expired but was never opened.

Are these medicines safe?  Would they still be effective if used?

When I was a kid I'd lose inhalers all the time.  If the one I was using ran out, and I for some reason didn't tell my mom I needed a new one, and I was having a raging asthma attack in the middle of the night, I'd rummage my room hoping to find a lost one.

Then I'd find one and take a puff.  If you've ever taking a hit off an expired Ventolin inhaler you'd know it, because it tastes like rotten mints.  Yet you wouldn't mind so much, because it still helped you get your breath back.

More recently I did some research to find out what the scientific evidence was regarding old and expired medicine.  I asked the pharmacist where I work, and he gave the old stand-by and political response, "It's good for up to a year."

Yet that didn't satisfy me.  So I continued my search for answers.  What I learned is that science has pretty much proven that no asthma medicine will harm you if you use it beyond its expiration date.

So in that sense you can feel okay about using expired medicines.  I mean, I'm proof expired asthma medicines don't kill.  If nothing else, I've proved that many times.

As far as potency, over time asthma medicines do become less potent, although they will still work better than using nothing.  In fact, most new medicines are good for two to three years from the day they are produced so long as they remain in the original packaging.

And considering a medicine may sit on the shelf of storerooms, trucks and then pharmacies, the expiration date is generally listed as one year as of your purchase date.

So you can see there really is no scientific reasoning for that expiration date.  The medicine might still be potent for some time.  So if your package is not opened, you should be able to use older medicine (within reason of course).

However, once the original container is opened for use or dispensing, the expiration date on the container no longer applies.  In fact, according to, this ABC News post, the expiration date of a medicine is actually just the predicted date at which the drug will lose 10 percent of its potency.

Once a medicine loses more than 10 percent of its potency it's no longer considered effective.  From that point on, it continues to lose more and more of it's potency.  Plus, if it's an an inhaler, it starts to taste nasty.

The expiration date also assumes you are storing the medicine at the recommended temperature and humidity.  Most medicine should be somewhere between 59 and 86 degrees F (15-30 degrees C) and away from light and moisture.  You'll have to check the package of your medicines to see the exact recommendations.

This means that asthma medicines should not be stored in the bathroom where
it will be exposed to high humidifiers during and after showers.  So I suppose the bathroom medicine cabinet’s not such a wise place to store your meds after all.

While most asthma drugs are not hazardous if used after their expiration dates, the efficacy of the medicine after that date can no longer be guaranteed.  Thus, if you are using an expired medicine you may not be getting the expected results.

So, should you use those expired asthma medicines?  At least now you can make an educated decision.

Does McDonalds Cause Asthma?

The following was originally published at myasthmacentral.com on May 16, 2011:

"Can eating high fat foods trigger asthma?"

American's love Big Macs, Whoppers, French fries, onion rings and deep fried chicken.  These are convenient foods that are simply delicious.  Yet the old saying goes, "If it tastes good, it's probably not good for you."

Now we already knew such high-fat foods are bad for your heart.  Yet new evidence suggests they may also be bad for your lungs.

A study completed by Australian researchers in 2010 tested asthmatics before and after eating a meal, and determined that lung function was worse after eating a high-fat meal.

If that wasn't bad enough, the study also concluded that high-fat foods also made it so asthma rescue medicine (like Albuterol) worked less well.

Scientists aren't sure why this is, yet there are theories.  One theory suggests that your asthmatic immune system might recognize saturated fat as an enemy and promptly acts to rid it from your system.

This response results in an increase in markers of inflammation such as leukotrienes and hystamine, and these increase inflammation in your respiratory tract.  This causes muscles lining your air passages to constrict, and thus an asthma attack is the result.

Perhaps due to the increased inflammation, asthmatics who used their rescue medicine after eating a high-fat meal did not get as much relief as those who ate low-fat meals.   Likewise, lung function improved less in subjects who used their rescue medicine after eating high-fat meals.

Obviously asthma rates have increased incrementally in the U.S. and other western nations over the past 20 years.  This new theory suggests one of the factors might be the high-fat foods we put into our bodies.

I've also read other studies that suggest that if you're exposed to something that triggers inflammation in your lungs, and exposed to it often enough, the inflammation may become permanent.  Thus, asthma is developed.

It's studies like this that remind us that the way we eat may determine the lives we live.  If you want to prevent asthma, or prevent an asthma flare, it may be a good idea to eat a healthy diet.

Does that mean we asthmatics should never eat great tasting, convenient and high-fat foods?  Absolutely not.  Yet it's good to know the facts, and it's good to know what foods might not be good for us.

MCAT question number 38

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

What is the best definition of ACID?

• a.  Crystal Meth
• b.  Any of a class of substances whose aqueous solutions are characterized by a sour taste, the ability to turn blue litmus red, and the ability to react with bases and certain metals to form salts.
• c.  An acronym:  Albuterol Cures Inclement Disorders

"Hey Respiratory!" RT Rule #53

I'm sure you've heard it where you work:  "Hey respiratory!"  It's the default way to get the attention of the respiratory therapist.  "Hey respiratory guy!" 

I hear a lot of respiratory therapists who feel they are so little respected that many nurses and doctors just call them by their profession: "Respiratory!" 

Working for a small, close knit facility where I work this doesn't happen too often.  Usually the people who call me that are new nurses or new doctors in the Emergency Room.  Otherwise I'm usually referred to by my name.

That is, unless there's a page over head.  Then it's "Respiratory STAT to..."

I think most RTs that are called by their profession are generally those who come from larger facilities.  And the recommendation they give is this:

"I don't answer them if they say "hey, respiratory" or "hey, breathing guy". I just look at them and keep doing what I am doing until they call me by name. Seriously. Try calling them by saying 'hey, nurse'. See how they like it."

I really don't care what people call me.  If you want to call me respiratory that's fine by me.  Yet I understand where the frustration comes from. 

RT Cave #53:  Keep your respiratory therpast happy by calling him/ her by name.  Do not refer to your respiratory therapist as respiratory.  Do not say, "Hey, respiratory!"


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