Refusals

Nothing is better than a good ole refusal.  You might as well refuse that of which is unindicated and superfluious anyway.  I wish more people would stand for their right and refuse therapy.  It makes my job easier, it makes their life better, and it saves the hospital and Uncle Sam money. 

It seems that in a world where most of what we do is to make money, or to prevent a lawsuit, the result is a lot of stuff being done that is not scientifically proven to do any good.  Sometimes doctors order stuff just for the placebo effect (Ventolin anyone?)

So, just so you know, it's okay to refuse treatment.  If you think something isn't doing you much good, don't be afraid to question the doctor, or simply refuse.  A wise doctor will not think any less of you for it, and your RT will probably be happy to stop by for a chat, and not give you the drug you don't need. 

Thoughts?  Or am I way off on this?

When do you end a breathing treatment?

A question of much debate in the respiratory therapy community is when to end a breathing treatment.  Many hospitals have a policy that the treatment should last up to ten minutes, while others contend it takes less than five.

Some respiratory therapists, and many patients, tap the nebulizer until they presume all the medicine in the cup is gone, while others simply end it once the medicine in the nebulizer cup starts to sputter.  So who is right and who is wrong?  Is tapping necessary?

According to the experts a breathing treatment ends when the medicine starts to sputter, and by this time most of the medicine is gone.  This was discussed by Dr. Bruce Rubin and James Fink, RRT, in their 2003 article, "The delivery of inhaled medication to the young child," in Pediatric Clinical of North America (50, pages 717-731).  They write:

Most of the available medication in the nebulizer cup is nebulized in the first
few minutes [10]. All nebulizer cups have some amount of medication remaining
near the end of therapy, when aerosol generation becomes intermittent. This
intermittent nebulization is referred to as sputtering; it has been documented that
aerosol delivery to the patient declines by half within 20 seconds of the onset of
sputtering [13]. At this time it is appropriate to discontinue therapy.

Accordingly, the the study showed that (2, page 316):

Albuterol delivery from the nebulizer stopped with the onset of inconsistent nebulization (sputtering).  Continuation past the past the point of jet nebulizer sputter is ineffective and should indicate an end of the treatment.  

So there you have it.  Now you know when is the best time to end a treatment.

Further reading:

• Most of aerosolized medicine is wasted

References:

1. Rubin, Bruce K, M.D., James B. Fink, RRT, "The delivery of inhaled medication to the young child," Pediatr Clin N Am 50 (2003) 717– 731.  Note:  James Fink is one of the foremost experts on aerosol delivery and has been involved in many tests and written many articles on the subject.  You should Google him to see what else he has written.  You might be impressed.
2. Hess, Dean, Neil MacIntyre, Shelley Mishoe, William Galvin, editors, "Respiratory Care Principles and practice," 2nd edition, 2012, Jones and Bartlett, page 316

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?

22 tips to get treatments done on those busy days

So you're having a busy day. Doctors are writing orders left and right, ER is calling you every 15 minutes, and now you have ten breathing treatments due all at once.

Or perhaps you have time now, and you're expecting the worse to happen anytime.

Or perhaps you are the night shift RT and you are working by yourself.
Here are ten tips to help you get the job done fast and efficient:

1. Get a good report. Know who really needs the treatments and who doesn't. If you need further tips regarding this, click here.
2. Prioritize. Do Q2 treatments first. If a patient needs treatment, do it.
3. Do Q4 treatments second.
4. Do Q6 hour treatments third
5. Know QID treatments can be done at your convenience unless the treatments are indicated. Unless indicated, don't worry about these. Get them done when you have time.
6. Don't sweat about TID and BID treatments. If the patient was truly in need of treatments they wouldn't be scheduled this way.
7. If you know someone doesn't need a treatment, don't try to talk him into it. Don't be afraid to chart that the patient refused.
8. Know that Q4 hour treatments can be done 1/2 hour early or late. If you're just standing around, do them a half hour early.
9. Know that Q6 hour treatments can be done 1 hour early or late. If you're just standing around, do them an hour early.
10. I know you love to, but don't chit chat with your patients
11. I know you love to, but don't ask the patient if there is anything I can get for you
12. Don't wait until all the mist is gone. Studies show the medicine dissolves first, so once the medicine starts to sputter it's just water
13. Don't be afraid or too proud to call for help.
14. If you work nights, talk to your patients at beginning of your shift and ask them if they want to be awakened during the night.
15. Assess the patient really good after you start the treatment in case you don't have time to re-assess afterwords
16. If you get called away, ask the nurse to finish therapy (this should only be done when urgent). If you abuse this nurses will lose respect for you.
17. Talk to doctor to see if you can get un-needed treatments discharged
18. Take full advantage of protocols that allow you to discontinue non-indicated therapy
19. Keep an amp of Ventolin in patient's room if the patient is really labored or is in serious need of on-time treatment. If necessary the nurse can give it.
20. Don't wake pt that is sleeping comfortably. Follow step 14 if possible, otherwise chart refused. This is also why it's good to follow tip #1.
21. At times you will be in the ER when treatment is due. Do not chart "RT not available." This looks bad in court of law. If you must, simply chart patient refused and do treatment as soon as possible. If you know patient must have treatment, follow tip 13 or 19
22. Follow hospital policy as best you can, yet don't be afraid to use common sense.

The above tips are made by a person who worked night shift by himself for 14 years. I think the most important things to remember is to always keep the best interests of your patients in mind, know your patients, know who you're working with, and prioritize well.
Likewise, common sense prevails. Keep in mind these are tips only, they are not rules.

Treatment stacking and why RTs are so busy

Treatment stacking is something that I think all RTs do from time to time. And while this may not be ideal, it is often a necessity due to high patient loads and the uncertainty of when the RT will be needed at an emergency.

Treatment stacking, or more appropriately termed concurrent therapy, refers to giving more than one patient a breathing treatment at a time, and in many cases several patients at the same time. This is often viewed as bad because due to issues of patient safety and quality of patient care.

The American Association of Respiratory Care (AARC) Whitepaper on Concurrent Therapy notes that under the current health care system there are increasing demands on respiratory therapists on duty due to staff shortages. To get all their procedures completed, RTs feel pressured to stack treatments, "although it's against their better judgement."

Another interesting thing the AARC notes as a reason for the need to stack treatments is that many doctors and hospitals encourage superfluous ordering of bronchodilator breathing treatments. In fact, while I would estimate this figure to be at around 80%, the AARC figures that as many as 60% of all breathing treatments are not needed.

However, recently we had 20 patients on treatments, and my co-workers and I estimated about five needed the therapy, and this comes to a 75 percent unindicated rate.  Regrdless, the estimates for useless breathing treatments are somewhere between 60 and 80 percent, with the professionals taking the more conservative number.

There are many reasons for non indicated breathing treatments being ordered.

1. Ignorance: The belief that all shortness of breath is caused by bronchospasm, the belief that all respiratory ailments will benefit from a bronchodilator, the belief that a bronchodilator will help a patient expectorate diseases, and the belief that nebulized bronchodilators work better than those given by MDI or DPI, and the beleif that nebulized Albuterol works similar to Tylenol to reduce a post operative fever.
2. Intensity of Service: CMS will not reimburse for patient admission unless certain procedures are ordered to justify the patient needed to be admitted.
3. Order sets: To meet intensity of service, many hospitals have incorporated these to make sure all patients diagnosed with certain illnesses (such as pneumonia) get breathing treatments.
4. To create work: Some hospitals (Shoreline Medical included) want more treatments to justify budgeting RT staff.
5. Pressure by bosses to get work done: RT Bosses believe a certain amount of pressure is justified because billings are dropped from our charting. After all, money is the bottom line.

So you can see, based on these five reasons for non indicated breathing treatments, many breathing treatments are ordered that simply are not needed.

To resolve the issue of treatment stacking, the AARC recommends that hospitals establish protocols. It notes that:

"The use of established protocols may help respiratory therapists deliver appropriate and efficient care under conditions of an increased workload. Protocols are based on scientific evidence and include guidelines and options at decision points. The use of protocols can help assure that all treatments have established indicators but also are highly effective in reducing the volume of unnecessary care. Evidence based literature exists supporting the use of protocols to minimize unnecessary treatments..."

Another option the AARC mentions to reduce the treatment load of RTs is to create a policy that allows the patient to administer his own breathing treatment, if the patient is stable and demonstrates that he is competent to do such a thing. I've actually done this, especially if I know the patient has treatments at home.

I would say that for larger hospitals protocols might work, yet at a smaller hospital that is trying to stay afloat, and often has only one RT on duty, it's difficult to go to protocols because the RT bosses are afraid this would result in too few breathing treatments, and an inability to justify budgeting the current level of RT staff.

Another reason administrators are afraid to go to protocols is because of the increased demand by CMS to order breathing treatments on account of their belief that certain procedures need to be ordered to meet criteria for reimbursement.

This is why our hospitals has developed order sets. Order sets work good in that they assure consistency in care based on best practice evidence, yet they also encourage unnecessary therapies just to be on the safe side.

So, ideally, an RT should never stack treatments. When I don't have ER, and don't have the stress that the ER pager might go off and I'll be needed down there for several hours, I am able to do one treatment at a time.

However, when I'm working alone at night, and I do have the ER pager, I find that I have no choice but to stack treatments just to make sure I get them done. However, I have certain rules that I follow when I do stack treatments.

The following are situations where treatment stacking is never justified:

1. Any patient in respiratory distress
2. Any patient with a compromised heart, or a heart you do not trust.
3. Any child who needs constant observation (any child)
4. Any unstable patient
5. Any patient that just doesn't look right
6. You do not know the patient

The following are situations where treatment stacking may be justified:

1. The patient is stable
2. The patient takes treatments at home and is stable
3. The patient feels comfortable giving himself treatments
4. The patient does not need the treatment to begin with (as many as 60% of treatments fit this category)
5. The patient is on a telemetry (still you must follow the do not stack rules above)

(I also wrote about treatment stacking here.)

Treatment stacking is against CMS guidelines because the patient is not receiving the individual care needed to obtain optimal care. Yet again, CMS is not in the room and is not aware of the immediate needs of the patient in that room, and neither is the doctor, nor the RT bosses.  Besides, if the treatment isn't needed (which is the case a majority of the time) why is RT needed to do the procedure in the first place?

The Joint Commission on Accreditation of Health Care Organizations (JCAHO), notes that treatment stacking is a "problem" and should not be done. When treatments are stacked there must be a "clear indication for it and a policy and procedure that govern its application. It must be differentiated from treatments given individually."

Or we could simply use common sense.

That's why many JCAHO accredited hospitals have stacking policies, and some do not allow for stacking. Thankfully Shoreline is not accredited by JCAHO and is accredited by ISO instead, which allows each hospital to come up with it's own policies to follow.

Personally I don't see a problem with stacking so long as the rules outlined above are followed, even if it is for convenience purposes.

SVNs work no better than a simple MDI

One of the ongoing fallacies in the medical profession is that a small volume nebulizer (SVN) works better at delivering medicine than a metered dose inhaler (MDI). The truth is, with proper technique, they both were equally well.

Still, even thought the AARC's "A Guide to Aerosol Drug Delivery," notes that the dose of a medicine delivered with an SVN is two times greater than 2 puffs of an MDI, this doesn't matter: the end result is the same.

The guidelines note the following: "Clinically it is often thought that nebulizers may be more effective than MDIs, especially for short-acting bronchodilators in acute exacerbations of airflow obstruction. A number of studies have established that either device can be equally effective, if the lower nominal dose with an MDI is offset by increasing the number of actuations (“puffs”) to lung dose equivalence."

Thus, one test showed that 5 puffs of terbutaline had an effect on FEV1 (the best indicator on a bronchodilator's efficacy on obstructed lungs) as 2.5 mg of terbutaline given via SVN. So it's clear that an MDI is equally as effective as an SVN.

This is true "provided that the patient can use the device correctly."

Q4ever treatments are the easy out for some docs

Where I work breathing treatments are ordered Q4ever. Well, not all of them are Q4, but doctors here never write for how long they want the treatment to be given, and most of the time they never write to discontinue therapy regardless of progress of the patient.

Sometimes therapies are discontinued after RT request, but even these requests often go unheeded. Why is this?

According to "Egan's Fundamental's of Respiratory Care," JCAHO standards recommend that all orders must specify the type of medicine, frequency, and duration of treatment."

Where I work JCAHO has been fired, and ISO has been hired. ISO is an organization that allows businesses to write their own rules and regulations, and it makes sure the hospital follows the rules and regulations it sets for itself. I'm sure it's more complicated than that, but that's the jist of it.

I don't know why JCAHO was fired (I call it fired), but from other RTs I have heard a lot of bad things about JCAHO. ISO, however, isn't necessarily any better. Except, from what I see here, it doesn't set regulations such as making it mandatory to write an order for duration of therapy.

The result of this is Q4-ever treatments on everyone.

I know some hospitals I used to work for had a standard protocol to put a sticker on the chart where the RT would recommend the treatment be renewed or that it was no longer needed, and the doctor could respond to this to make sure un-needed procedures were stopped.

Egan's also recommends that the doctor specify the goals and objectives of therapy. I imagine our hospital switched to ISO because the admins here, perhaps, are aware that there really is no purpose to most breathing treatments.

In fact, Egans states, "Unfortunately, adding goals and objectives to the respiratory care order does not assure that the therapy is needed. To be cost effective, all therapy must be justified and discontinued when no longer needed."

For some reason, the admins at Shoreline medical don't care that un-needed therapies are given. This seems to be a trend across the board for RT departments across the nation.

I have a pretty good feeling the reason for this is the desire to keep the procedure count up in our department to justify having RTs here.

If that's not the reason, then I'm am baffled.

Treatment stacking

All RTs must understand the rules of treatment stacking. It's not ideal, but sometimes we RTs have no choice.

So, what is treatment stacking you ask? Let's make up a definition:

Treatment stacking: Giving breathing treatments to more than one patient in more than one patient room. You'll be leaving one patient unattended while treating another.

Part of being a good RT is staying in the patient room, doing a great assessment, and chatting with the patient. That's part of the fun of being an RT too: getting to know our patients.

Likewise, I hate leaving my patients unattended during a treatment. I hate it because when I was a kid I'd be alone in my room and I'd look forward to my RT visiting me. I hated RTs who left the room, or stayed in the room and paid me no attention. So I try my hardest not to do it.

So, ideally we should not stack. However, sometimes we have no choice.

Note: you must never stack treatments on any of the following patients:

1. Any patient in respiratory distress
2. Any patient with a compromised heart, or a heart you do not trust.
3. Any child who needs constant observation (any child)
4. Any unstable patient
5. Any patient that just doesn't look right

That said, you also should not stack unless you have a valid reason to do so. For example, where I work I'm the only RT on duty working nights. If I have several treatments due at 10:00 p.m. and ER has been paging me like crazy, I will stack as appropriate. Another good example is an RT working for a larger hospital who is given 50 patients all on treatments.

Another good example is if you have been at a code, or busy in the ER, and it is now 10:15 and you have several 10:00 treatments to do, and now you are way behind.

However, as a general rule of thumb, you must never leave the room of a patient you do not know. If you have been off for several days and don't know your patient, then it's a good idea not to leave the room. If you get a new admit, you should stay with that patient until you get to know him or her.

The following are patients you may consider stacking:

1. You have determined with relative certainty the treatment is not indicated (Lord knows there's plenty of these to go around)
2. You have a patient who is stable and takes treatments at home.
3. You have a patient who's comfortable taking treatments alone.
4. The patient is on a heart monitor and in the critical care unit (a place where the patient is being constantly monitored.

I also notice that some hospitals require no stacking, and also that the RT stay in the room for 10 minutes. If that's the case then you'll have to follow policy. However, there will come certain situations where you'll find yourself needing to stack, and now you know the proper way to do it.

Likewise, it is my humble experience that a treatment does not last 10 minutes. Ideally, a good assessment and treatment can be completed in less than five minutes tops. So if you're in a hurry, do the treatment right, but don't waste time in the room -- make every minute count.

Indications for breathing treatments

Since I write so often on these pages reasons nurses call for breathing treatments and doctors order them (my latest version is here), I think it is due time I create a list of the true indications for a bronchodilator breathing treatments.

Keep in mind a bronchodilator only treats bronchospasm. Likewise, rescue inhalers used properly with spacer are proven to be as effective in most cases as a breathing treatments.

That in mind, here we go:

1. Asthma
2. Bronchitis (acute or chronic)
3. Emphysema (actually, this is not a true indication)
4. Cistic Fibrosis
5. Airway swelling due to allergic reaction (actually, bronchodilator doesn't treat swelling)
6. Pt with above diseases who cannot manage an inhaler (Albuterol, Atrovent, Flovent, etc.)
7. Bronchospasm secondary to other disease process such as CHF, pneumonia, pulmonary fibrosis, RSV, lung cancer, sinusitis, bronchiectasis, etc.
8. Bronchospasm secondary to allergic reaction (bee sting)

Note #1: The diseases in #8 do not necessarily cause bronchospasm, but may irritate the sensitive airways of people who have the diseases mentioned above

Note #2: It appears doctors believe treatments are cures for all ailments, and are indicated for all the wheezes and all that causes shortness of breath as you can see for yourself by reading the Real Physician's Creed.

We'll make this RT Cave Rule #25: A wise medical care worker will know the indications for ordering a breathing treatment and not request a treatment (or order one, or give one) unless a patient meets this criteria.

Note #3: Again, I am going to file this under humor, although it is not humor it is serious. Too many doctors fail to understand the true indications for breathing treatments

28 non indications for breathing treatment

Just a friendly reminder: the following are not indications for bronchodilator breathing treatments:

1. Dr. ordered it
2. Don't know what else to do
3. Nurse wanted it
4. Pt wanted it
5. Stridor
6. Sinusitis
7. Mesothelioma
8. Lupus
9. Laryngospasm
10. Audible wheeze
11. Rhonchi
12. Crackles
13. M.S.
14. Homeless
15. Depression
16. Pt has home nebs
17. Pt likes tx
18. Pt likes company
19. Bed ridden
20. History of smoking
21. Irritating lung sounds
22. Low SpO2
23. Trach
24. Intubated
25. Post operative
26. Atelectasis
27. Fever
28. Heart failure
29. Cardiac wheeze
30. Pneumonia
31. Pleural effusion
32. Pneumo
33. Rickits
34. RSV
35. ARDS
36. RDS
37. P.E.
38. Cough
39. Sputum induction
40. All wheezes (all that wheezes is not bronchospasm)
41. All SOB (SOB is not always caused by bronchospasm)
42. Just because the patient is wearing a mask

How to give a breathing treatment

Here is a nice instructional video of how to do a home nebulizer. I follow this up with our Hardluck Asthmatic and Boston Marathon finisher Breathin' Stephen giving his own demonstration of how to do a breathing treatment.

Note in the later video that Stephen is laboring through the demonstration and going on as though it were nothing. This is a perfect example of dyspnea tolerance many of us long time asthmatics sometimes demonstrate. Stephen and I have discussed this a few times, and I will discuss it further on this blog in the days to come.

In the meantime, enjoy the videos:




Okay, now here's the breathin' stephen version

Ventolin does not prevent asthma -- my opinion

When I was 15 and a patient at National Jewish in Denver, all of us asthmatic kids were forced to take 2 hits off a Ventolin inhaler prior to working out.

"Why do this now, when I'm going to need it as soon as I finish working out," I said once. My gym instructor made me run an extra lap for my mouth. So I learned not to speak up, regardless of my opinion.

Still, as soon as I was done with an aerobic session, I found that I needed a little hit of Ventolin regardless of the pre-workout dose. Not always, but there was still that bit of tightness after working out.

In retrospect, I think that even 18 years ago, long before I would even think of entering RT school, I was questioning doctor orders. Still to this day I do not think that Ventolin is a preventative medicine, but it's still ordered that way.

Why else do you think doctors order it QID on COPD patients who show no signs of being short-of-breath, or TID or even Q4 for that matter. At least in the hospital, I see no need to order Preventolin. A steady dose of Allbetterol might work better for some of the sick patients we have, but not Preventolin.

The other morning I had to give a treatment of Ventolin 30 minutes prior to a stress test. This was on a lady who had a history of asthma, but has not had a problem this visit. If she's SOB I see no problem with this, but not just because.

"Well, she has exercise induced asthma," my RT co-worker said.

"So, that's not a preventative medicine."

Is it? I have heard this talk all my life, but on me personally, taking a hit of Ventolin has never prevented asthma. There are other more appropriate medicines that can work preventatively, like Flovent, Atrovent, Singulair, Advair, Azmacort, Spiriva. These are medicines made to help prevent asthma. Ventolin does not prevent.

I have talked to an Internist of whom I really respect, and I asked her if we could DC the treatments that were ordered QID on a COPD patient who had been on treatments for two weeks, but never indicated any signs of SOB.

She said, "NO. We need to keep the Ventolin in his system to prevent an attack. You know that!" She looked at me like I was a dufass.

Oh well. That's all I can do is state my opinion. I have that right. I have a right to my opinion, I have a right to be wrong. I have a right to be stupid. We all have a right to form opinions, as have all the doctors and nurses.

It's one of the better parts of living in America.

Again, I have had asthma almost my entire life. I have been using Bronchodilators off and on since I was about five, have had my own inhaler to abuse since I was 10 (Alupent), have had a prescription to Ventolin since 1991, and have never noticed Preventolin (that's what I call Ventolin when it's used to prevent asthma) ever having an effect on me.

If I was going to have an exercise induced asthma attack, it's going to happen regardless of whether I take a hit of Preventolin. In fact, that's why I take Advair and Singulair, to prevent me from having problems while running. And I do run (okay, since you want to be technical, I jog) 2.5 miles every other day without having asthma, and without using Preventolin. I also do not use Ventolin after I work out.

I've never noticed it to prevent anything. I do notice it treats bronchospasm, but that's old school now I guess. Now that Ventolin comes packaged and marketed as the next coming of holy water, it seems to have unlimited uses.

For more uses for Ventolin, check out my list of 'olins at the bottom of this blog. Of course this is all in good fun, and it's all at the expense of stupid doctor orders -- my humble opinion of course.

Please feel free to agree or disagree with a comment.

Most Drs are patient, but some just intubate

To be fair to the nurses and the doctors in my last post who were eager to intubate the patient who tried to kill herself with a massive amount of a certain drug I can't remember the name of, I did leave one very important key point out. I was suffering from lack of sleep yesterday, and from massive burnout, so you have to cut me some slack here.

When the patient was first transferred to her new bed in CCU she had no gag reflex when I suctioned her airway to remove a massive amount of secretions that had accumulated there. Then she provided no response to the sternal rub. She was out. That, coupled with the fact she was agonal breathing, the nurse and the patient's physician decided the patient should be intubated to protect the airway.

Technically speaking, that was not a bad idea. However, I knew for a fact the patient was not like this an hour before, and that's why I thought maybe there was something else we were missing that might prevent her from needing to be intubated. So I did a blood gas while the nurses called the patient's physician.

When I noticed the gases were not exceptionally well, I called the patient's RN from the laboratory and informed her Dr. Krane should be notified with these ABG results since this was her patient in her, and I told the nurse I'd rush down to ER and show her myself. Then, en route, I decided I would just go up to the CCU to be with the patient, and, lo and behold, when I got up there Dr. Krane was standing alongside the patients bed.

"Holy cow," I said, "How in the world did you know we needed you? And how did you get up here so fast?"

"I was just concerned about the patient," Dr. Krane said, "And I wanted to make sure she was okay for you guys."

"Well, I'm very impressed."

Then she stunned me with this: "Give a breathing treatment."

Oh, come on. Here the patient is crashing and you want to give a breathing treatment? Like a good boy, I set up the treatment and fitted the mask on the patient's face. This ought to cure her of all her ailments.

Then Dr. Krane provided us with some information we did not receive in report. "I just talked to the husband, and he informed us that she (the patient) uses her rescue inhaler 5-8 times per day."

Aha, well, that makes more sense. "Well," I said, "In that case she probably uses it 10-16 times per day, because it's usually double what they say."

"True," she said.

Dr. Krane and I watched over the patient, literally, for the next 30 minutes, and I kept watching the clock and the entry way to the CCU for any signs of the doctor who said he would be here any minute. I prayed he was really late.

As she watched over the patient, eyed the numbers on the monitor which showed a heart rate of 126 but otherwise normal vitals, I wondered if she thought she had overlooked something in ER. Was she sleeping the last 6 hours the patient was down there and too lazy to check in on the patient and the nurses didn't pick up on the fact the patient was failing?

"You saw this patient in ER," she said, "Did you notice she was labored?" Perhaps I'm right.

"No," I said, "She wasn't labored at all. What do you think?"

"Well, I think she's going to be fine with the breathing treatments. I think that she hasn't had her bronchodilator in well over 12 hours, and her body responded to the transfer to the floor by having an excacerbation of asthma." She continued to look at the patient, and only occasionally looked up at me. "I think if we just be patient here we won't need to intubate."

"I really like that idea," I reassured her, as though it mattered what I said.

"What do you think of this doctor," she said. I figured she was referring to Dr. Seamon.

"I don't know Dr. Seamon very well," I said, "But I think he'll want to intubate as soon as he gets here regardless, and he'll want a massive tidal volume like 1000 or something stupid like that." Dr. Krane laughed.

Seriously, while I think she does order some stupid treatments, she is really nice. I didn't always think that way though. I've learned to keep an open mind about people I meet while working, and not take anything they say personally. Many people I talk to can't stand her because she is such a control freak.

"I think she will be fine," she said.

"Well, did she have a gag reflex in ER?" I asked.

"Yes, we tried to put in an oral airway, and she definitely responded."

I hesitated a second, as I didn't want to ask a stupid question, then I decided the heck with it. "Why do you think she's has no gag reflex all of a sudden?"

"I think the (drug she took) has peeked. In ER she was just lying there almost obtunded, but she was comfortably breathing. She was in a deep drug induced sleep."

"How long is that drug supposed to last?"

"I know she does cocaine and other stuff too, but poison control said about 24 hours. We can't know for sure how long it will last, but if we monitor her very closely we should be able to avoid intubation. However, that's my opinion, and I won't have jurisdiction over this patient as soon as Dr, what's his name? gets here."

"Dr. Seamon."

"I thought you guys said he would be here any minute." She smiled.

"That's what he said.

Now, fast forward over what I wrote yesterday to the intubation. As soon as we turned the patient on her back she started fighting. When the anesthesiologist started to insert the tube, the patient fought vigorously and even sat up -- twice.

She was obviously no longer under the deep, dark influence of the drug. And she had an obvious gag reflex. That, coupled with the good repeat ABGs, made me wonder if the patient didn't need to be intubated after all. But Dr. Krane was no longer in control, and I had transferred my beeper to my relief.

While watching all this, and assisting in holding the patient down so she didn't whack some nurse or my fellow RT in the head, I watched as the anesthesiologist drew up a white medication via syringe. These doctor's are very intense on intubating this patient. Are they forgetting to look at the big picture?

I audaciously tossed out an idea, "Um, you guys might want to disagree with me here, but I just wanted to toss this idea out. Since she appears to be responding to your efforts here, do you think we still need to intubate?"

"Oh definitely," Dr. Seamon said without hesitation, "We need to protect the airway."

My coworker, while holding cricoid pressure with one hand and bagging with the other, looked at me with a funny grin and rolled his eyes. We RTs, you know, have no control. And it's not that we don't want to take care of another vent patient, it's more that we wonder if sometimes, just sometimes, hospital staff get over aggressive with some patients.

After a lot of tinkering, finally the patient was intubated, and the airway secure. Dr. Seamon said, "Let's see, I think a tidal volume of 750 should be good, a respiratory rate of 14 and, oh, how about 50% oxygen."

My coworker looked at me, cocked his head and rolled his eyes. I knew exactly what he was thinking. "I calculate a tidal volume of 600 for this patient, and definitely no more."

"Well," Dr. Seamon said, "I learned to go by weight, and this patient weighs 230 pounds."

"No!," my coworker chimed, "We go by size..size definitely. How tall is this lady."

"I was told she's 5 feet 3 inches," I said, "and I calculate 350 to 600 is the tidal volume range based upon our ventilator protocol of 6 to 10 millimeters per kilogram of ideal body weight." There, that should help you out Dave.

"Okay, well, start out at 700 tidal volume then," Dr. Seamon ordered.

Dave rolled his eyes again, and made no effort to hide it from Dr. Seamon.

I laughed audibly. I'm sorry, but I was very tired, as I had been at work 13 hours at this time. Nobody but Dave noticed I was laughing, though. I looked at each person in the room, and they were all intense with their respective tasks.

I couldn't hold it in any longer. I wished Dr. Krane was still here, because she had a clue.

Later, as I was finally giving Dale report, he said, "What the hell tidal volume do you figure for this patient."

"Max 600, but with her asthma I'd go lower."

"Good, because the vent was set at 500, and that's what I used."

"I thought it was cool you showed frustration to Dr. Seamon," I said, "but I had that discussion earlier with him and I didn't care what he said, because he doesn't have vent privileges here, and we have our protocol. I was just doing to set it at what I wanted, and hope the Internist agrees with me when he gets here.

"Right on," he said, and smiled. "I just give up."

We have to keep in mind here, however, that the medical field is an art that is based on science. And there is often more than one right answer. Thus, while I disagreed with this intubation, I could still be wrong.

Neat website I found with old asthma medicines

It's very slow tonight at work, so I spent the majority of my time cleaning my locker, walking the halls looking for work, visiting with my co-workers and friends, and perusing this really cool website I found.

While the number of asthma cases has escalated in recent years, there have been documented cases of the disease going all the way back to ancient times. And, where there is a disease, there is an attempt to find a cure. Or, in the case of asthma, relief.

While I was surfing the net recently I found this really cool website, inhalatorium, which has many antique inhaler and aerosol devices from before the 1950s.

Many of these devices involve a small glass tube with a rubber bulb on one end. A liquid medicine called epinepherine was put into the glass tube and it was turned into a mist by squeezing the bulb. By placing your mouth around the mouthpiece you breathed in the mist. And, if all worked out well, you'd catch your breath.

In 1985, when I was a kid I was given a rubber bulb to use with my nebulizer in case my air compressor was not working, or if the power went out. I used it a few times just because I could. I got the medicine to aerosolize this way, but it took a long time to get the full effect of the medicine, and your hand got awful tired in the process.

I accidentally threw this bulb away when I was moving. It would be cool to still have it, but not as cool as the stuff on this website. I bet these items were hard to come by, and were probably expensive in their time (speculating), but if you had asthma, man it sure would have been "a relief" to have one or more of these.

Along with asthma cigarettes I described in my two previous posts, there were also asthma powders that were put "on a plate and the fumes inhaled through an upturned funnel." The medicine used, usually Belladonna, would make an asthmatic breath easier in 5-20 minutes.

Well I love history. One of these days I'm going to have to buy a book to satiate my growing hunger to learn more about the history of asthma treatment. In the meantime I suppose we're stuck learning things in bits and pieces on the net.

Well, you can check it out. The link is above.

If you guys have any information on asthma history, or know of any other cool sites or books, let me know.

Asthma cigarettes served a useful purpose

In yesterday's article I mocked the idea of "asthma cigarettes. But, after further study, I now believe it was quite a smart idea.
The medicinal dirivitive of the Belladonna plant that causes bronchodilation is called medical Cannabis. For many people it was able to generate the instant relief that today's asthma patients receive from fast acting rescue inhalers and other aerosol therapy.

While the medicine could be taken via pill form, it may take up to an hour to gain the desired effect by this method. This long time span could prove lethal in a patient experiencing a bad asthma attack. Hydrolic syringes were first used in the medical field in the mid 1860s, but this form wasn't very effective either.

There was steam, but no adequate method was ever developed to deliver the asthma medicine via this method. Nor were perfume sprays an effective means of delivery this fast acting therapy.

Thus, the idea of asthma cigarettes became popular in the mid 19th century all the way to the mid 20th century. It was such as valueable industry that one manufacturer even invented a case for asthma cigarettes. It certainly wasn't pretty, but it served its purpose, and kept the medicine fresh for those emergency circumstances when they were needed

And, believe it or not, asthma cigarettes are still in use today in some third world countries where modern medicine is not available.

There have been instances of the use of non-conventional therapies in Britain and the United States, and many of these involved asthma cigarettes. In one such instance a patient presented to the hospital "hyperactive, disoriented, garrulous and very anxious." It turned out that he had swallowed asthma cigarettes -- whole.

That turned out to be an incentive for him to stick with what the doctor gave him.

Still, in third world countries, this has proven to be a viable means of getting instant relief from an asthma attack.

It wasn't until the post-WWII era that effective use of aerosolized therapy was discovered. And it was from this era that breathing treatments and MDI therapy has evolved.

From asthma cigarettes to a normal life

Millions of people are alive today becuase of modern medicine, as would probably be true of a majority of the patients we as RTs take care of on a daily basis.

When I was a kid, as I puffed on my Ventolin inhaler for the umpteenth time, or visited the hospital and was given instant relief after a shot of Susprin (Epi), I often wondered if I had lived a hundred years earlier if I would have lived to be a year old. Chances are I would not have.

I remember my grandma telling me the story of her peering through a slightly ajar door into a small room at the old Mercy Hospital as doctors picked up her little brother and frantically held him upside down, patting him on the back, trying to clear the junk from his lungs.

Her little brother didn't live to his second birthday.

He had bad genes, as I have bad genes, as probably do most of our respiratory patients. And, perhaps, had he survived that illness, he would have grown up to have asthma, and probably would have lived miserably as the treatment for that disease was primitive.

When I worked for the museum in Port City they had a shelf with a bunch of 100 year old medicine from an old pharmacy, and one of the medicines was an old box of "Asthma Cigarettes." During an exacerbation of asthma patients were encouraged to smoke.

The medicine had a drug called Stramonium, which, according to this article by the American Journal of Respiratory and Critical Care Medicine is a "dried leaf and the flowering or fruiting tops of the plant, Datura stramonium. This is also referred to as the thorn-apple plant. The active ingredients in this were alkaloids of belladonna, which we now know had the effect of inhibiting cholinergic neurotransmission and thereby reflex bronchoconstriction."

Preventative medicine, also according to this article, was used in the treatment of asthma back then just as it is today. And still, however far we have revolutionized the treatment of asthma, "It is still somewhat controversial as to whether allergen elimination leads to an improvement in asthmatic status. There have been recent controlled clinical trials in which selective covering of mattresses with house–dust-mite–proof covers failed to show a benefit in asthma severity or lung function."

The Belladonna plant was used in the ancient world as far back as Ancient Greece, but more as a sleep aid or as a opiate for poisons rather than as a bronchodilator.

A derivative of the Belladona plant called Atropine was used in the treatment of asthma until the early 1990s when a more toned down version called Atrovent was developed, which basically has fewer side effects.

I remember taking Atropine as a child, and when I accidentally splashed it into my eyes I'd be blurry for a while until the medicine wore off. It was kind of annoying actually. And the only way to take it was via the nebulizer.

But these drugs are used more so as prophylactic or secondary therapy as opposed to as a rescue medicine, since now we have the miracle drug Albuterol (Ventolin) and Levalbuterol (Xoponex).

The iron lung was invented in the mid 1950s as a means of keeping kids alive who had become paralyzed by the polio-epidemic. And the evolution of this ventilator pretty much engraved the career of Inhalation Therapy, now known as respiratory therapy.

This was a negative pressure machine that required for the patient to be inside a box as it sucked the chest out and forcing the patient to breath that way. These machines were complex, and made taking care of the patient difficult.

Later positive pressure ventilators were invented, but these entailed respiratory therapists to get out their watches and calculators and use formulas to determine adequate tidal volumes, pressures, etc. These were a far cry from the microprocessor ventilators we use today that make our job easy as eating pie.

And, they make life for the patients better too, as they have, as I like to tell my patients, mini brains inside them that allows the patient to control the ventilator instead of the other way around. Now, instead of having a patient linger on the ventilator for weeks or months, he or she can be weaned in days.

When I was in respiratory school in the late 1990s, we were informed that nearly all infants born with diseases or prematurely died. By 1998, nearly 80% of infants born survived, and infants as small as 750 grams had a 40% chance of surviving. I'm certain those numbers have risen since then.

So, not only does modern medicine keep people alive longer, it allows them time on this planet that they otherwise wouldn't have had. I know I'm stating the obvious, but it's interesting to think about.

I'll put it this way: 100 years ago most of those infants would have died. It's simply amazing how far modern technology has come in helping people stay alive. It's to the point where we almost take it for granted.

It's thinking of this that makes me wonder if it is modern medicine that has caused the rapidly growing cases of diseases such as asthma as opposed to simply living in the modern, clean environment as proposed by the hygiene hypothesis.

Sure, technology up to about the mid 20th century provided some relief with knowledge that asthmatics must avoid allergens, and with the ironic asthma cigarettes, but in 2008 no asthmatic should have to live anything other than a normal life.

Basically, due to modern technology, any person with a disease that affects breathing, from asthma to COPD to cystic fibrosis has a chance to live a normal life.

And, perhaps, some day in the future this same technology will lead to an outright cure.

Modern technology basically keeps people alive long enough so that we can have statistics. That's a good thing in my book. Not only has modern technology kept me alive, it's provided me with a really cool career.

Asthma patients: I've been there, done that

Growing up with bad asthma: Chapter 1

Though this is not why I became an RT, I can tell you that I have more empathy for my patients than most of my coworkers here in the RT cave. Unless you are like me, I probably have more empathy than you too.

I say this not because I'm a more loving person, but because I've been there, done that.

When I was a kid I visited the ER for asthma attacks fewer times than I should have, and I spent at least 2 weeks a year as an in patient more often than I wanted.

In the next few weeks I plan on publishing some pithy posts about what it's like to grow up with bad asthma. If you ever had similar experiences as me, I'd love to hear about it because I know I'm not the only one.

It is abnormal to be short-of-breath (SOB). I know I'm stating the obvious, but I think it's important to state that mainly because I was SOB many times as a kid and nobody noticed. Therefore I suffered unnecessarily. Why? Because it's abnormal; and people who have never been SOB don't think to recognize that someone else is SOB. Why would they?

My parents rarely recognized that I was SOB when I was a kid, and I never thought to tell them. I mean, think about it, I was just a kid, how was I supposed to know it was not normal to be SOB. Therefore, I suffered more than I should have. I didn't go to the ER many times that I should have, especially when I was really little.

I remember one time I was about 8 YO I was really SOB on vacation, and my parents didn't bring my medicine. Actually, they left the responsibility on me, and I forgot. But, in retrospect, they were my parents so they should have made sure I had my medicine. Right?

No parents are perfect. I'm not trying to make my parents look bad. I'm just stating the truth here as I remember it. My memory could be flawed.

I didn't want to ruin everyone else's vacation, so I sucked on cough drops all night. I remember I almost choked when I fell asleep with one in my mouth.

Even when I got older, and my rescue inhaler ran out, I would be reluctant to tell my mom I needed a new inhaler because, well, she just bought me this one 2 weeks ago, and it was supposed to last 6 weeks, or at least a month.

Then I finally got the nerve to tell her I needed a new inhaler, but didn't tell her I was SOB because I didn't want her to know. Now was that stupid or what? But I was a kid.

I remember staring out the window waiting for mom to come home. Dad was home and he had no clue as he watched his football game or took a nap. My brothers were playing in the dusty basement, but that's probably how I got SOB in the first place, so I didn't want to go back down there to play with them now, even though they kept pressuring me to do so.

I remember staring out the window for hours waiting for her. I was calm, because I was good at hiding I was having trouble. And, so you don't think my dad was a bad guy for not observing I was in trouble, I was really good at staying calm and not letting others know. I was a professional asthmatic.

And when I went to bed that night, my inhaler was right there in my grasp. It stayed there even after it was empty a week later, and my stress about telling my mom it was empty was renewed.

Here's my favorite story: I remember when I was a teenager going outside and playing football when smoke was billowing from neighborhood chimneys and having an asthma attack while playing and not quitting. I didn't want to disappoint my brothers.

I would take breaks occasionally, walk into the house gasping for air, try not to make it obvious to my parents as I walked through the house to my bedroom, take a quick treatment, and go back out for more punishment. I might repeat this 2 or three times.

I just wanted to be normal. I wanted to play football. I was needed to make the teams even, and refused to be the one to disappoint. I was not a quitter. Stupid? Maybe. But I had fun playing football and I don't regret it.

Today I'm on preventative medicines and live a normal life. I think there is no excuse for anyone not living a normal life. Asthma should rarely be used as an excuse not to do something, especially with all the new medications. However, that doesn't mean you shouldn't avoid certain things, like a dusty basement, or a friends house that has a pet you're allergic to.

Then again, even the best of us asthmatics conveniently forget we have asthma sometimes, and do things we know we shouldn't, like clean a dusty basement, or visit that brother who has 6 cats and 2 dogs and a huge musty basement you know very well you're allergic to.

While I'm on preventative medicines, I still use my Albuterol at least 2-3 times a day. However, when I clean my basement because no one else will, I often have a reaction, and that entails me to abuse my inhaler for 2-3 days until I get back to normal.

I know some of you will cringe at this and tell me I should go to my doctor instead of treating myself, but if you've had this disease as long as me, you learn how to treat yourself. Who wants to go to the doctor every time you have an attack. Not this guy.

I know there have been occasions I should have at at least seen my doctor, but I'm so used to it I just suffer through it. My wife teases me that one of these days I'm going to be an end state COPD patient on oxygen. It's possible I suppose.

And I've never missed work because of it. I might if I was a construction worker, or if I worked in a musty, dusty factory, but I was smart and became an RT where I get to work in a nice, clean environment.

So, when I find an inhaler hidden in a side table drawer of an asthma or COPD patient, I'm not one to tell them they can't have it. I might educate them, but I won't take it away. And this is one of the reasons I wrote Rescue bronchodilators: Here are my unfettered answers to all of your questions about them a few weeks ago.

Just now I was called down to ER to care for an asthma attack. The order was: Duoneb now and then in one hour. I cringed. What a stupid order. I'm nice and just give the treatments as ordered, but it's not at all how I would deal with this patient. I wonder if that doctor has ever been SOB.

So, when I say I understand my patients, I really mean it. When I say I know when a patient needs a treatment, I really mean it. When I say Ventolin is a safe medicine, I really mean it. I've been there, done that.

For part II click here.

Respiratory Therapy School: What you need to know about complainers inside the RT Cave

I'm going to expound here on RT complainers, however, it's hard to talk about complainers without sounding like one myself. Likewise, it's hard to discern between constructive complaining and non-constructive complaining.
I've had to rewrite this a few times with that in mind.

Before you read the following, I want you to know that I really do like my job as a respiratory therapist. And, I think this is an excellent job for people to go into, especially if you want to take care and treat patients with respiratory illnesses.

It's a really great job. At times it can be challenging. At times your adrenaline will be rushing especially when you have a critical patient, and what you do or don't do could determine whether or not that person lives or moves on to meet his maker.

Many times you will be able to work with doctors determining what route to take in caring for a patient. And, of course, sometimes doctors might not want your help. Okay, so it's that way with any job.

I think the job of RT is a great job for anyone who wants a job and needs to start working right away. That's why I chose this field. You get to start working as soon as you start school. Then, as you become certified and registered, you get your pay raises.

This is an ideal job for people who want to use RT as a stepping stone to moving onto other medical related fields, such as PA or DR. To be honest, I think all doctors should be RTs first. This is an ideal job for former stay at home mom's, construction workers or others who want an easier life, and asthmatics who want to work in a clean environment.

Basically, this is a great job for anyone who wants to start a career later in life and wants a guaranteed return on his investment. This is a great job for anyone who wants a career you can take with you no matter where in the world you live.

When you start working you may meet the complainers. I was lucky and didn't meet them until my third student rotation. I later found out that they often go into hiding when RT students are around.

You know them, because they are abounding in every profession. Don't let them get you down. Because you know that your job is what you make it.

You also should know that if they really hated their jobs they could easily get another one. You might tell them that at some point, but then they'd complain about you too. The truth is, they don't want to change careers. They are content with what they are doing, they simply find release in complaining.

They do not want to change jobs for reasons I stated earlier, that this is probably their third chosen career, they are getting up in age and don't want the stress of changing careers again, or they have families and don't have the resources or time to go back to school. Those are the most common reasons.

Herewith, I am going to make an attempt at explaining the RT complainer to you, because they are different from complainers of other career paths. Your teachers in RT school will not tell you any of this, so I am.

I've read a few posts this past week about RTs complaining too much about their jobs. In the post I linked to above I stated that about 60% of RTs are complainers, and someone corrected me by stating that she thinks it's more like 80%. Either way, they are abounding.

One of the biggest complaints I hear is: "What's the point of increasing my RT knowledge when doctors don't let me use it?" This is what I will focus mostly on in this post. I will not delve into "the hospital admins make decisions regarding us without consulting us," or "you'd think at a hospital they'd at least have good health insurance." I won't go there.

We'll focus on RT knowledge. As I stated above, greatest complaint regarding RTs is the result of them being over educated for the job.

Of course, you know why you should always try to increase your knowledge, because if the opportunity presents itself you want to be prepared. If a doctor is looking for ideas about what to do for a patient, you can say, "Hey, I read somewhere that..." He will be impressed with you.

The biggest advantage to improving your education is that if the career opportunity presents itself, and you are prepared and ready for it, you can apply. Now I've never had such opportunity, but if it ever comes up I will be ready.

But what's the deal with this "what's the point of learning" complaining?

The bottom line here is this: Most of us RTs feel that we are overqualified for our jobs. We have 2-plus years of education plus whatever experience we've accumulated on the job plus knowledge we obtain through continued education, all of this making us specialists in the respiratory diseases and how to fix them.

And yet, in many hospitals, we are not allowed to use this knowledge because many doctors do not want to give away any of their autonomy.

I will give you a few examples from my own personal experience.

1. Non-constructive complaining:

I feel absolutely stupid going into a room of a post-op patient with no signs of respiratory distress and telling that person I have to give a breathing treatment. There is no reason for it, and it's frustrating.

Many RTs bicker about this. It's best to keep your mouth shut.

2. Non-constructive complaining:

When I have a ton of therapies, and 70% of them are not indicated, and I still have to do every one of the non-indicated treatments while making sure my treatments on my SOB patients are never late, while still taking care of ER and STAT therapies, this can be taxing on me. It can cause unnecessary burnout.

I describe this in a recent post, "R. By the time I got to work I was already burned out, and I took it out on my co-worker. Not a good idea.

We all have our opinions, and the chronic complainers will let us know about them on a regular basis. But when I complain, it's usually when I'm burned out.

3. Constructive complaining and non-constructive complaining combined:

What if we have one patient who is SOB, and I know I have the cure for his ailments right in my pocket, but I have to wait a half hour for the doctor to respond. I have to stand idly by while my patient suffers. As a fellow asthmatic, I can't stand this part of the job.

I think I am justified in not being happy about this.

I find myself grumbling and griping, "Why hasn't the doctor called back yet?"

My solution to this problem is what I call my "Act now and apologize later protocol." I have never been written up for doing this. Never. So that solves that complaint. However, isn't this something that should be complained about.

This example could possible by non-constructive, if I grumble and gripe too much.

4. Constructive complaint:

In "Grumpiness stays in the RT cave" I detail another complaint that's really not a bad thing to complain about. I write about a nurse who called for a treatment on a patient when the treatment really wasn't indicated.

While most times I keep my mouth shut and just do the treatment, sometimes I like to take the time to educate the nurses. While most times they want to learn, sometimes they take it as a complaint. And, if I'm burned out, I probably come across as I'm complaining. So, I've learned it's best just to keep my mouth shut even in these situation.

5. Non-constructive complaint:

Using the above example, we know that educating is not complaining. However, when you have to do this on a daily basis, particularly over and over to the same nurse, it can become frustrating and can lead to non-constructive complaining. Most nurses, however, want to learn and will listen.

If the nurse is really busy, she might not want to hear it. This can get frustrating in itself. More than likely in this case, she just want you to make sure you take care of the patient, regardless of whether the treatment is needed or not. And, many times, RNs and doctors determine that giving a treatment is better than doing nothing, even when it's not needed.

In cases like this, I've learned to keep my mouth shut as, I'd presume, most RTs have.

6. Non-constructive complaining:

I will use all the above examples here. While RT complainers excel at this, all other RTs will complain about just about anything from time to time. It can't be helped and it's a fact of life. (If a content does this, you know you're in trouble.)

7. Constructive complaining:

I always tell my friends that I'm not complaining, I'm simply stating a fact. And, when I show people my list of 'olins (listed at bottom of blog), or I tell them some of my RT humor (plastered all over my blog), I think this is the best way to complain. Just by thinking of all this stuff we have to be learning something. So long as we don't go overboard, I think this is the best way to let off steam.

Well, at least I think so.

I can probably think of more types of complaining, but my mind is strapped at this time.

Overall, the greatest complain is regarding non-indicated breathing treatments. If you are a true professional, you would understand explaining them away like this:

When doctors and nurses call me for therapies I feel are not indicated, I like to think they simply want an RT to be assessing the patient QID or Q4 just to be on the safe side. That's not such a bad thing, is it? (It is if it leads to burnout.)

If you're still not content with non-indicated therapies, I suppose Taylor on Kid Nation says it best: "Deal with it."

The best way of dealing with the grumbling and griping is to continue to work toward impressing doctors and nurses by generating respect with them by always staying on the cutting edge of knowledge.

Likewise, if we do not have protocols already, we must study the protocols of other hospitals, continue the education process (as we do on these blogs), and work, slowly and patiently if needed, to get them implemented. Will this get rid of all non-indicated therapies, probably not.

By continuously working to better ourselves, we strain away our desire to complain. Most important, we know that by our complaining we only cause other professionals (Drs, nurses) to stray further away from us. They hate complainers. This is the best way to not make progress, as you can read about at Snotjockey's Revisited.

And you will be reminded many times that "the grass is not always greener on the other side of the fence."

You will find complainers everywhere you work. I was a journalist once, and they were there; 80% of them. I was a hotel desk clerk once, and they were there; 80% of them. I worked in the fast food business once, and they were there; 80% of them. It never ends.

Still, if you've set foot in any RT Cave, you know that RT complainers are not interested in making the RT Cave a better place, because deep down they are simply content to keep things the way they are. For reasons I listed above, they know they will be trapped in the RT Cave for the rest of their working lives.

To make themselves feel better, they gripe and groan. The rest of us are forced to take the brunt of it.

However, if you can stand to listen to a complainer, they are very intelligent people. As you know, they complain mostly because they are overqualified for the job. I really think that's true. I've obtained tons of material for this site by listening to complainers. They are up on their knowledge.

It's just too bad they don't use all that energy and focus it in on progress.

Here's a thought before I end for the day: "If it weren't for complainers, nothing would ever get accomplished in this world." I'm sure you've heard the old saying, "The squeaky wheel always gets the grease."

Grumpiness stays in the RT Cave

For whatever reason business really picked up last weekend. That, coupled with the chronic lack of sleep and family life, brought me to work on Thursday night on the edge of insanity.

While I'm normally pretty equanimitous no matter what I'm doing, I grumped to my co-workers as soon as I saw the increased number of patients on the worksheet. I clicked on the worksheet I-con on the computer and deleted all the diagnosis's and put in my own.

Here's what the new worksheet looked like. I've always been a proponent of writing reason for treatment instead of diagnosis, and that's what I did here:

• Post-op Bowel: Just because


• Post-op Bowel: Just because


• COPD: needs


• Liver CA/ sepsis: needs


• Hip Fx: Jealous of room mates treatment


• Asthma: exaggeration of


• Pancreatitis: Had a cough once


• Failure to thrive: Nosocomial COPD


• Pneum/COPD: needs


• Hip FX: Bored, needs attention


• Failure to thrive: had ronchi at admission

"Rick you're grumpy," my co-worker wailed. She was a complacent.

"I'm sorry," I grumbled, "but I'm sick of running around doing these useless breathing treatments when I got patients who need my services. All this crap does is wear me out."

She looked at me stunned. She was surprised at my sudden anger, I could tell. She was knew I enjoyed RT humor, but to complain like this was not normal for me. And, if that's what she was thinking, she was right.

I took a deep breath. "Well, now that I got that off my chest, how about report." That was the end of the outward grumpiness for the most part the rest of the night.

However, when a nurse called me to do a treatment on a CHF patient I had just recently did a treatment on, I was blunt on the phone: "She doesn't need a treatment."

"But," the RN said, "She's short-of-breath and wheezing."

"Did you get her up to the bathroom?" That's the only way she'd get SOB that fast, I knew the type. I know my patients that well.

"Yeah, we got her up to the..."

"Well, that's why she's short-of-breath. All you need to do is let her rest." She's a cardiac patient. She has a weak heart.

"But she's really..."

Right here the professional Rick turned on. I know from experience that all the explaining in the world isn't going to work with this RN. "Hey, I will be right there." I should have just said that in the first place.

Being the consummate professional, I knew that I couldn't let my exhaustion effect my work, and whether the patient was recovered in 2 minutes or not I was going to check on her just to be on the safe side. I think all responsible RTs would do the same.

However, I took my time getting there. I was almost certain she'd be fine with rest, and that she really didn't need a treatment for anything other than an oxygen boost.

When I looked in on the patient she was sleeping comfortably. Even though I believe that if someone is sleeping she's comfortable -- most of the time. I woke her anyway. "Hi Mrs. Dee. I'm sorry to wake you."

"No problem, Rick. How's it going today."

"Wonderful," I lied, and then smiled.

RT Cave Rule #8: A true RT professional never carries a mood into the patient room. It's best to keep it in the RT cave.

"I heard you were winded. Are you feeling better?"

She confirmed she was fine. Then I left the room and hunted down the nurse. I probably could have left it at that, but the political me wanted to make sure things were square with the nurse. After a brief hunt, I found her.

"You called for Mrs. Dee, right?" I said.

"Yeah. She's sleeping now, though," the RN said. This was a very nice nurse, but in the past I've had trouble explaining to her RT facts.

"Uhuh. I woke her up anyway. She's a nice lady."

"Yeah. She was really short-of breath. And she was really wheezy."

"I know," I said. "It was a cardiac wheeze."

She gave me a look I interpreted as the, "you are a prick" look. She was thinking I was just another lazy RT. I know when you're exhausted you see problems that aren't really there, so I considered this and decided I would be best to walk away.

The rest of the night I went from one procedure to the next. You know those nights: every time you sit down the pager goes off. By 4:00 in the morning my eyes are burning and my body felt
like it would melt at any moment. My feet were killing me. All of you guys have been here at some point, or will be. Heck, you city dwellers probably go here every day.

My boss called me. I have no clue why she comes in so early, but she does. I trudged to the RT Cave. "Hey, Boss."

She was blunt: "I saw what you wrote on the treatment sheet, and I changed them for you. If Julie saw those she'd write you up." I could tell she was in a good mood. Hell, why wouldn't she: it was her Friday. She didn't have to work weekends like the rest of us.

"Yeah, I meant to take those off by now, but I just didn't get a chance yet." It was the truth.

"You shouldn't put those on there."

"Who's gonna look at my board? And if they do, they'll learn the truth." I tried to feign a smile, but my face was stayed limp. That's how tired I was.

"You know it's not very professional." She was never shy of saying what was on her mind.

"I don't care," I said. I normally would have said something more professional, but when you're really exhausted your true feelings slip out at times. It was one of those nights. "I'm sick and tired of running around ragged when I shouldn't have to."

"I know," she said calmly, "but you really need to stay professional."

"You're right," I said, and set down at the computer to make my changes. Then I thought what I really wanted to say:

I'll be professional all right. When she writes me up, I'll be real professional in front of the admins and explain to them the truth about what the doctors are making us do. I will. Then they'll really be able to cut back on unecessary costs. It's time one of us spoke up. That's the reason things have gotten so bad is because nobody has the nerve to speak up.

"Was it really so bad," the reasonable part of my mind said, "You love your job."

As all of you RTs know, professionalism is more important than releasing frustration. And that is why we participate in RT humor amongst ourselves. That is our release.

This was a very rare occurrence for me to feel grumpy like this. However, and my point in writing this, is while I felt one way, not one of my patients had a clue I was grumpy. And, hopefully, not one of the nurses did either.

The only people I vented to were fellow RTs. Then, to the best of my ability, I left my grumpiness in the RT Cave. A true consumate professional becomes very good at doing this even in the worst of nights.

Rescue bronchodilators: Here are my unfettered answers to all of your questions about them

The following are some questions real patients have asked me recently regarding rescue bronchodilators. The answers here are my humble personal and professional opinions and nothing more.

Keep in mind that your doctor might disagree with me, and that's fine. He can overrule me whenever he wants. But, the answers here are based not just on my 10 years as an RT, but over 30 years as a chronic asthmatic who's abused more than his share of inhalers and lived to tell about it.

Q) What is the recommended dose for albuterol

A) Every 4-6 hours as needed ( no surprise here.)

Q) What if I need it more often than that

A) For most patients, I'd recommend seeing your doctor if you need it more often than every 4-6 hours, because it's a sign that your asthma or COPD is getting worse and needs to be better controlled. However, it's a relatively safe medicine, and some doctors prescribe it to be used as needed for some chronic patients.

Q) What do you think of a doctor ordering Albuterol MDI every four hours?

A) Albuterol is typically a rescue medicine, and should be taken when you are short-of-breath (SOB) due to bronchospasm. It's not going to hurt if you use it more often than when you need it, but I don't see why it would be beneficial.

Q) My doctor says Albuterol will work to prevent an asthma attack, so I should use it every four hours all day. Is this true?

A) I was taught when I was kid to take my Albuterol before I took gym class, and I did. However, it never prevented me from getting SOB. It did, however, make me feel better once I was SOB. So to answer this from my own personal experience, I'd have to say no; Albuterol does not prevent asthma symptoms. However, you can try it to see if it works for you.

There are many doctors who do believe it can be used as a preventative drug. Not only that, it states this on the Albuterol package insert. However, if it is deemed necessary that preventative medicines be taken to prevent an asthma attack, there are far more effective medicines to be using, such as Vanceril, Flovent, Atrovent, Cromolyn, Advair, etc. (this will be discussed in a later post.)

Q. I've had an Albuterol inhaler for the past 3 years. Sometimes I use it more that 10 times in a day, which is more than the prescribed frequency of every 4-6 hours. Can I use Albuterol this much and feel safe?

A. I'm treading on thin water here, but I will say yes. I find from my own personal experience as a former Albuterol abuser, and professional experience giving treatments, that Albuterol is a very safe medicine. The most common side effect is that it might make you jittery, which you probably already know if you've done it before. If you were going to have a negative reaction to the medicine, like an increase in heart rate, it would have happened already.

However, if you have other medical issues besides just COPD or Asthma, then I'd be really cautious of using too much Ventolin. I'd recommend consulting your doctor if you need to do this. Personally, though, I still think Albuterol is safe and effective in most situations where real bronchospasm is the issue.

Q. But my doctor has me on all the right preventative medicines and I'm still finding myself going through an inhaler a week. Will this have long term implicaitons on my life span?

A. I asked my doctor that exact question when I was a kid, and he told me using my inhaler was better than suffering and chancing an anoxic episode. If you absolutely have no choice than to use your inhaler more than every 4-6 hours, make sure your doctor knows about this. Chances are, he will still renew your prescription because he doesn't want you to suffer. However, he may also continue to try to adjust your other medicines to make your life easier. Sometimes, however, as in some cases of COPD or end stage COPD, this is not possible.

Let me answer this question this way. I went through an inhaler a week from the time I was 13 or 14 until about a year ago when I started taking Advair. That was 25 years. I'm getting along just fine now. Will my Albuterol abuse cut some years off the end of my life? Well, nobody really knows. Albuterol has only been around since 1987. Personally, I doubt it will.

Q. My doctor prescribed Atrovent as my rescue inhaler, what do you think of that? Should I be worried if I use it more than four times a day, because I do?

A. Atrovent is not a rescue inhaler. Atrovent takes about 20-30 minutes to work, while Albuterol, idealy, should work almost instantaneously for bronchospasm. Then again, if Atrovent works for you, then that's great. If it isn't, then I'd talk to your doctor about getting an Albuterol inhaler.

Q. Am I safe using Atrovent more often than every four hours, because I do?

A. I don't see what it would hurt. When I was in school ten years ago we were taught never to use Atrovent more often than Q4. However, some new research shows that addtitional Atrovent during an exacerbation does benefit patients. If Atrovent is working for you as a rescue drug, all the power to you. However, if you continue to be short-of-breath, you should talk to your doctor about getting an Albuterol inhaler or (ideally) adjusting your preventative medications.

Q. Can I use my Combivent more than every 4 hours?

A. Again, I don't think it would hurt you, but it's not necessary. Technically speaking, the Atrovent in this medicine shouldn't need to be taken more than every four hours. If you need to use Combivent more than every four hours, then you should talk to your doctor and get an Albuterol inhaler. You can then use your Combivent four times a day, and Albuterol in between if you get short-of-breath. (and still I'd only recommend this only if other preventative medicines weren't working.)

Q. Do you think Xoponex is better than Albuterol?

A. No. I have never noticed a difference. Original studies claimed that Xoponex was stronger than Albuterol, but I've never noticed that to be true in my real life experiences with the two drugs. Not only that, I don't think the claim that Xoponex has fewer side effects than Albuterol is true either. Recent studies have confirmed this.

However, if you have experienced cardiac side effects, or excess jitteriness or nervousness, then you might be a candidate for a trial of Xoponex, if you want to flip the bill: Xoponex costs 5-10 times more than Albuterol.

Q. What if I go through an inhaler a week?

A. Every patient is different. Do you have end stage COPD? If so, you have to do what you need to do. Do you have asthma? Then perhaps you could trial Advair. Advair worked like a miracle drug for me. I went from one inhaler a week and 600mg of theophylin twice a day down to two 300mg pills a week and 4 puffs of Albuterol a day after being on Advair 9 months.

You and your doctor have to find what works best for you. If there is no other alternative, then an inhaler a week might be the best solution.

I meet albuterol abusers at work all the time, and the majority of them are end-stage COPD patients. However, on occasion, I have met a fellow asthmatic who abuses too. Most of them think they are the only one. And, most of them think they are doing this furtively without their doctor's knowing.

Many times I walk into a patients room to give a breathing treatment and find that MDI hidden under the pillow, a sign of a true rescue inhaler abuser.