What is a severe asthma attack?

The following was originally published at healthcentral.com/asthma on February 2, 2015

What is a Severe Asthma Attack? 

A severe asthma attack (not to be confused with severe asthma) is an asthma attack that is really bad. The medical term for this is status asthmaticus, or an asthma attack that is unresponsive to attempts to correct it.

Such an attack is caused when the muscles surrounding your air passages spasm and squeeze your airways so air can get in but not out. Increased sputum production may cause mucus plugs that also block air passages. A severe attack may include any of the following:

• Uncomfortable coughing
• Chest tightness
• Wheezing (or no wheezing)
• Chest pain
• Unable to speak in full sentences
• Leaning on things to breathe
• Need to sit or stand to breathe
• The need to keep shoulders raised to breathe
• Sucking in stomach when inhaling
• Bluish tinge around lips and fingertips
• Feeling panicked
• Confusion
• Unable to concentrate
• Inability to decide what action to take
• Anxiety, may be severe anxiety
• Retractions, nasal flaring, grunting (common in children)
• Peak flow readings less than 60 percent

You may not experience all or only some of these symptoms, as they tend to vary from person to person. Still, when you experience these they are signs that you must take immediate action. 

You should work with your asthma physician to create a plan to help you determine what action to take. Usually this will involve the following:

• Immediately get away from what is triggering your asthma
• Immediately refer to your asthma action plan, if you have one
• Immediately use your rescue medicine as directed (all asthmatics should have rescue medicine nearby at all times)
• Call your physician, have someone drive you to the nearest emergency room, or call 911

Still, the best way to prevent severe asthma attacks is to prevent all asthma attacks. The best way to do this is to obtain good asthma control, which can be obtained by following these ten simple steps.

Links between COPD and sleep disorders

The following was originally published on March 25, 2015, on healthcentral.com/copd.

The Link Between COPD and Sleep Disorders

About 50 percent of people with COPD also suffer from sleep disorders, or conditions that prevent a restful sleep. Here are three of the most common sleep disorders associated with COPD, signs and symptoms to watch out for, and possible treatments.

1. Hypoventilation

This is a medical term describing a decreased rate and depth of breathing. Reduced breathing activity is normal during sleep, but generally causes no problems. Even if oxygen levels drop slightly, they remain at safe levels. However, people with lung disease may already have chronically decreased oxygen levels, so relaxed breathing activity may result in oxygen levels becoming dangerously low.

Complicating this is the COPD disease process itself. Some have chronically elevated carbon dioxide levels. Some use accessory muslces to breathe, and these muscles are paralyzed while sleeping. Both of these processes may cause hypoventilation and unsafe oxygen levels while sleeping.

Signs and Symptoms. This may result in disturbances in sleep quality at night, resulting in feelings of sleepiness and fatigue during the day. It also increases the risk of bronchospasm or COPD flare ups at night. It also increases the risk of dying at night.

Treatment. The simplest treatment is to wear oxygen while sleeping. Usually this is accomplished with a low flow of oxygen through a nasal cannula. Some studies have proven that nighttime oxygen may increase life expectancy in patients with COPD.

2. Obstructive Sleep Apnea

About 4 percent of men and 2 percent of women have this, and the risk is the same among the COPD population as the general population. This is a medical condition that causes a person to stop breathing for a few seconds to a minute while sleeping. It's caused when tissues in the upper airway become too relaxed, thus blocking the airway. These episodes are ended by the person waking up slightly to an audible grunt or snore. A typical person may have 30 or more such episodes each night.

During episodes oxygen levels drop, although will usually rise back to normal levels. Since COPD may result in chronically lowered oxygen levels, these may drop to critical levels while sleeping. Lower oxygen levels then cause blood vessels to constrict, and the heart rate to work harder to pump blood through the lungs in search of more oxygen that is not there. Over time, this may cause heart failure or even death.

Signs and Symptoms. While most patients are unaware of these episodes, a bed partner may recognize them, along with the grunts and snores. Daytime symptoms may include trouble staying awake, trouble concentrating, morning headaches and depression.

Treatment. Some patients may benefit from wearing an oral appliance to keep the airway open at night. Others may benefit from CPAP at night. This involves wearing a mask that supplies pressures during exhalation to keep the airway open. If these treatments don’t work, surgery is another option.

3. Insomnia

Anxiety due to the disease process itself may result in trouble sleeping. Bronchodilators, including theophylline and albuterol, may act as stimulants and cause trouble sleeping, especially when taken in higher doses. Corticosteroids may also make it difficult to sleep.

Signs and Symptoms. Lack of quality sleep may result in the feeling of not being well rested. It may also result in daytime headaches, irritability, anxiety and depression. It may also result in poor concentration, and an increased risk of making errors at work.

Treatment. The simplest treatment for this may be a medicine to help induce sleep at night. However, a physician will want to be careful here, as some sleep medicines may relax breathing and further complicate the problem. The medicine should ideally be short acting and low dose.

The bottom line

Seek Help. It's bad enough having a lung disease, let alone a sleeping disorder to go along with it. If you recognize any of these symptoms, it's time to seek help. If a loved one is concerned about pauses and snoring while you are sleeping, it's time to seek help. Getting proper treatment should help you live better with COPD. It may also help you live longer.

Further Reading:

• Sleep abnormalities and treatment in emphysema
• Sleep quality in COPD
• Sleep abnormalities and treatment in emphysema
• The Basics of CPAP
• Understanding sleep apnea
• Obstructive sleep apnea: overview

Dr. Creed: One Budesonide Amp should cure stridor

Real Doctor's Creed: Appendix Z: Problem Solving

Section 982: Pediatric Croup.

By Dr. Richard Crank, Shady Health Medical Center, January 7, 1982

The boy had croup.  Even without auscultation I could hear the inspiratory stridor. Upon auscultation, I could hear it radiating throughout the lung fields. The emergency room physician reported giving the patient a shot of decadron.  Upon admission, I ordered Q2 hour racemic epinephrine if needed.

The child did very well during the night, with the exception of one episode where the child became croupy in his sleep.  His sats were always 98% or better on room air.  During the day today the child has gotten progressively worse, per the respiratory therapist, with the need for Q2 hour racemic epinephrine over the past six hours. The therapist said the patient's SpO2 remains 98% on room air. The therapist also suggested that perhaps the decadron was wearing off, and another one should be given. He suggested maintenance doses.

Question #1: So, what do you do next?  What medicine do you order?

Understanding the Code 787 of the Creed recommends that we never let anyone with an associate's degree tell us what to do, I did not immediately respond to the request.  This bought me time to remember a study that was done in 1981 where pulmicort was given to four patients with croup.  Withing a day or two of one dose the patients went home.  The logical conclusion was it was the Pulmicort.

So I ordered a one time dose of pulmicort.

The respiratory therapist called an hour later.  He said he gave the pulmicort reluctantly, and that 90% of the medicine was wasted because he gave the medicine to the infant via blowby.  So the child only had a chance to get 10% of the medicine.  However, he said, the child cried throughout the treatment, so 90% of that 10% was wasted.  This means the child only got 1% of the medicine.  Then the child writhed and turned, resulting in 90% of this 10% being wasted, and this gets us down to, he said, the patient getting only 0.1% of any mist produced by the nebulizer.  He also said it takes Pulmicort 2 weeks to get into the system and start working, so it would have no immediate effect on croup anyway.  He said what was needed was a systemic steroid to resolve the stridor, because the nebulizer route wasn't going to work for this kid.

In other words (my words, not his, although this is what he was thinking), the treatment was a waste of time and I'm a dummy for ordering it.

This brings us to question #2: What do you do next?

I did nothing.  I simply wrote on the chart:  Discharge patient in the morning if stable.

Conclusion: There is no need to doubt this study even though nearly every other study and clinical evidence suggests that it's poppycock.  If it sounds good it is true. Period. Ignore rants of silly respiratory therapists who think they know all.

The eight stages of medical scams

Today's version is Ventolin

Taking note of the fact that the long-held conventional wisdom that aerosols like albuterol help with secretion clearance and mobilization have been overturned, we can now offer up the eight stages of how a medical hoax, faux theory, or scam is overturned and proven false.

1.  The theory is proposed by scientists on a nonscientific mission. (Example: the study of 4 COPD patients to which the hypoxic drive theory was devised.)

2.  It is believed because it plausibly explains an observation.  It taps into large anxieties about not being able to help those with chronic diseases we actually don't know much about, and make us feel like we are actually doing something good.

For example, albuterol mobilizes secretions and enhances clearance, or under oxygenating COPD patients will prevent their hypoxic drive from being blunted.  The solution taps into the hearts of physicians and nurses: it sounds like a good idea; it makes them feel like they are helping or doing something good.

They start ordering it, nobody complains, the patients eventually get better, and so the theory starts to become treated as a fact  -- even though no science has ever proven that it's true or that it does any good.

3. The causal relationship is worse than first supposed.  The research is found to be sloppy, the facts to be fudged or not even existent.  Subsequent studies do not support the original claims, or in the case of the hypoxic drive hoax, all subsequent studies completely disprove the initial claim. Nevertheless, the theory by now is beloved by the medical community and taught at both teaching hospitals and nursing schools.  The orthodoxy is promulgated all the more harshly for being doubted.  Those who doubt are ridiculed and made fun of and told that they are lazy and trying to get out of work.

4.  By now pride has taken hold of too many physicians and nurses who simply will not believe that what they learned in school in the 1980s could possibly be false.  Ideological interests have also taken hold. Professors consider for a moment the arguments against what they teach and then say things like, "There's no way IPPB only works to over distend good alveoli. It's just not possible something we learned in medical school could be proved untrue.  There's no way a silly respiratory therapist with only an associate's degree could be right."  They supply an ongoing supply of opinions to ensure the perpetuation of the alarm; in the case of the hypoxic drive hoax, that a patient's drive will be obliterated if we adequately oxygenate. We must not give COPD patient's more than 1-2lpm. By God, if you give more than 2lpm you will kill that patient." The irony that it never happens eludes them.

5.  Skeptics who have patiently argued on the basis of facts that the science of each phenomenon was weak are ostracized by the opinion establishment of medicine. Cranks but the cranks are right and the orthodox priests and Levites are wrong.

6.  Eventually, after 50 or 60 years, the subject of discussion just changes.  In the case of albuterol helping to mobilize and clear secretions, the evidence gets weaker and weaker.  The clinical evidence reported by millions of respiratory therapists that albuterol does not produce, thin, enhance, or mobilize secretions becomes overwhelming, and reaches a stage where it can no longer be ignored.

7.  The retreat of the orthodoxy is coveted by a smokescreen of fresh concerns for some other catastrophe.  No admission of errors is ever issued.  No apologies for therapist burnout, wrecked careers, or wasted money is ever issued. No apologies for following bad science is ever issued.  Time flows on, bringing neither knowledge nor greater understanding of the role of folly in human affairs and medical wisdom.

8.  Stages 6 and 7 have been reached in the medical reform cycle; they are beginning in the anthropogenic hypoxic drive hoax, or IPPB and aerosol scam.  Fifty years from now, there will still be clanking windmills in the minds of some old physicians who were educated back in the 1980s, or in the year 1915 by old dogmatic medical professors. Whether anyone will pay attention to them is doubtful. Yet the lobbies that like to cause alarm where no alarm ought to be ringing in order to come up with solutions that become the next hoaxes and scams, will still exist.

Name a hoax and all these steps play out.  How about the scam that carbohydrates are bad for you, or the scam that albuterol benefits all pulmonary disorders.  Consider that back in the 1950s IPPB was thought to enhance distribution of aerosols, and it took about 50 years for that scam to become completely extinct, only to be replaced with some other scam that encapsulates the medical profession.

This post is a facetious respiratory therapy perspective on "The Eight Stages of Scam."

Further reading:

• RT Cave Interview: Debunking the Hypoxic Drive Myth
• The Eight Stages of Scam

Doctors die with grace and dignity

Most non-medical people develop a false belief that modern medicine can prolong the quantity of days a person will live, and that "doing everything" to prolong life will result in a high likelihood of a good quality of life thereafter.

For this reason, I think that every person should spend a minimum of six weeks shadowing a respiratory therapist, nurse, or doctor. Doing so would cause people to learn three things:

1. Everybody dies
2. Death does not always come easy
3. Bad things happen to good people
4. You cannot take the risk out of life

Everybody dies.  As recently as the turn of the 20th century most people dealt with death on a regular basis, as the life expectancy was not that great.  Today, however, thanks to better medicine, people are living longer. This has made it so people don't see death often, and so they develop this false perception that people don't die, or that they will live forever.  

Death does not always come easy.  So they develop this false perception that modern medicine can keep them alive longer.  Sure we can do that. We can intubate you and put you on a ventilator.  We can put a pacemaker to keep your heart beating. We can artificially feed you.  We can clean your bottom. But you may not like the quality of your life once we start doing all of this. 

Bad things happen to good people.  You can be the best Christian in the world and still get sick and die young.  Yes, there is truth to the song, "Only the good die young."  It happens.  

You cannot take the risk out of life.  There's a serious effort in this nation to get people to eat healthy, exercise, get in shape, and lose weight.  Surely there are people who don't take care of themselves and end up as regular patients in hospitals and nursing homes.  Still, there are many people live unhealthy lives who live long lives, and there are people who live perfectly healthy lives who still die young.  So, no matter how much we can try, you cannot take the risk out of life.  You will have 41 year old otherwise healthy men get lung cancer.  It happens. 

CPR works, but not as well as most think

Doctors die with grace and dignity.  Actually, anyone who works with sick people for any length of time develops the skills necessary to die with grace and dignity. This is not always true of the general population, especially in a world where people are not exposed to death, and are exposed to the fantasy world of Hollywood where CPR works an amazing 64% of the time.

There are many examples of CPR being performed in a movie or TV show and the person living.  One such incidence that is fresh on my mind occurred in an episode of "Walker, Texas Ranger," which starred Chuck Norris from 1993-2001.  I described it n my post "No Vent, DNR, or Full Code: What's Your Choice?"

What might confuse people is what you see in the movies. There was one episode of "Walker, Texas Ranger," where Chuck Norris's character was having chest compressions performed on him, and his friend who broke his arm was watching on. Then Chuck woke up, the ambulance arrived, and the person who was taken away on the ambulance was not Chuck, but Chuck's friend with the broken arm.

A recent study performed at the University of Southern California Davis School of Gerontology showed that the survival rate for CPR was actually as high as 37%, although the survival rate of CPR performed on TV was a whopping 70%.  No wonder people get a warmed view of what modern medicine can do.

The study also revealed that:

The depictions show CPR mostly being performed on adults age 18 to 65, when in reality more than 60 percent of CPR recipients are older adults over 65... Also, trauma was behind nearly 40 percent of the CPR instances in the shows, even though traumatic injury cases only account for 2 percent of all CPR usage in real life.

When comparing these results to a similar study conducted in 1996, accuracy rates of television CPR depictions appear to not be improving. And though they seem like harmless entertainment, widespread inaccuracies in medical dramas could have real-life consequences.

Harmless indeed! Some experts speculate that the false perception of what medicine can do has lead many to falsely believe doctors can fix any problem, prolong life by "doing everything" including CPR, and that after "doing everything" quality of life will not be impeded.

This is not harmless.  It causes people to delay dealing with end of life care.  It causes people to avoid discussing with their loved ones, with their doctors, how they want to die.  And considering the difficulty of the discussion, doctors tend to avoid the subject altogether.

Just to provide an example, a 67 year old lady with end stage COPD was rushed to the emergency room by ambulance. The first question the doctor asked her was, "What do you want us to do if your heart stops."  She said, "I want everything done."

An hour later she was intubated and put on a ventilator.  Then her blood pressure dropped so low we couldn't feel a pulse.  Now we are forced to begin full blown CPR with chest compressions.  Yes, this did result in ribs cracking.

The chances of her surviving this are not good.  If she does survive, she's going to still have end stage COPD, meaning she is going to feel dyspneic. Only now she is also going to have some pretty bad chest pain due to the chest compressions.

Did we do the right thing.  Well, the emergency room doctor had no choice.  We had no choice but to follow the wishes of the patient, even though we all knew full well that this patient had set a path to a death that was not going to be very pretty.  She was not going to die with grace and dignity.

What can be learned from this.  Doctors must talk to their patients about end of life care.  They must be honest with their patients.  "Hey, you have end stage COPD.  If you should end up in an emergency room in respiratory failure, what do you want done? How far do you want us to take you with our medicine? Do you want CPR?"

Of course this discussion must progress to a definition of what CPR is.  It may progress to a discussion of what intubation is, and of what a ventilator is? It may progress to a discussion about the difficulty of getting a patient with end stage COPD off a ventilator? It may progress to a discussion of recent studies that show that ventilatory support has yet to be shown as useful in patients with chronic respiratory failure?

Options must be discussed. Hospice must be discussed. It must be explained to the patient that choosing to be a DNR, or choosing hospice, does not mean giving up: it means dying with grace and dignity.

Further reading:

• Wall Street Journal: Why Doctors Die Differently (or find full article at zocalopublicsquare.org)
• RT Magazine: CPR: It's Not Always A Lifesaver, But It Plays One On TV
• RT Cave: No Vent, DNR, or Full Code: What's Your Choice?
• RT Cave: How do people die?

6 Steps to Better Asthma Control

The following was originally published on January 16, 2015 at healthcentral.com/asthma.

6 Steps to Better Asthma Control

So you've come to grips that you have asthma, and now you want to gain better control. Here are five tips to get you started on your way to turning yourself into the perfect asthmatic.

1. See your asthma doctor regularly. Too many asthmatics only see their doctors when they feel sick. A better idea is to find a gallant asthma doctor and make regular visits, no less than every six months until your asthma is controlled, and then no less than once a year. There is no better time than the present to review your doctor situation. You and your doctor must become a team. Only by working with a gallant asthma doctor can you obtain perfect asthma control.

2. Avoid your asthma triggers. Avoiding asthma triggers is one of the most difficult parts of being an asthmatic. Your doctor can help you learn what your triggers are. Once you know what triggers an asthma attack, avoiding them may prevent your asthma altogether.

3. Take your medicine as prescribed. Too often asthmatics have poor asthma control simply because they fail to take their medicine the way they are told. Finding the best asthma medicine for you may be a matter of trial and error, but they only work when you take them every day, even when you feel well (especially when you feel well).

4. Create and follow an asthma action plan. Too many asthmatics play it by ear on how they treat their asthma attacks. A better approach is to work with your doctor to create an asthma action plan. Such plans help you to decide what action to take based on the symptoms you feel.

5. Exercise on a regular basis. Regular exercise, that includes muscle toning and at least 20 minutes of aerobic activity at least three times per week, is one of the simplest things you can do to obtain good asthma control. Check out these tips on how to exercise with asthma.

6. Create a healthy diet. Studies show that a high-fat diet may trigger asthma, and excessive fat tissue may cause asthma. So there is plenty of evidence to suggest that eating a healthy diet is another simple thing you can do to obtain good asthma control.

Links between COPD and smoking

The following was originally published on March 10, 2015 at healthcentral.com/copd.

The link between COPD and smoking

Studies suggest that about 50 percent of people who smoke will develop lung disease. This might explain why so many smokers develop COPD, and why COPD is now the third leading cause of death in the U.S. So what is it that so closely links COPD with smoking?

Chemicals. There are over 5,000 chemicals in a cigarette, and these are inhaled with both first and second hand smoke. They sit on the moist lining of the respiratory tract. While the exact mechanism is yet unknown, long term (chronic), or repeated, exposure to these chemicals has an influence on a person's genetics.

Genetics. Genes cause the release of proteins, and each protein carries out some bodily function. So some genes and the proteins they make are responsible for the normal development and maintenance of lung tissue. Long-term exposure to chemicals in cigarette smoke may cause genetic mutations that result in proteins that destroy instead of build lung tissue. Since each person has a unique genetic makeup, the impact of genetics on COPD may vary from person to person.

Tissues. The proteins from gene mutations cause changes within the lungs. Some prevent the normal development and maintenance of lung tissue, resulting in emphysema. Others cause changes to the tissues lining airway walls, causing airways to be chronically thick and narrowed. Others cause an increase in goblet cells that cause an abnormal amount of mucus. Others cause the destruction of cilia (hairlike structures) lining the airways, making it so this excess mucus is difficult to cough up.

Disease. These changes are permanent, meaning they are chronic (always there). While lung disease will naturally occur in most adults, cigarette smoking speeds up this process by as much as 50 percent, resulting in a diagnosis of lung disease by the ages of 45 or 55. Loss of lung tissue is called emphysema, making it so your lungs have less capacity to move air. Excessive secretions and chronically narrowed air passages is chronic bronchitis. Together these make up a disease called chronic obstructive pulmonary disease, or COPD. 

Living Well. Smoking is proven to both cause COPD, and speed up the natural progression of the disease. While there is no way to reverse the disease process, quitting smoking is proven to slow its progression. This is why it is of utmost importance that you quit inhaling cigarette smoke, whether its from your own or someone else's cigarette.

Further reading:

• How Chronic Bronchitis Affects the Lungs
• The Natural Progression of COPD
• Impact of Genetics on COPD
• 6 Tips to Quit Smoking

How to make health care costs affordable?

There are people, including our current president, who believe the way to lower healthcare costs is to take the profit out of it. They essentially believe people should not be allowed to profit off helping sick and vulnerable people. I would like to argue that this is not true, and that profit is an essential component of medicine, mainly because profit is the incentive to make it better.

According to the July 26, 2009, issue of the Wall Street Journal, Obama accused doctors of being more willing to decide to perform a tonsillectomy rather than search for other treatments because performing surgeries makes more profit for them.  While I don't doubt some doctors do that, it's a rather unfair to assume all surgeons would prefer to operate over treating their patients with less costly and less risky options.

Eduardo Porter of the New York Times even wrote an article about how for profit healthcare is bad, and how not for profit healthcare is good.

He wrote:

Thirty years ago, Bonnie Svarstad and Chester Bond of the School of Pharmacy at the University of Wisconsin-Madison discovered an interesting pattern in the use of sedatives at nursing homes in the south of the state.

Patients entering church-affiliated nonprofit homes were prescribed drugs roughly as often as those entering profit-making “proprietary” institutions. But patients in proprietary homes received, on average, more than four times the dose of patients at nonprofits.

Writing about his colleagues’ research in his 1988 book “The Nonprofit Economy,” the economist Burton Weisbrod provided a straightforward explanation: “differences in the pursuit of profit.” Sedatives are cheap, Mr. Weisbrod noted. “Less expensive than, say, giving special attention to more active patients who need to be kept busy.”

This behavior was hardly surprising. Hospitals run for profit are also less likely than nonprofit and government-run institutions to offer services like home health care and psychiatric emergency care, which are not as profitable as open-heart surgery.

He added:

"One study found that patients’ mortality rates spiked when nonprofit hospitals switched to become profit-making, and their staff levels declined. These profit-maximizing tactics point to a troubling conflict of interest that goes beyond the private delivery of health care. They raise a broader, more important question: How much should we rely on the private sector to satisfy broad social needs?

Essentially, he says that private sector profit seeking health care, higher death rate. Nonprofit medical care, lower death rate.  What he's saying here is that capitalism is bad and socialism is good. I would now like to explain why this entire premise is fallacious.

There's some who say the government should set price controls on medicine so that people can afford them.
Surely this would drop the cost of medicine, but it would also result in fewer medicine because profit is currently the incentive for pharmaceuticals to take the risks of finding that new medicine.

There's some who will say that the government should run healthcare, and the government should run the pharmaceutical market.  They want to do this because they don't think people should be making profits off the sick. In this case, doctors and nurses and pharmacists would all be paid the same. The problem with this is that it would take away the incentive and the desire to choose those careers.

Another problem with this is the government will eventually run out of other people's money to pay for it. When this happens, decisions will have to be made where to make cuts, and the risky and expensive pharmaceutical market could easily be one of them. Individuals will no longer have a choice between an expensive newer inhaler that works better than an older cheap version of a similar medicine.

Another scary thought here is that the government could also decide who gets what medicine.  Lord knows that Advair works better than Flovent, although Advair costs a ton more. The government official may decide that since Flovent is cheaper that's what asthmatics are going to get.

This is already starting in a way. I did an experiment with nearly every asthma combination inhaler on the market.  I tried Symbicort and Dulera, and both made me jittery.  I tried Advair and it works good.  I tried Breo and it makes me feel like I don't have asthma. Yet my health insurance won't pay for Advair and Breo, claiming that the other medicines are the same thing yet they are cheaper.  You see, we already have less choice at the expense of worse asthma control.

Another way the government could cut costs would be to decide in favor of a productive 40-year-old member of society getting a prescription for Advair at the expense of the 100-year-old lady with a will to live a quality life.

A similar situation was addressed at an ABC prime time special back in 2009 when a woman told Obama, about her one hundred years old mother who really had a will to live. She has a great spirit, a great will to live. She said, "My question to you is, outside the medical criteria for prolonging life for somebody who is elderly, is there any consideration that can be given for a certain spirit, a certain joy of living, quality of life? Or is it just a medical cutoff at a certain age?

Obama essentially said, "No. That's too nebulous. The will to live? How do you assess that? No, probably the compassionate thing to do is just give them a painkiller."

When it comes to respiratory diseases, that 100 year old lady will get the cheap pill that doesn't work as well as the $250 inhaler. Probably the logical choice would be to just give her a painkiller and wave good bye. When someone else is paying you don't get to choose. 

Essentially, drugs do not cost too much because of greed on the part of pharmaceutical companies: they are high because of the risk involved in trying to find new medicines to help people like you and me. And they have to make a profit because that's why they hunt for better medicine in the first place. So rather than complain that pharmaceuticals are greedy, we should be thanking them.

I believe that the way to improve healthcare, and to lower costs, is to try something that has never been tried before: Capitalism.

Further reading:

• whitehouse.gov: Remarks By The President In ABC "Prescription For America" Town Hall On Health Care, 6-24-09
• NY Times: Healthcare and Profits a Poor Mix
• Wall Street Journal: Dr. Obama’s Tonsillectomy
• Newsbusters: Surgeons Rebuke Obama's $50k Per Amputation Claim, Media Mum

Why is healthcare a such mess? How can it be fixed?

Your Question:  The healthcare system is a mess.  How did it get this way? What is the solution?

My Answer:  Let me start by saying that in front of me right now is a bill from Paula Sterns Hospital in Ludington, Michigan, from March of 1943.  It is the bill for my grandma's entire three day stay when she had my dad.  The cost was $23.00.  The ambulance bill was $2.  If you adjust these bills for inflation, they come to $317.26 and $27.59.

The cost of just one breathing treatment today is $123.00, so you can easily see that something occurred in healthcare that inflated the cost of it by a stunningly high margin way over the rate of inflation.  What happened was that, during the 1960s, the progressives decided that the healthcare system was messed up and they could fix it. So they created regulations. So now hospitals have to hire people to make sure the regulations are met.  To pay these people the cost of healthcare increases.

In the 1970s they realized that the prices were too high for many people, so they had to come up with another solution. This time they created medicare and medicaid and DRGs and more regulations.  To make sure regulations are met, more people must be hired.  To cover the cost, prices go up.  But now people still can't pay, so third party system is created.  So now the hospital bill does not come directly from the hospital at all, but from insurance companies.  So not only do you have to pay the hospital bill, now you have to pay an insurance bill as well.

So this is the system until 2010.  Now you have healthcare prices that have skyrocketed beyond belief. You have 40 million people who have no insurance at all, some by choice and some not by choice.  You have the same people who messed up the system in the first place try to fix the problem, once again, with more government.  More regulations are created.  Hospitals now have to hire hundreds more personnel just to make sure regulations are met.  This is done at the expense of patient care, even though it is meant to improve patient care.  Instead of prices dropping, they skyrocket once again.

So who is going to solve the problem now.  Hopefully not the government.  The government got involved in healthcare during the 1960 and created the same problems they propose to fix.  And the more they try to fix it with their ideal solutions the more they make it worse.  They do not ever solve the problems they propose to fix, they only succeed at creating chaos.

The solution to all of this is simple: let capitalism work.  That's the only thing that has not been tried, at least since the 1960s.  When you go to the hospital to seek a service, you should get a bill from the hospital for that service.  The price would not include any middlemen, and therefore would be very inexpensive, like it was in 1943 when my grandma only paid $25 for an entire hospital stay.

Surely the price would be a little higher due to inflation and technology, but price of healthcare today is beyond reasonable.  Why? Because, back in the 1960s, government officials, sitting around a table in leather chairs drinking coffee, decided they could make it better.  Did they? Absolutely not.  These people need to get out of the healthcare industry, and let the people, the markets, the states, solve the healthcare crisis.

The real solution is capitalism. Here you would have individual hospitals compete for your services.  What one hospital did best to win you over, other hospitals would copy.  When one hospital creates a program that fails, other hospitals will not copy that program. That is what's needed. Competition is the best method of driving down prices.  If you charge too much, people can go somewhere else.  If you provide good service at a good price, then your hospital will be the one chosen.

I am not naive.  I understand there are outside forces involved in price increases.  There is better technology today, there is better education that costs more, etc.  But, still, the healthcare solutions since the 1960s have all come from Washington, and everyone of them has failed to solve the problem.  And so many people say, "Well, what else can we try?"  I propose to try capitalism, because it is the only solution that has yet to be tried -- at least not since 1943.

Study links rescue inhaler overuse to depression

A new research study reveals that "overuse of rescue inhaler in chronic asthmatics linked to depression." While the researchers were not conclusive on how to interpret these results, they seem to be leaning towards blame the asthmatic.

The study was conducted by the University of Arizona and involved 416 patients.  The results were as follows:

• About half of all participants used albuterol as expected, while 27 percent of participants overused albuterol and 22 percent underused albuterol.
• 45 percent of over-users used albuterol on a daily basis.
• Participants across the board used albuterol on symptom-free days about 20 percent of the time.
• Eighty-eight percent of daily users were over-users of albuterol.
• Over-users had more days in which they had symptoms and scored worse on the asthma control questionnaire, the shortness of breath questionnaire and the asthma symptom utility index.
• Over-users of albuterol had worse mental functioning when compared to expected users of albuterol.

So that was the first part of the study.  The participants were also studied to see how they scored on a depression test, with the following results. 

• 19% of those who underused albuterol had a depression score of 16 or more
• 17% of those who used albuterol as expected had a depression score of 16 or more
• 32% of those who used albuterol too much had a depression score of 16 or more

Researchers who interpret studies concluded the following: 

What isn’t clear is whether depression leads to worsened asthma symptoms and an increase in albuterol use or whether albuterol use contributes to the development of depression. Asthma has a significant relationship with one’s mental status, and emotional states like anxiety can contribute to asthma exacerbations, leading to the need for a rescue inhaler.

It also isn’t clear whether or not albuterol over-users were more or less compliant with the chronic medications asthmatics take on a regular basis in order to avoid exacerbations of their disease process. If this is the case, doctors need to educate patients — depressed or not — on the use of chronic asthma medications so rescue inhalers like albuterol are less necessary.

My problem with these results is this: Why do they always blame the asthmatic?  If I don't have good asthma control, it's because I don't take my asthma controller medicines.  Plus, how do you define albuterol overuse? I mean, I know they define it as using it more frequently than a doctor prescribes for, but how do they know the doctor is right.

Let me put it this way, many recent studies have confirmed that corticosteroids, a top line medicine used to reduce inflammation in asthmatic lungs to make them less sensitive to asthma triggers, does not work on those with severe asthma. Inhaled corticosteroids do not help those with severe asthma gain good asthma control.  So these patients, by default, will need to use their rescue medicine more frequently.

Likewise, most asthmatics do not have pure asthma, or asthma by itself.  Like myself, most asthmatics have something else with it, like allergies.  Actually, studies show that 75% of asthmatics also have allergies, and this is a double whammy.  My point here is that, even if you have good control, you can still have trouble breathing on a regular basis.  You may still need to use your rescue inhaler daily.

Yes, if you have pure asthma you shouldn't need your rescue inhaler more than 2-3 times in a 2 week period. There are many asthmatics who would fall into this category.  Still, there are likewise many asthmatics who do not qualify for this method of defining control because they do not have pure asthma.

I describe what real asthma control is in my post"What is good asthma control?"  I wrote:

The National Heart Lung and Blood Institutes (NHLBI) Asthma Guidelines define control pretty much the same as the GINA guidelines: Control is the degree the above guidelines are met plus the degree YOUR goals of therapy are met.

Your goals may be:

• I just want to be able to walk
• I want to be able to exercise
• I don't want to miss any more school or work due to my asthma

Another means to monitor control is your own personal satisfaction. Are you satisfied with your life given your asthma severity?

Plus this notion of monitoring control by how often you use your rescue inhaler doesn't work if you don't have pure asthma.  For instance, my current doctor ordered my rescue inhaler to be used four times a day. Well, how does he know when I'm going to be short of breath?  Sometimes I go weeks without using it. Other times, such as right now when I have a cold, I use it several times a day.

My point here is that you need to be careful when reading the results of research like this.  You have to take what you read, even in peer reviewed journals, with a grain of salt. While the studies themselves come to accurate conclusions, the people who interpret the results sometimes get it wrong.  They get it wrong because they do not have asthma so they don't know what it's like.

Further reading:

• Eureka Alert: Study: Severe asthma fails to respond to mainstay treatment
• Hardluck Asthma: What's it like to have asthma?
• NHLBI: Asthma Guidelines
• RT Magazine: overuse of rescue inhaler in chronic asthmatics linked to depression
• Lung Disease News: Overuse of rescue inhalers in asthmatics linked to depression
• Healthcentral: What is good asthma control?
• Healthcentral: How to obtain good control of your asthma?

What is Rescue Medicine?

The following was originally published at healthcentral.com/asthma on December 18, 2014

What is Rescue Medicine?

Dictionary.com defines “rescue” in part as “to free from violence or danger.” Since an asthma flare-up (attack) is a violent reaction within your air passages that places you in impending danger, it’s only fitting that the medicine discovered to end asthma flare-ups be referred to as “rescue medicine.”

Asthma is a medical condition where the cells lining the air passages (bronchioles) are chronically inflamed. When exposed to asthma triggers, the inflammation worsens, causing muscles lining these air passages (bronchial muscles) to spasm and contract. These muscles, in essence, squeeze the air passages, making it difficult for air to get out of your lungs, creating a feeling that you can’t catch your breath (air hunger, dyspnea, fish out of water).

Since asthma is a reversible disease, it can be reversed either by waiting it out, or by using medicine. For most of history, since most medicine caused only mild relief, most asthmatics were forced to suffer until the symptoms ceased on their own.

So, what exactly does this mean? What is rescue medicine? This means that the medicine, once injected or inhaled, is attracted to and attaches to beta 2 (B2) adrenergic receptors that line the respiratory tract. A chemical reaction then occurs that causes bronchial muscles to relax, causing air passages to open up (dilate), thus ending the asthma flare up.

While this type of medicine is generally referred to as rescue medicine, it is also commonly referred to as bronchodilators, beta 2 adrenergic medicine, or simply B2 agonists.

While epinephrine worked great to make breathing easier, it also worked like a charm as a vasopressor. In other words, while it was a great asthma rescue medicine, this came with many systemic and undesirable side effects, such as increased blood pressure, fast and pounding heart rate, tremors, increasd anxiety and nervousness.

The good news is that, over the years, scientists learned to make synthetic medicine (made in a factory) that mimics the B2 response of epinephrine but avoids the B1 and A1 response. This means that the medicine works better than epinephrine with negligible side effects.

Epinephrine is still available, although it's mainly reserved for emergency situations in hospitals. The most commonly prescribed asthma rescue medicines today include albuterol (Ventolin), which was introduced to the market in 1969, and levalbuterol (Xopenex), which was introduced to the market in 1999.

Albuterol and levalbuterol are available in hospitals and for home use by asthmatics, and are inhaled into the lungs by either using a rescue inhaler or a nebulizer.

1. Rescue Inhaler: This is an small, easy to use portable device that can easily fit into a pocket and can be taken with you wherever you go. It usually takes just one or two puffs to end an asthma attack. While generally referred to as rescue inhalers, they may also be called “asthma inhalers” or "puffers.” Because they are easily portable, inexpensive, and easy to use, they work fine for most asthmatics in most instances. Check out my post "How to use an inhaler."
2. Nebulizer: This a small cup with a mouthpiece. The medicine for this comes in tiny plastic amps. The amps are opened and the medicine is poured into the nebulizer cup. The nebulizer is then connected to a small air compressor that turns the medicine into a mist to be inhaled using the mouthpiece over 10-20 minutes. These are not as portable as inhalers, although most asthmatics say that they work better during severe asthma attacks. Check out my post "How to properly take a breathing treatment" and "What is a nebulizer?"

Most asthma guidelines recommend that all asthmatics have some form of rescue medicine on hand at all times, whether it be in the form of an inhaler, nebulizer, or both. Providing asthmatics with a prescription for rescue medicine is usually the first thing an asthma physician will do once the diagnosis of asthma is made.

While every asthmatic should have access to rescue medicine, it is no longer considered a top line asthma medicine. This is because emphasis has been changed from treating acute asthma symptoms (flare-ups, asthma attacks) when they occur, to preventing and controlling asthma.

Today, asthma is generally controlled using asthma controller medicines, such as Flovent, Advair, Symbicort, Dulera and Singulair. Studies show that when these medicines are used every day, they help to both control and prevent asthma, thus eliminating (or greatly reducing) the need for rescue medicine.

Yet even people with controlled asthma may still have asthma flare-ups from time to time, and it's for this reason every asthmatics should have both an Asthma Action Plan, and a rescue inhaler or nebulizer available at all times.

The natural progression of COPD

The following was originally published at healthcentral.com/copd on March 4, 2015.

The Natural Progression of COPD

Lung tissue naturally breaks down with age. Smoking, however, speeds up this breakdown, causing smokers to develop lung disease at an abnormally young age.

Nowhere is this shown better than the Fletcher-Peto Curve. The first time I saw this curve was on the wall of a pulmonologist’s office. Perhaps the reason this is an ideal spot for such a curve is best explained by Scott Cerreta in “It’s Never Too Late To Stop Smoking,” AARC Times:

“Health care professionals should learn how to use some version of the Fletcher-Peto curve in their discussions with patients about quitting tobacco use. The lungs and lung damage can be very abstract for patients, but showing them a graph gets their attention. Immediately, they wonder, “Which line is me?”

The curve was created by Charles Fletcher and Richard Peto by using data from an eight-year study of working English men. It was published in a 1976 report, "The Natural History of Chronic Bronchitis and Emphysema."

The curve is criticised by some due to the short duration of the study. Still, regardless of its limitations, COPD experts were so impressed by it that they even used it when defining the disease for the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.

The study measured FEV1 by spirometry over the eight-year period. This is essentially the measure of how much air a person can exhale, after a deep inhalation, in one second. It's a measure of expiratory airflow. Learn more about FEV1 and lung function from my previous post.

The chart shows that people who never smoked will lose lung function over time, and this process increases with advanced age. This explains why people over the age of 75 who never smoked develop what is called senile emphysema. It's a natural process.

For those who chronically smoke cigarettes, this natural loss of lung tissue and airflow will speed up by as much as 50 percent compared to those who never smoked.

Usually people who smoke will start displaying symptoms -- like a cough or shortness of breath with exertion -- between the ages of 35 and 45. But most do not recognize these symptoms before the age of 55, mainly because the disease progresses so gradually, and most people simply attribute it to the normal aging process. This might explain why over 12 million Americans have COPD but don't know they have it.

So the age of 55 is the average age at which symptoms become so severe that they require the need to seek medical attention. Usually, by the time this occurs, about 50 percent of lung function is already lost.

Another neat thing about the curve is that it shows that, while you cannot undo damage that has already occurred due to smoking, quitting smoking can prevent further damage. In fact, it shows that quitting smoking at any time in one’s life slows the progression of the disease, thus prolonging life. So this justifies the adage used by many physicians and caregivers during their attempts to encourage smokers to quit: “It’s never too late to quit quitting!”

There is one other statistic that came from this report: about 13 percent of people who smoke will develop COPD. This percentage is often rounded off to 15 percent, and sometimes 20 percent. Recent studies, however, have upped it to as high as 50 percent.But more research is required to support this number.

Further reading:

• 6 Tips to Help You Quit Smoking
• 10 Tips to Live an Active Life with COPD
• When to Seek Help for COPD
• Gaining Control of Your COPD
• Coming of Age: It’s Never Too Late To Stop Smoking

H.R. 3862: Obamacare Amendment

H.R.3862 - Respiratory Care Amendment to Obamacare 115th Congress (2015-2016)

Sponsor: Rep. Ding, Bill  [R-NY-11] (Introduced 03/06/2015)
Committees: House - Ways and Means
Latest Action: 04/23/2015 Referred to the Subcommittee on How to Screw Up Healthcare Even More

Shown Here:
Introduced in House (03/06/2015)

Amendment to Obamacare  - Amends the Patient Protection and Affordable Care Act of 2010 to:

• Creates many senseless policies to ensure a high procedure count for respiratory therapists; to assure that they can keep their jobs; to keep the U3 unemployment number as high as we can get it so we can assure the president looks good.
• Authorize the newly created state police to better prepare patients for emergency services in the hospital setting.  
• Mandate that all patients with lung diseases be clean shaven so it's easier to fit a BiPAP mask over their faces.  
• Based on studies that show the COPD patients who wear BiPAP at home are less likely to make repeated and costly visits to the emergency room, it is requires that all COPD patients be fitted with, at a minimum, the cheapest BiPAP equipment and be required to wear it between the hours of 10 p.m. and 6 a.m.  Settings will be made up by physician rather than wasting government monies on sleep studies or relying on a respiratory therapist who knows how to actually manage the BiPAP.
• Requires all physicians to talk to their patients about end of life planning so physicians no longer have to waste their time asking, and respiratory therapists and nurses no longer have to waste valuable time that could be spent watching reruns of Columbo wondering.  
• Requires that all respiratory therapists prioritize emergency room patients over all other patients, even if the patient in ER was using it as a medical clinic.  
• Further enforces that all patients who are to be admitted to the hospital must be sick enough to have received three bronchodilator breathing treatments in the emergency room.  
• Once admitted to the hospital, all respiratory patients or patients who produce or might eventually produce annoying lung sounds (i.e. asthma, pneumonia, heart failure, pulmonary fibrosis, kidney failure, faux pneumonia, phthisis, lung cancer, ETOH, dehydration, Sepsis, DIC, altered mental, over the age of 85, on a ventilator, will be on a ventilator, might need a ventilator, requires BiPAP, smells nasty, is annoying to nurses and doctors, sun downers, etc.) must require at least a minimum of four breathing treatments a day to meet criteria for admission and criteria for 
• On the other hand, if a patient really does require 3-4 breathing treatments in the emergency room, this certainly does qualify them for admission.  It is, however, essential that these patients be ordered to receive Q4ever breathing treatments. 
• Initial orders for breathing treatments for children under the age of 10 must include Q2 times 4, Q3, times 4, then Q4-6.  It is also highly recommended that mucomyst and pulmicort be thrown in.
• No two respiratory medicines can be mixed in the same nebulizer.
• All nebulizers must be cleaned with normal saline after each use by a respiratory therapist.  Surely there is no evidence this will do any good, but it makes us feel like we are doing something useful
• Requires that all patients show evidence that they are trying to obtain their ideal body weight, with a three year time frame to obtain it.  Punishment for violators is: 1st offense -- 3 days forced BiPAP with a rate set 6 higher than spontaneous rate; 2nd offense -- one practice intubation and extubation (to be performed after office hours as to not interfere with profitable hours); 3rd offense -- a practice intubation by a first year respiratory therapy student followed by one day on a mechanical ventilator without any sedation and run by a physician who barely passed med school and was trained at the same school that teaches physicians not to oxygenate ALL COPD patients.  
• The 15 year phase-in of a respiratory therapy bachelor's requirement for all respiratory therapists, because just having an associate's degree does not qualify someone to know more than a physician. Of course a bachelor's degree won't either, but, hey, we like to create laws that don't make sense. Violators will be subject to an increasing workload of stupid doctor orders until retirement (which may be forced, because dogmatic, seasoned therapists know too much and must be stopped from educating the young ones that we are tying to indoctrinate.  
• Nurses and respiratory therapist must scan a patient's band and the medicine prior to administering a medicine, regardless of how urgent it is needed.  Patient suffering and risk of not administering a medicine is no reason to skip steps and cut corners.  Punishment for violators is spend a week doing nothing but making wrist bands for patients. 
• Punishment for taking the time to check and see what someone else charted and just copying it is branding with the word "Dipshit!" or "Dingdong!" on forehead.  
• Respiratory therapists are no longer allowed to write "no change" or "no difference" in the post treatment assessment phase.  The reason for this is because we know (we, as in people who sit in suit coats in Washington) that no doctor would order a breathing treatment unless it had some potential benefit.  "No Effect" is likewise unacceptable in the post treatment charting area.  Punishment for violation will be to read the entire 3,000 pages of the Patient Protection and Affordable Care Act

New Bronchowatch to set frequency of bronchodilators

From the inventors of the famous Wheezoscope, Telekinoscope and the GPSoscope comes an amazing new invention called the Bronchowatch.

The watch consists of a telekinoscopic fluxometer incorporated with the newly patented flux capacitor fire HD that sends electomagnetic waves across a wrinkle in time to each 30 minute increment from the time the little black button to the right of the watch is pushed until the patient is discharged.

In this way, the watch will let physicians know exactly when a patient will be short of breath so they no longer have to just guess.

A study of 4 patients with COPD,  1 with asthma, 2 with cystic fibrosis, and 1 with generic respiratory distress, revealed that the Bronchowatch was 100% accurate in predicting when shortness of breath will occur.

The watch shows the doctor if treatments should be ordered Q30, Q1, Q2, Q3, or Q4.  If dyspneic periods are not found during a scope of the next four days, the watch will automatically check for any other possible indications for a bronchodilator, such as:

1. Patient develops pulmonary edema
2. Patient develops rancid smelling farts or shits (in which case the treatment will be scheduled as to make sure it is still going when the smelly flatuence occurs)
3. Patient is about to become unruly, and the nurse will require assistance
4. Patient gets dyspneic due to exertion
5. Patient gets lonely or depressed (in which circumstance Palbuterol will be indicated)

If no such instances are found, Augur Lungs, the manufacturer of the Bronchowatch, recommend albuterol be scheduled BID, TID, and QID in order to prevent those frequencies from feeling left out.  This will assure that adequate secretion enhancement and clearance takes place for these patients. 

"I used to wonder how emergency room doctors could order albuterol Q30 minutes until discharge even before the ambulance arrived," said Jared Smart, an LRT at Jefferson Medical Center.  "I would get irritated and grumpy.  Then I saw a doctor with this cool watch and a light came on. He explained to me what it did. Now I get happy when he orders treatments because I know they are needed... or at least I know they will be needed."

The watch will be tested on two more patients. Upon completion of the study, the Bronchowatch will be made readily available right here at the RT Cave. 

Breathing Treatments: The ideal way verses the real way

When I have a respiratory student I can't help but think of the two different worlds we live in side by side, at the same time, and these are the ideal world and the real world.  We as therapists try to live as though we are in the ideal world, although ultimately find shortcuts, we need shortcuts, to help us adjust to real life situations, and so we end up working in the real world.

For the purposes of discussion, allow me, once again, to define the two worlds we live in.

The ideal world:  The ideal world is the one concocted in a lab, it's the fake, world. It's euphoria. It's the place where everything is supposed to work as designed. It's where everything is perfect. In this world you walk into the room, identify the patient, and then leave the room to go to the pyxis to get the medicine. Then you go get the computer, log in, find the patient in the computer, click on the patient, and log into the emar. Then you grab the scanner and scan the patient. Then you scan the medicine. Then you assess the patient, and chart your assessment. Only now do you open up the medicine and start the treatment.  Then you ignore the patient (because in the ideal world the patient doesn't need you) and you chart. Then you look at the patient, maybe talk to him or her while you wait for the treatment to be done. And of course all this time no one else needs you, because in the ideal world you can pay 100% of your attention to just one patient at a time. Then the treatment is done.  You stop the treatment. You take the nebulizer to the bathroom where you take it apart and rinse it out in sterile water. Then you assess the patient again. Then you do your post treatment charting. Only now do you leave the room and move on to your next procedure. In the ideal world everything goes according to plan, and every solution is manufactured, as if in a factory.

The real world:  This is how things really work.  This is reality.  This is where things do not work as planned, because in the real world you never know what to expect.  In the real world there are outside forces placing pressure on you to take shortcuts so you can get done with this faster so you can move on to another task.  In the real world the patient wants to talk to you, or the patient may need you for some other reason, like walking to the bathroom or setting up a tray.  In the real world the patient matters.  In the real world you might need to talk to a nurse during the treatment.  In the real world all sorts of stuff happens that you cannot plan for in a factory, things that might pull you away from the patient and the computer.  It is the real world all the solutions manufactured in a factory (or in the case of medicine, in leather chairs in Washington D.C.) do not work.  In the real world you walk into the room, identify the patient , and start the treatment. Then you assess the patient. Then you log into the computer and scan the patient and the medicine. Then you chart the pre and post assessment and log out of the computer real fast.  Then you sit and pay attention to the needs of the patient.  You might have a discussion about how much the healthhcare profession is messed up.  Then you do you post treatment assessment and then stop the treatment, coil it up in a bag and set it on the windowsill.  Then you move on to your next procedure.  You jot down a few notes, maybe, and later (when you have time, if you get time) you log back into the computer and chart your post treatment assessment.  This shortcut, real world, way of doing a treatment is the only way that works in the real world, otherwise you would be so far behind you'd never get all your word done.

Of course, if they ask, you did it the ideal way.  You are, in this way, a trained politician; a trained liar.

You see, this is a perfect example of how everything in this world, including medicine, is politicized.  It's not based on science, it's based on politics. You have these people sitting in leather chairs, the so called experts, who think they can fix all the problems of healthcare with their pens and their papers, and then what they do is they create this ideal, fiction, euphoric world where everything fails to work as planned and chaos ensues. Their attempt is to increase safety and reduce costs, and what ends up happening is they make things less safe and more costly. This, my friends, is socialism at its best.  What we have in 2015 is a healthcare system based on socialism.  That is why it is failing. That is why nurses and doctors are so frustrated with it.

So, anyway, that is the difference between the ideal world of doling out breathing treatments and the real world way of doing it.  Surely, you want to do it the ideal way.  But in the real world, nothing ever works out as planned.  In the real world you play it by ear and use common sense, because nothing else works. If you sit and try to be ideal, you will fail to be a good respiratory therapist.  The trick is to find a way of being real and safe at the same time.  It is hard, and it takes effort.  And it can be done.  It would probably drive prices down too.  In fact, I know it would.  Because the only thing that has never been tried in healthcare is capitalism.

Further reading:

• Articulating Ideas: Idealism versus Realism
• RT Cave: Real World Versus Student World

Kid asthmatics love their respiratory therapists

The final asthma comic I did was not supposed to be my last.  However, after I wrote this one the comic budget was cut and no further comics were made.  Sad!  It was such fun doing these.  Plus I had not even gotten into the Goofus and Gallant Asthmatic posts that I had initially planned to do.  I eventually did write some posts with these characters, although these weren't as fun as the comics would have been.

This last post was based on a true story.  I was sitting here in the RT Cave when one of my senior coworkers (her name was Joella), said to me, "You know what!  I remember one night...," What she told triggered my memory and the idea for my last comic.  You can read the accompanying post, "Kid Asthmatics love Their Respiratory Therapists."

While hospitalized with asthma symptoms as a child, I encountered many different respiratory therapists -- some more warm and compassionate than others. Years later, he discovers that one of his co-workers
had left a special impression on him. Illustrated by Dash Shaw. Originally published at healthcentral.com/asthma.

The Doubting Thomas Asthmatic

Some adults just contribute the gradually increasing shortness of breath to aging.  So when they present to the emergency room, and you offer an asthma remedy, they doubt they have a need for it.  They probably would not even have sought help if not for the insistence of their wives.  They are, no doubt, your prototypical Doubting Thomas Asthmatics.  While I came up with the idea, it was my publisher who came up with this name.  You gotta love it!  You can probably throw COPDers into this category as well.

You can read the accompanying article: "Doubting Thomas Asthmatic: The Modest Asthmatic."

The Doubting Thomas is an adult with asthma symptoms or who has recently been diagnosed with asthma who just doesn't believe that asthma is their problem, and they may avoid treatment because of their doubt. But Rick Frea knows what to do with them. Illustrated by Dash Shaw.  Originally published at healthcentral.com/asthma. 

Medicine based on consensus, not science

Medicine is an art based on science.  Much of medicine is based on flawed science. Or, as Richard Feynman once said, science is the belief in the ignorance of experts. 

Much of science is not even science: it's consensus.  It's basically the world's leading experts voting on what they think is fact, rather than waiting for the evidence to reveal the truth.  It's creating theories and voting on which ones should be in the forefront of our minds.  So when deciding on what to believe, we must never forget that "science is about evidence, not consensus."  

It is so hard in the medical profession to separate consensus from science.  In fact, one of the things that fascinated me most about the medical profession is it's loose relationship with science.  In fact, early on in my studies I learned that medicine is loosely based on science, and more so based on consensus, which is not science at all. 

Look at the hypoxic drive theory.  It was based on a study of four COPD patients, and became a gold standard based on a presentation by EJM Campbell to pulmonologists in 1960 about the results of a study based on only four COPD patients.  So basically the hypoxic drive theory, or hoax as I like to call it, was based on a consensus of experts, and had nothing to do with science. 

So basically physician's under oxygenated their patients for over 70 years, and many still do, based on a consensus.

Look at all the breathing treatments we give based on a consensus that albuterol cures every lung ailment you can think of. Our new healthcare law insists that a lung patient must be sick enough to need 3 breathing treatments for reimbursement criteria to be met. This includes COPD, CHF, Asthma, Pneumonia, etc. So 3 breathing treatments are ordered on all these patients, and it's assumed they are needed. What's wrong with this picture? It certainly has nothing to do with science. 

Other examples of consensus over science include:

• BiPAP pushes fluid out of lungs
• The earth is flat
• Man made global warming
• The continents cannot drift
• Stress causes ulcers
• Asthma is one of the seven pychosomatic disorders
• Phlogiston was necessary for combustion to take place

All of these theories are, or were, so widespread, and so well accepted, that they caused people to focus on treatments and therapies that probably did more harm than good (like under oxygenating COPD patients). As in the case with asthma, consensus caused experts to focus so much on a dead end path that it prevented the advancement of knowledge to the detriment of those who suffered from it (i.e., experts focused on treating asthma with psychosomatic medicines when they should have been looking treatments for inflammation and bronchospasm). 

So when you're thinking about whether or not you want to believe something is true, consider the evidence and not the consensus.  The fact that a majority of people believe something to be true does not make it so. In other words, it's okay to oppose the majority opinion, so long as the evidence is on your side. 

When a doctor orders something, it's your job as a therapist, or a nurse, to do as you are instructed.  For instance, if a doctor orders you to give a breathing treatment, then you must give it regardless that you know it is a waste of time.  As the old saying goes, "It can't hurt." 

Still, it really does hurt, because you're putting medicine into someone that doesn't need to be there, and, even though we can't always see them, all medicines come with side effects.  And then there's also the side effect of second hand ventolin on those who are doling it out all day long.

However, when a doctor orders for you to maintain an SpO2 in the low 80s because of the hypoxic drive myth, it's time to rise up and challenge the consensus for the benefit of the patient, because, Lord knows, oxygen is beneficial to the living heart. Thankfully the hypoxic drive consensus/hoax is slowly fading, and COPD patients are actually being oxygenated these days. 

Further reading.

• Rush Limbaugh: Peer Reviewed Science Exposed as Fraud
• NY TIMES:  Many Psychology Findings Not As Strong As Claimed, Study Says
• Wall Street Journal: Science is About Evidence, Not Consensus
• RT Cave: Second Hand Albuterol