Here's what Albuterol really does, and does not do

Albuterol is the world's most abused medicine. Listed here are some of the medical conditions it is so often prescribed for in the hospital setting. This is followed by a pithy explanation of why it does or does not work for that particular diagnosis.

Asthma. Bronchial airways are chronically inflamed and hypersensitive (twitchy) to asthma triggers. Exposure to which causes an abnormal immune response that causes worsening airway inflammation. This irritates bronchial smooth muscles that spasm and constrict (bronchial constriction). This is responsive to bronchial dilators (beta adrenergic medicines) like Albuterol. This is because they are lined with beta 2 adrenergic receptors. Albuterol attaches to them and causes bronchial smooth muscles to relax, thereby opening airways and relieving asthma symptoms. This same type of bronchial constriction occurs with cystic fibrosis and in patients with chronic bronchitis, so it works for them too.

Pulmonary Edema. Heart failure. It causes an audible upper airway wheeze. It causes orthopnea. It causes severe dyspnea. It also causes increased intrathoracic pressure, and this squeezes airways, causing bronchoconstriction. This is not responsive to bronchodilators. Yet, because these patients wheeze and have dyspnea, the "feel good" solution here is to order a bunch of albuterol treatments, none of which do any good.

Pneumonia. I explained this in my post "Links between pneumonia and COPD."  I wrote, "It’s an infection of the air exchange units in your lungs, mainly the respiratory bronchioles and alveoli. An immune response causes this area to become inflamed. White blood cells (WBCs) are sent to the area of infection. The purpose of this response is to trap, kill, and remove the pathogens. As the disease progresses, the accumulation of WBCs cause pus to fill these areas, making them poor air exchange units. This means they become poor at allowing blood to cross into the bloodstream, resulting in a drop in blood oxygen levels."

A natural response to this by physicians is to order bronchodilators. However, unless a person has asthma, pneumonia does not cause bronchospasm. Bronchodilators are 0.5 microns, ideal for impacting bronchial walls. Terminal airways, respiratory airways, and alveoli are less than 0.2 microns, so bronchodilators don't even get that far. And, even if they did, there are not beta 2 adrenergic receptors there, so they do not good. Bronchodilators are not anti inflammatory medicines, and therefore are useless for pneumonia. However, despite this fact, a common criteria or admission to the hospital is three failed breathing treatments. This is a good criteria, considering (as you now know) albuterol is useless for pneumonia. The treatments will fail no matter how many you give because pneumonia is not bronchospasm.

Some doctors have sited studies showing albuterol increases sputum production as evidence it helps with pneumonia. However, what the hell does increased sputum production do with treating pneumonia? For more on this, check out Rick's post, "A World of Bronchodilator Lies." Also check out his post called, "Does Albuterol Treat Pneumonia?"

Emphysema. I explained this in my post "Bullous Emphysema." It's caused by the destruction of elastic tissue. This results in inflammation and breakdown of alveolar walls. Alveoli lose their elasticity, or ability to regain their normal shape after normal inhalation. "They eventually rupture, creating air spaces. Lacking elastic tissue, alveoli lose their ability to contract during exhalation. When the elastic tissue of enough alveoli are destroyed, these portions of the lungs expand all the way to the rib cage, giving the person the appearance of a barrel chest.  As the lungs are pulled outward, this causes bronchial airways to become stretched, thereby making them narrow (bronchial constriction). This causes increased resistance to air flowing through airways during both inspiration and expiration, slowing the flow of air. This is airway obstruction that does not respond to rescue medicine."

But we give bronchodilators to these patients anyway. However, despite this, most emphysema patients (a.k.a. pink puffers) claim they do not notice any difference afterwords.

Lung Cancer. Lung cancer takes up space in the lungs and prevents gas exchange from occurring. It results in wheezing and dyspnea. Albuterol is often given to these patients, but it will not make the cancer go away, and will not help these patients unless asthmatic bronchospasm is occurring, which is more than likely not the case unless there is also a diagnosis of asthma or chronic bronchitis.

Pleural Effuston. This is where you have excessive fluid buildup around the lungs. Because it can cause shortness of breath, the logical solution by physicians is to order Albuterol. However, albuterol does not suck fluid out of lungs, and therefore will not benefit this medical condition. It doesn't matter, because it will be ordered anyway.

Pneumothorax.  This is also called a collapsed lung. The belief among the medical community is that albuterol will re-inflate airways. The reality is that this is not going to happen. What is needed is a chest tube. The use of a chest tube in and of itself is often an indicator of the need for albuterol. However, Albuterol does not speed up time from chest tube insertion to complete recovery, at least not since the last time I checked.

Rickets. It is the softening of the bones in children. Albuterol will not help. However, and unfortunately already busy respiratory therapists, Albuterol will probably still be ordered for these patients.

Audible wheezes. If it's audible, it cannot be bronchospasm. It's audible because secretions are sitting on the vocal cords. This is very common when a person has pulmonary edema, such as what occurs in heart failure. What I say here makes sense, because true bronchospasm can only be heard by auscultation; it cannot be heard by the unaided ear. However, despite this fact, bronchodilators are so often prescribed for audible wheezes. I would go as far to say that about 80% of breathing treatments in the emergency room are for heart failure, which is the most common cause of audible wheezes. Another cause is dehydration, something that occurs in the aging and in ETOH and detox patients.

Further reading:

• RT Reform
• Bronchodilator Reforrm
• Bronchodilator Reform Part II
• A world of bronchodilator lies
• The dilemma of bronchodilator reform
• A letter to end bronchodilator abuse
• Faux respiratory therapy lexicon
• The Ventolin Pill
• The 9 different types of wheezes
• How to hear bronchospasm
• Lungsound lexicon
• Laryngospasm: It's often confused for a wheeze
• Rhonchi-eeeeeeeeze

What is the usefulness of best practice medicine?

I would like to define "Best Practice Medicine" and then analyze it's usefulness as far as it pertains to the respiratory therapy community. My "theory" is that it is not used properly.

Best Practice. According to The University of Iowa College of Nursing, it means: "The use of care concepts, interventions and techniques that are grounded in research and known to promote higher quality of care and living for... people."

Best Practice Medicine. It is using the "best practices" available based on the medical research, particularly respiratory therapy research. and in real life practice.

Now, let's examine another term:

Evidence Based Medicine. According to Sackett, et al, 1996, it "is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

So you have researchers performing studies. They come to conclusions based on a preponderance of the evidence. They come to conclusions. They are just humans, so their analysis and conclusions may be accurate. However, they may also be flawed. This brings me to two more definitions.

Scientific data. It's what is considered as fact. It's what is. Science shows that beta 2 adrenergic medicine like albuterol relaxes smooth muscles and opens airways in individuals suffering from asthma attacks. This is proven. This is fact. This cannot be debated. Trees are green. This is fact. Science has shown that albuterol does not treat inflammation, and therefore has no use in treating pneumonia. It also has no use in treating bronchiolitis, that suction of the airway is all that is needed. Science has shown that wheezing caused by airways narrowed due to increased intrathoracic pressure due to heart failure and pulmonary edema will not resolve by using albuterol, that it requires other medicines.

Theory. This is what is assumed. It is not a fact. It is what isn't or what is: we do not know. It is not up to a consensus (see below). So, a theory may be that bronchodilators benefit all that wheezes. A theory may be that albuterol will benefit heart failure, that it will benefit bronchiolitis, that it will benefit all respiratory diseases that produce annoying lung sounds.

Consensus. It is what a majority of people believe. It is often mistaken for science. It is often mistaken for fact. For example, you often hear in the news that a consensus of scientists, or 99% of them, believe in global warming. So you have people in the media using this data to claim that global warming is a fact. A consensus of doctors believe all that wheezes benefits from albuterol. A consensus of doctors is that albuterol will resolve wheezing and dyspnea caused by pneumonia, pneumothorax, pleural efffusions, heart failure, and dehydration. However, a consensus does not prove science. In science, it either is or is not. There is no in between. Trees are either green or they are not green. Bronchodilators either open airways or they do not. A consensus does not change this. Unfortunately, a consensus is usually all that is needed to make people think something that is not actually is.

Analytical data. It's what is shown. It's what happens in the clinical setting. Albuterol breathing treatments are given to many asthmatics. Asthmatics feel better after the treatment. Albuterol breathing treatments are given to heart failure patients because they produce that annoying upper airway audible wheeze as secretions sit on the vocal cords and these patients are short of breath. The treatments have no effect. In fact, as they enter more fluid into the airway, they often make that audible wheeze louder. They are given to kids with bronchiolitis. These treatments have no effect. They are given to pink puffers. These treatments have no effect. This is what happens in the clinical setting. This is what is observed before, during, and immediately after a therapy is given.

Conclusion. This is what the researchers assume based on the scientific data and the analytical data. However, conclusions are often flawed based on the bias, ignorance, or lack of clinical practice by the researchers involved. This is not a knock on researchers, it's just a fact. It can then be assumed that albuterol is useful for asthma based on the scientific data and analytical data. However, it is often assumed that albuterol is useful for all these other lung ailments, even though the scientific data and analytical data do not match. This is because there is a third element that comes into play here.

It sounds good, it makes me feel good, so it must be true. You have a patient come in with trouble breathing. You have no idea the cause. You have no idea if it's caused by bronchospasm. So, even though there are many other potential causes, you order the respiratory therapist to give beta adrenergic breathing treatments. You have no idea of the usefulness of doing this. But, if makes you feel like you are doing something. So, my argument is that this is what constitutes as best practice medicine.

Cook book medicine. You do not know what medicines will work for what patients until you obtain your definitive diagnosis. So, what you do is you throw everything you have at this patient that is considered safe. Any patient who comes into the hospital who is short of breath is treated as though they have asthma. It's the same as primitive medicine, and is often described as "all that wheezes is treated as asthma."

Protocols. This is where you assess the patient, determine a score based on an algorithm, and treat the patient based on the score. I will give two extremes here in my example. For instance, a zero means your patient has clear lung sounds, no wheezes, no paradoxical breathing, and is not short of breath. A 10 means the patient is in severe respiratory distress. A zero means you do not give a breathing treatment. A 10 means you give a continuous breathing treatment with albuterol. The experts say this protocol is based on best practice medicine. However, those who do the treatments, i.e. the respiratory therapists, think it is a waste of time in most instances. When you ask them why, they say, "Because, how do you know, that just because a person scores a 10, that they are having bronchospasm? How do you know the albuterol breathing treatments will do any good?"  You don't. And this proves my point, that the medical profession is not based on best practice medicine, or evidence based medicine, it is based on "it sounds good, it makes me feel good, so it must be true."

Okay so the researcher says, "If the bronchodilator is not working, then more are needed to open the airways." To this I say, "there are other medicines that will treat the underlying problem." So you will have researchers say, "Well, the patient says she feels better after the treatment." To this you say, "This is called the placebo effect of albuterol."

References:

1. "Csomay Center - Best Practices for Healthcare Professionals," University of Iowa College of Nursing, https://nursing.uiowa.edu/hartford/best-practices-for-healthcare-professionals, accessed 3/4/17
2. Sackett, David L., et al., "Evidence based medicine: what is it and what is it not?" British Medical Journal, 1996, http://www.bmj.com/content/312/7023/71, accessed 3/4/17
3. Perleth, M., "What is 'best practice' in health care? State of the art and perspectives in improving the effectiveness and efficiency of the European health care systems," 2001 Jun;56(3):235-50, https://www.ncbi.nlm.nih.gov/pubmed/11399348, accessed 3/4/17

Prehospital Ultrasounds May Help Diagnose Respiratory Distress

About 90% of breathing treatments ordered in the emergency room are for patients ultimately diagnosed with heart failure. This is according to a non-scientific poll of respiratory therapists

This certainly bodes well for job security, but such injudicious use of Ventolin has also been implicated in respiratory therapy apathy syndrome. It also results in a needless hospital expense, as bronchodilators do not suck fluid out of lungs and do not benefit patients with pulmonary edema and heart failure.

I always thought it would be nice if there was a test to determine who was actually experiencing bronchospasm and who was not. Apparently, researchers have been experimenting with using ultrasounds to find the true cause of respiratory distress, or to differentiate between COPD and cardiogenic pulmonary edema.

Rather than just using a stethoscope, which has its limits as a diagnostic tool, researchers developed a ultrasound protocol that takes less than three minutes to perform. In fact, it can be performed by paramedics in the prehospital setting so that an appropriate diagnosis can be made and appropriate treatment started. 

Researchers say that paramedics, using traditional methods, were accurate in their initial diagnosis only 23% of the time. However, once the ultrasound protocol was adapted, they were accurate 90% of the time. If this is true, then it's something that should be adapted sooner rather than later. 

Further reading and references:

• RT Magazine: Diagnosing respiratory distress via ultrasound
• EMS World: Using Ultrasound For Respiratory Distress

How to know if its science or consensus

I like the idea of best practice medicine. These are the recommendations or guidelines by which we live with when treating patients.  The problem with these is that many of the guidelines are based on consensus and not science.  This results in healthcare providers offering profligate or surreptitious treatment to our patients, and often with the side effect of frustration, burnout, and apathy.

If you know that what you are ordered to do is a complete waste of time and money, and you have no choice but to do as you are told in order to keep your job, chances are that you are well aware that medicine is not based on science but consensus.  As John described a while back, a consensus is not science.  If it comes to a vote, it's not science, it's a consensus. If it's believed because it's popular, it's not science.

Science is infiltrated with consensus.  So how do you know if it's science or consensus?  When you go to school, teachers must teach you the consensus view.  It's then up to you to form an opinion.  So how do you form opinions?  There are basically two ways.  When posed as a question, you can ask one of the following two questions.

1. Does it feel good?
2. Does it do any good?

So, let's pose a question.  You have a 72 year old male admitted to the emergency room with pink frothy secretions coming from his nose and mouth.  The doctor orders a bronchodilator.  

1. Does it feel good?  Yes.  It makes me feel like I'm doing something to help this patient
2. Does it do any good?  No.  All it does is add more fluid to the airways. 

You see. Now, let's pose question #2: You have a 48 year old man who is not in respiratory failure but is suffering from kidney failure. In order to prevent pulmonary edema from developing, the doctor orders intermittent BiPAP. 

1. Does it feel good? Yes. I believe the increased intrathoracic pressure will assure that fluid is not forced out of pulmonary vessels. The increased pressure forces fluid that seeps out back into the vessels. Believing that it does this makes me feel good.
2. Does it do any good? No. There is no science that shows that BiPAP in any way will prevent heart failure and pulmonary edema. 

Example #3:  Okay, so you have a patient with pneumonia. The doctor orders an albuterol breathing treatment. The patient feels no different after the treatment. The patient has crackles in the left base before and after the treatment. But the patient is admitted, and treatments are ordered every four hours. 

1. Does it feel good? Yes. I believe that the albuterol will somehow cause the patient to cough up that pneumonia. It makes me feel good to know I'm doing something.
2. Does it do good? No. The treatments do not make the patient feel better, so they are a waste of time. There is no science that shows albuterol goes into alveoli, let alone that it reduced inflammation in alveoli enough to fit in and join to beta adrenergic receptors that do not exist in alveoli. 

See what I mean. Science is not a consensus. If it's up to a vote, it's not science. If 99.9% of doctors believe albuterol cures pneumonia, that does not make it true. Science means that it either is or it is not. It does not matter what doctors think. Either albuterol treats pneumonia or it does not. See. 

Fake Diagnosis: Is any diagnosis accurate?

Fresh out of respiratory therapy school 20 years ago the medical profession seemed so right.  Doctors always properly diagnosed patients and everything they ordered was always necessary. Then, after studying charts and assessing patients before and after every procedure I did, unexpected revelations occurred.

1. Most of what we do is a waste of time or delays time
2. No diagnosis can be trusted

Look, what I am about to say does not reflect, in any way, my respect for physicians and the institutions they work for.  In fact, I in no way expect any person to be perfect, and therefore it's not possible for every thing they order to be necessary, nor every diagnosis to be accurate.  

What is my evidence?  Why is this true? Yes, I will get to the answers. 

I've written enough about useless breathing treatments on this blog to choke a cow, so I don't want to get into that too much here.  But any respiratory therapist is taught to assess a patient before and after every treatment. When three treatments are ordered 20 minutes apart, and the patient is breathing normal after the first and still breathing normal before the second is due, that the second one is not needed. 

But the Quality Assurance people will cry on your shoulder if you did not do the second two treatments, because the patient required three failed breathing treatments to qualify for admission.  

So, while doctors sometimes order breathing treatments because they "think" they will help, or because they will make the patient "feel like we are doing something" or because "it can't hurt."  Many more now appear to be ordered just so the hospital gets paid.  

Now I don't know if it started with ICD-10 or DRGs, but most diagnosis' now appear to be incorrect as well.  Long ago a coworker of mine showed me a diagnosis of pneumonia.  He went over the patient's chart with me and said there is no evidence here that the patient has pneumonia at all.  

"Look," he said, "the x-ray is normal, there is no elevated white blood cell count, and the patient is not having trouble breathing. The only reason this patient was diagnosed with pneumonia is because the patient was too sick to go home and needed a reimbursable diagnosis."

From then on I paid attention every time a diagnosis of pneumonia was written, and, on many occasions, there was no evidence of pneumonia.  

Recently a doctor came to me and asked me a logical question.  He said, "How do you, as a respiratory therapist, define hypoxemic respiratory failure? Or, worded another way, what do they teach about it in respiratory therapy school?" 

I said, "Well, the easiest way to diagnose it is a CO2 greater than 50 and a PO2 less than 60. Why?

He said, "I just find that hypoxemic respiratory failure is often written as the diagnosis and there is no evidence of it.  Most of these patients do not even have a blood gas." 

I said, "Keep in mind that a patient can be in acute respiratory failure and have an SpO2 of less than 90 and still be diagnosed with it.  During some such episodes there is not time for a blood gas."  

He said, "True.  But in most cases, that is not the case, and yet patients are still getting diagnosed improperly. I'm getting tired of it." 

I said, "I see your frustration.  I think most doctors have no clue what a bronchodilator is and when they are needed.  I think that most doctors order albuterol because they think it will do something for pneumonia, and there is no reason why it would. And this has gotten so out of hand that CMS requires albuterol for the patient to meet admission and reimbursement criteria."

He said, "I agree. If I don't order albuterol I have QA people knocking on the back of my head saying, "Hello.  Hello. We need albuterol ordered on this patient. We need a diagnosis of pneumonia.  We need a diagnosis of asthma.  We need a diagnosis of COPD.  Those are much more reimbursable than what you wrote.  We need a diagnosis of hypoxemic respiratory failure."

I said, "It's sad."  

He continued to show me examples.  He opened the chart of a cancer patient.  Her charting showed the following:

• Respiratory Assessment: Dyspnea noted
• Breath sounds; rhonchi
• SpO2: 98% on 2lpm
• Temperature: 98.5
• White Blood Cell Count: normal
• ABG: pH 7.4, PO2 95% on 2l, CO2 35
• Diagnosis: hypoxemic respiratory failure; also pneumonia, lung cancer

He said, "An accurate diagnosis is exacerbation of COPD secondary to pneumonia or lung cancer.  You see how this is not a good diagnosis.  It throws off statistics, and it also causes the doctor to seek medical solutions that are not best for the patient. It causes the doctor to treat what doesn't need to be treated, wasting money and resources."

I said, "I agree."

He gave me another example.

• Respiratory Assessment; no respiratory distress, coughing spasm
• Breath sounds; rhonchi
• SpO2: 98% on room air
• Temperature: 100.5
• White blood cell count: normal
• ABG: none ordered
• Other: patient has peg tube
• Diagnosis: hypoxemic respiratory failure, aspiration pneumonia, sepsis

He said, "First, there was no ABG done. Second, the physician charted that the patient was in no respiratory distress. So how could he diagnose hypoxemic respiratory failure?"  It's simply wrong. 

I said, "Agreed."

He said, "So I charted that I disagreed with the above diagnosis, and entered that the patient had probable aspiration pneumonia. The next day the QA officials was all over me.  She said, 'That's a difference of $20,000 in reimbursement.' I said, "It's also fraud, and why healthcare costs are so high.'  So she was mad at me. The other doctor was mad at me, and I proceeded to explain to her why I was right and she was wrong. It was a learning experience for her.  But the next day I worked I saw that she had written, 'I respectfully disagree with the other doctor's diagnosis.'  Fine.  And you wonder why the healthcare profession is so screwed up.  QA officials are so concerned with making money for the hospital that they are trained, encouraged to falsify, or exaggerate, diagnosis. It has caused doctors to become lazy. Rather than think, they just chose a diagnosis from a list of ten most reimbursable."

I said, "The same happened with asthma.  Since DRG law was passed in 1978 or 1979 or 1980, asthma rates have skyrocketed.  Did asthma rates really skyrocket, or was it because asthma is a reimbursable diagnosis?"

He said, "Agreed.  It sucks."

It does suck.  

Why protocols will not eliminate useless Ventolin orders

So one of my respiratory therapist friends, of whom I will not name here even though he said I could, sent me an email a while back explaining why it is that respiratory therapist driven protocols will never result in a decrease in treatment loads.

1. There will always be the belief that if the patient is short of breath we must do something
2. People sitting in leather chairs in Washington decided that in order to meet criteria for admission a patient must have needed at least 3 treatments in ER.  It eludes them that hospitals would have physicians order them just so the hospital can be reimbursed. 
3. People sitting in leather chairs in Washington decided that in order for a patient's stay to be reimbursed for certain respiratory conditions (pneumonia, CHF, COPD) the patient must have breathing treatments ordered.  This is under the fake belief that if treatments aren't needed why keep the patient.  It eludes them that there may be other reasons for keeping the patient, nor that ventolin does nothing for non-bronchospastic lung ailments. 
4. They are convinced ventolin cures pneumonia
5. They are convinced ventolin cures heart failure
6. They are convinced ventolin enhances secretion clearance

Generally, physicians and administrators and politicians tend to ask this question when making a decision regarding respiratory therapy: "Does it feel good."  For instance, should we order treatments for pneumonia? Well, does it make me feel good.  Yes!  I feel like I'm doing something important and helping people out.  Yes! It makes the patient feel better, or at least like we are doing something useful

Generally, respiratory therapists and nurses ask the following question: "Does it do good? For instance, should we order treatments for pneumonia?  Well, does it do any good?  No! So then we recommend it not be ordered.  

We are usually trumped by too many people ask the wrong question. If ever there came a time when "Does it feel good?" is replaced by "Does it do good?", then and only then with true bronchodilator reform occur. 

Need I go on.  

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

Aerosols no longer indicated for airway clearance

We respiratory therapists seem to grumble and gripe a lot about useless breathing treatments, and usually to no avail.  However, it seems the good people working for American Association For Respiratory Care (AARC) have heeded some of the criticism and performed some of their own research into the matter.

RT Magazine reports the following:

A new evidence-based Clinical Practice Guideline (CPG) published in Respiratory Care found that evidence is lacking that proves pharmacologic agents routinely administered for airway clearance are effective in improving oxygenation and respiratory mechanics, reducing ventilator time and ICU stay, or resolving atelectasis.

The CPG is based on the work of an American Association for Respiratory Care (AARC) task force and Vanderbilt University researchers.

The following are the new recommendations regarding use of aerosols for

• The routine use of aerosolized acetylcysteine (Mucomyst) to improve airway clearance is not recommended in hospitalized adult and pediatric patients. 
• Aerosolized agents to change mucus biophysical properties or promote airway clearance are not recommended for adult or pediatric patients with neuromuscular disease, respiratory muscle weakness, or impaired cough.
• Mucolytics are not recommended to treat atelectasis in postoperative adult or pediatric patients, and the routine administration of bronchodilators to postoperative patients is not recommended. 
• There is no high-level evidence related to the use of bronchodilators, mucolytics, mucokinetics, and novel therapy to promote airway clearance in the studied populations. 

This is vindication, of sorts, to all of us RTs who have complained for years that this type of therapy rarely results in the desired benefits.  We'll have to wait and see if the medical profession eventually catches on to this new wisdom.  Using history as our guide, this will probably occur in the year 2035.

Further reading:

• RT Magazine: New CPG Questions Value of Aerosols for Airway Clearance
• RT Cave: Hypoxic Drive Theory: Reality or Hoax

Understanding stupid doctor orders, or SEE I TOLD YOU SO

Going all the way back to the ancient world doctors have written orders based on the following question: "Does it sound like a good idea?"

Unfortunately, even in the modern era where science rules the day, most medical theories are still based on this question.

It was based on asking this question that all pulmonary diseases have been treated as asthma since the beginning of civilization.  This was how the gods were thought to cause, prevent and cure all diseases in the primitive world: it sounds good.  This was how the hypoxic drive theory was postulated and became the golden rule of COPD, even though it was based on one fallacious study.  Despite it being disproved over a hundred times over the years, physicians still believe it to be true "because it sounds good."

Yet modern thinkers have challenged many of the old medical dogma's that have plagued the medical profession, and we can begin right here in the respiratory therapy profession.  I myself, for example, with the support of many of my peers, challenged the medical profession long ago on this blog by stating that albuterol does not enhance sputum production.  

We came to this conclusion by asking a better question: "Does it make sense?" Does it makes sense that oxygen knocks out the drive to breathe in COPD patients?  No, it does not.  Why? Because we oxygenate COPD patients all the time and they never stop breathing.  So we came to the conclusion that if they stop breathing, it's because they were going to anyway.  It is a proven fact that people need oxygen or they will die.  If they stop breathing, we use provide positive pressure breaths to improve ventilation.  

Does albuterol cure pneumonia? Does it sound like a good idea? Yes.  Does it make sense? No, it does not. Albuterol particles are the perfect size to attach to Beta 2 receptors in airways, but too large to even make it to the terminal air passages and alveoli, where the pneumonia is present.  Plus their are no beta receptors in the terminal airways anyway, so the albuterol wouldn't do any good anyway. Plus, albuterol is a bronchidilator, and pneumonia is inflammation.  

So a doctor challenged me on this as a result of my article "A World of Bronchodilator Lies."  He said the fact that some studies show that albuterol does increase sputum production is evidence that I am wrong.  I stuck to my guns on the basis that his theory sounded good but made no sense.

But now I have been vindicated.  Now I get to say "See, I told you so."  The new AARC Clinical Practice Guidelines, as reported By RT Magazine, now state the following:

There is no high-level evidence related to the use of bronchodilators, mucolytics, mucokinetics, and novel therapy to promote airway clearance in the studied populations. 

So, does albuterol enhance sputum clearance?  Well, does it sound good? Yes, so doctors will order it. Does it make sense? No, so respiratory therapists will doubt it does any good.

Further reading:

• A world of bronchodilator lies
• RT Magazine: New CPG Questions Value of Aerosols for Airway Clearance
• Respiratory Care: AARC Clinical Practice Guideline: Effectiveness of Pharmacologic Airway Clearance Therapies in Hospitalized Patients

Laryngospasm: It's often confused for a wheeze

Comics and writers like Stephen King can call it a wheeze.
But clinicians should know that if it's audible, it's laryngospasm.
For lack of a better description, you can call it rhonchi.
Oh, for crying out loud, call it a wheeze if you must,
but don't be fooled into thinking it's bronchospasm.

Clinicians don't learn about laryngospasm in nursing school, medical school, nor respiratory therapy school.  The reason is because most clinicians confuse it as bronchospasm, and call it a wheeze.  However, it is not bronchospasm, and it is not a wheeze: it's laryngospasm.  You should call it rhonchi.

So what is laryngospasm.  It's a harsh (coarse) audible sound during expiration. It's the sound of air moving through secretions sitting around the vocal cords, so when the patient exhales it is made audible.

Frequently it's caused by pulmonary edema and heart failure. Sometimes it is caused due to dehydration, such as when a patient suffers from detox or ETOH.

Many times it gives the appearance of airway obstruction, because the patient has a prolonged, forced, expiratory phase.  But when you ask these patients if they are short of breath they deny it.  This is because they are not experiencing bronchospasm, and the sound is perhaps "annoying" but it is not a wheeze.

If you don't want to call it "laryngospasm" you can call it rhonchi.  Rhonchi is the sound of air moving through secretions, and, more than likely, this is what you are hearing.  But you are certainly not hearing a "bronchospasmic wheeze," because a bronchospasmic wheeze is never audible. Bronchioles are teeny tiny airways, and you cannot possibly hear a wheeze produced by bronchospasm without the aid of a stethoscope.

What is a true bronchospasm wheeze?

A while back a fake buddy of mine made the observation that most people often confuse rhonchi for a wheeze.  He described it as "rhonchi-eeeeeeeeze."

Respiratory Therapists are often asked to give regularly scheduled breathing treatments that aren't needed because "the patient has a wheeze."  Sometimes the nurse says, "Can't you hear it?  I can hear it from here!"

My buddy also wrote a post about how what defines a wheeze is subjective, or that one person's wheeze is another person'a rhonchi or another person's coarse lung sounds.  Yet the bottom line is there is a lot of confusion regarding what a wheeze actually is.  This inspired the post "8 different types of wheezes."

My fake friend also wrote "Coarse lung sounds: the lazy clinician's lung sound." Here he wrote about how there is no such thing as a "coarse" lung sound, that what the clinician is actually hearing is rhonchi.  It's the sound of air moving through secretion filled air passages.  It was actually an NBRC test question once, proof that the experts who write the test were aware of the confusion long ago.

Sometimes rhonchi sounds bubbly on expiration.  A lazy clinician might confuse this as crackles or rhales, but it's actually rhonchi.  Coarse is rhonchi, and bubbly on expiration is rhonchi.  If you can hear it, it is rhonchi.  If you hear it over the throat, it's rhonchi.  Actually, if you place your stethoscope over the throat and you hear it, it's probably laryngospasm, but that's the subject of a future post.

Think of it this way.  If a person is having true bronchospasm, which is the true indication for bronchodilators such as Ventolin, Xopenex and Duoneb, the sound will not be coarse (i.e. rhonchi), and it will not be heard when you listen with the stethoscope over the neck where the vocal cords are, and it will definitely not be audible.

Think about it.  The air passages are tiny microscopic structures that can only be observed under the light of a microscope.  They are so tiny that there is no possible way that when they are obstructed the wheeze made will be heard unaided by a stethoscope.  It's simply not possible.

A wheeze is a high pitched sound, like eeeeeeeeeeeeeeee.  It even sounds like eeeeeeeeeeeeeee.  It can only be heard by auscultation.

A true wheeze (wheeeeeeze) is an indication for bronchodilator.  However, some people don't wheeze in the presence of bronchospasm, so another indication is no wheeze. So if you sit around waiting for a short of breath person to wheeze before you panic and order Ventolin, you may being your patient more harm than good.

So this is why it's important to know your lung sounds, as opposed to treating the patient with ventolin based on appearance and annoying audible noises coming from the patient.

Albuterol is the current big con

Whenever a physician, nurse, patient, or even another respiratory therapist, tries to explain to me why a patient needs a bronchodilator breathing treatment when they don't, I can't help but to think of the 1973 movie "The Sting.

The movie stars Robert Redford as Johnny Hooker and Paul Newman as Henry Gondorff. Hooker is a young con man who is being groomed by the more seasoned con Gondorff. In explaining how to be a successful con, Gondorff says, "You have to keep this con even after you take his money. He can't know you took him."

This was one of those movies where most of the audience was shocked when the final sting occurred because they had been conned for so long.  Yet for the few who figured out the truth long before the final sting it wasn't as much of a surprise. 

You see, most people, other than the trained respiratory therapist, have been duped into believing that albuterol is the saving grace of dyspnea. They also believe that nebulizers work better than inhalers, even though nearly every study I've ever seen proves they work equally well, even in emergent situations.

"So, who did the conning?" some ask.

"Pharmaceutical and hospital administrators who got rich during the 3rd period of respiratory.  therapy, that's who," I say.  

Look, there is no evidence that albuterol works for anything other than bronchospasm.  Once bronchospasm is ruled out, albuterol will only have a placebo effect. 

Evidence of the big albuterol con comes when the only argument for giving it is "It can't hurt." And boy do I hear that puerile argument a lot.  

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Is the false hope worth $120 a pop?

Your question: #1: do no harm. I can't speak for all rts, but most of my pts improve with the therapy given. Some pts despite all efforts whether mythical or not do not. I've never killed anyone with an albuterol. Sure, some docs think it cures everything, but it can make people feel better even if its just in their head. Now lets talk nurses overmedicating and rts having to fix their mistakes. Thoughts?

My answer: Actually it is a fallacy that ventolin causes no harm. We must not for get the s-isomer, which has been proven to cause inert bronchspasm. The more you take the medicine, the more you need it. It's an endless cycle.

I do see your point though. Patients do get the psychological benefit of thinking we're doing something, and the company of an RT.

Yet this has been a problem that has plagued the entire history of medicine, is that most medicine has no benefit other than psychological. Ventolin, like charms, amulets, prayers, and incantations of the primitive world, provides nothing more than the best remedy of all time: HOPE.

In other words, there are times when Ventolin has a real scientific benefit to the patients who receive it. The other 90% of patients receive nothing more than mythical benefits.

Does this "mythical benefit" and "false hope" justify the $120 it costs insurance companies for every treatment given?

Think of it this way, you give a treatment that's not needed every four hours, that's $720 a day, and $5,040 in a week. Is that price worth hope? Of course then you add all the prn treatments given in between because the patient got dyspneic on exertion to the commode, or developed an annoying wheeze, and the price only goes up even more.

Also, taking up a respiratory therapist's time giving a treatment that's not needed takes away time from someone who does need attention. This is a principle concept discussed often in economics 101 courses. It reminds me of the Broken Window Theory.

In the Broken Window Theory you have a boy walk by a sweater shop, and he tosses a rock through the glass. Some economists say this is good for the economy, because it creates a job for the glass maker. What is not seen is the effect on the sweater maker.

During the time the window is broken, the sweater keeper is not allowed to sell any of his sweaters. He therefore is out of a job until the window is fixed. He makes zero sweaters.  If he sells zero sweaters, the sweater maker sells zero sweaters.  Various other unseen people are also affected, such as the delivery man, and the man who sells little gadgets to support his family.

But the people don't see this aspect of the economy, all they see is what is obvious: a broken window and it being repaired. They see that the repairman is making money.  They think this is good for the economy. It is, but what they don't see is that the sweater company being closed greatly effects the economy in an unseen way.

So, I guess I'm comparing useless ventolin therapy with the sweater salesman. While the patient and the physician see the breathing treatment, what they don't see is that it did no good. Regardless, studies show that 50% of patients who received a placebo also said they benefited from the patient. So this proves that the patient is unreliable.

Likewise, in a similar scenario, while the breathing treatment is being given, the patient is given lasix. While the lasix is forming pee, and thus removing fluid from the lungs, thus making it easier to breathe, it is not seen.

In this way, lasix is also like the sweater maker. Since the ventolin is seen, it is given credit. It is also like the primitive medicine man getting credit for saving the live of a patient, when the truth is that nature did the same. But since he did something, he is given credit.

Also, and I'd like to see a study on this, when an RT is burned out at the end of a day due to too many frivolous therapies, it diminishes his ability to make good decisions at the end of his shift. A burned out therapist is not always at the top of his game.

This, in my opinion, may work to the detriment of good patient care. A burned out RT who is grumbling and griping at yet another useless ventolin order is probably not good for public relations either. And it's not like you can fire this RT, especially, as I've observed, this is common among all RTs. So you can't fire them all.

Now, these are simply thoughts. Although in all the years I've communicated such thoughts, I have never had anyone come up with a counter argument. Not one person has ever come up with any facts to prove that ventolin is needed for CHF, pneumonia, cancer, pleural effusion, and other lung diseases that provide asthma like symptoms.

I have had many doctors say things like, "I think that ventolin helps with heart failure." I ask this doctor, "Do you have the evidence to support this claim, or is it just a feeling?" Never has a doctor proffered any evidence. Usually they get mad as I offer my proof. They get mad at me for being honest.

Getting back to the broken window theory, as I'm giving the breathing treatment that isn't needed, what is not seen is that two rooms down is a man in the early stages of heart failure.  He is the man I would be visiting if I wasn't stuck in this room. Later on he will be intubated, and and only because of that breathing treatment that was thought to do no harm.

The idea that ventolin therapy does no harm, in my opinion, is no better than treating diseases the primitive way with a medicine man dancing, rattling his shakers, beating his drums, and chanting incantations. Since this is what the sick person sees, when the patient gets better the patient will say, "The miracles of the medicine man cured my sickness."

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The worse part of having 30 patients on treatments

The worse part of having 30 patients on breathingi treatments, with 28 who don't need them, is that I don't care about conversing with my patients the way I usually do.  My sole MO is to dole out nebs (yes, to be a neb jockey, or the nurses bitch).

The patient wants to start a conversation with me, and I feel guilty, but I'm so burned I can't even crack a smile.  My wife says I should be happy to do this, because I get paid to dole out stuff that's not needed.  But even that doesn't do it for me any more.  I just feel so pointless when I'm working like this.

Every room I go to, every doctor I talk to, every nurse I talk to, I keep coming up with ideas for my blog.  A doctor says, "I want to change that QID treatment to Q4 around the clock."  Why?  I just got done doing a treatment on that patient, and he was neither short of breath nor wheezy nor dim.  WT?.

A nurse comes to me and says, "I need you to give a treatment to the lady in room 33245234."

"Why?"

"Because she's wheezing."

"Is she short of breath?"

"No, but she sounds bad."

"She always sounds bad," I say.

If I walk away now the nurse thinks I'm lazy.  I once got written up because I didn't do what the nurse wanted.  So I go in the room and find a patient sleeping in no distress with an audible wheeze.  I say to the nurse, "If it's audible, it's not bronchospasm.  It's a cardiac wheeze.  It's in her throat."

But this is the 3,343,343,342,563,645,754 time I've explained this to this nurse, so I know this information is going to bounce off her gray matter like a rubber ball on cement.  So I do the treatment.  Yes, I'm this nurses bitch.

(Trust me, most nurses aren't this way.  Although when you're burned out is always (generalization) seems that such annoying nurses come out of the woodwork).

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The great RT dilemma, as noted by one of you

One of the things I wish I could get my readers to do is write their names when making a comment, or even give me a fake name.  Of course I understand why you guys and gals don't give names, because you don't want to get into trouble.  I duly respect that.  And that's the only reason I leave you with the option of responding anonymously.  

So, while I cannot give the person who left this comment due respect, I believe he or she has made a great point, and a point worthy of a discussion.  The comment went as follows: 

Respiratory Therapy is a strange profession in that we often take our orders from people who know less about our field than we do. Doctors go through 4 years of college, 4 years of med school, 3-7 years of residency... but they have to know about gallbladders and kidneys and glandular issues and depression, among other things. 

We get a fraction of the schooling and training, yet it is all about one subject and becomes more in depth on that subject. So we take orders that we know are wrong or not ideal, and we learn to take it with a smile. It's an interesting concept. Often, disagreeing with ICU nurses and ER nurses can get RTs in trouble.

It's no wonder that many RTs just stop learning and become doers rather than thinkers... what good is that knowledge if it you're just going to defer to someone else and do what you're told? What good is that knowledge if other RTs will just see you as a show off?

I'm just going to leave it at that and let you folks ponder the thought.  Once you've rolled the idea around in your minds a while, or have discussed it among your fellow RT buddies, leave a comment below.  I'm just interested to learn your take on this.  Please feel free to complain, but hold off on obscenities.

If you're the brilliant RT who wrote this comment on "Low information doctors," you're probably smiling right now, and maybe even surreptitiously covering your smile.

Are Respiratory Therapists hospital's bitches?

The following may be a controversial topic among the respiratory therapy profession. 

However...

Considering the popularity of  questions I've received on the subject herewith, I have decided to publish the controversial post on the controversial subject. 

I humbly submit this with permission by said author, and by request of an anonymous friend from whom follows the RT cave from somewhere on earth but we do not reveal where as to not get him fired.

Note:  All names places, dates, periods, and capital letters are exaggerated as to not give away any reliable information.  Please consider this while pretenting to read said post. 

Hi Rick. At the hospital I work for we were so excited to finally have an emergency room breathing treatment protocol.  Man, this made me feel so good.  It was finally going to allow me to use the skills I learned in RT school, to decide who does and who does not need breathing treatments.  

Well, after about two years of implementing this protocol, it has resulted in zero fewer emergency room breathing treatments.  If anything, it's resulted in more -- many more. Thus has hammered RATS even deeper into my bones.  

I will give you an example as it occurred today.  I'm called to the ER for RT Consult.  The patient is not short of breath, but is diagnosed with pneumonia.  I'm asked to use my skills to decide if a treatment is needed.  

Nurse:  "You need to give a treatment."

Me:  "Upon my assessment no treatment is needed."

Nurse: "You need to give a breathing treatment."

Me: "No breathing treatment is indicated per RT Consult."

Nurse:  (Irritated) It's your job to give breathing treatments.  There's no reason you can't prepare one.  That's your job.  (right in front of the patient)

Irritated, I give the treatment.
Me: (to patient) "Do you feel any different after the treatment?"

Patient:  "No."

Of course then the patient coughs, brings up a loogy, and spits it into the sputum cup.  The nurse picks up the cup, and holds it up to me as she says, "And you said the treatment wasn't needed."

Me: (Rolling my eyes)(sighing)(leaving room)

Nurse:  (Writes letter to my boss complaining about how I'm lazy and trying to get out of work. Complains how I am grumpy with her.)

My boss then recommends that I take a customer service course, and give more treatments.  

Of course since the treatment is now "indicated" according to our protocol, I have to check up on the patient every half hour until discharge.  

Me:  irritated, go home and drink four Bud Lights, 2 glasses of wine, and one shot of Peppermint Schnapps.  

Sorry for the French, but as RTs, we've become the hospital's bitches.

Anonymous RT (with permission from RT Cave)

Keep in mind, here this is the perspective of the anonymous RT and not necessarily representative of the view of this blog.  However, the RT Cave does not deny it either.  

Now, we should have a raging discussion on this.  Thoughts.  

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Old theories create awkward moments

So in line with a topic of discussion the other day, another thing I've decided to do is never tell a lie to my patients.  If you ever get into a spot where the truth cannot or should not be spoken, then the only alternative is to remain silence.  And here we go back to the old saying, "An awkward silence is better than saying something you'll regret."

So we have a couple physicians who order Albuterol every four hours based on a theory by one surgeon that Albuterol prevents post operative pneumonia.  It was never proven, and most physicians have abandoned this type of order.  However, out of old habit, our physicians still order it.  They probably don't even know what the order is for, nor why they order it.  But old habits they die hard.

So I'm giving such a treatment to one of my patients, and a family member says, "So, why are you giving this treatment to my mom.  She's not having trouble breathing."

Of course by this time its the end of my shift, so the old slippery tongue theory comes into play here.  I said, "It's because Dr. Slippery went to medical school in the 1950s, and he still orders based on 1950s medical theories."

Now, while truthful, it was something I never should have said.  I sort of backed myself into a corner of sorts.  I put myself on the defense.  Which goes to show that sometimes a lie is better.  Or, better yet, a line of BS or a moment of awkward silence.

To tell the family member the treatment was to help the patient breath better would have been the normal lie here.

Useless breathing treatments may never end

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thoughts?

See bronchodilator reform

ISO bans use to RT cheat sheets to improve quality

Would you believe I was told by my boss I can no longer carry with me a cheat sheet in my pocket.  I was stunned, and I decided I was still going to carry it with me and just not tell my boss.  It's this type of lying that's been deemed necessary by the International Commission of Idiocy.

According to my boss I can carry cheat sheets with me, but only ones that are officially approved by the powers that be.  You can carry a book like "Dana Oach's Practitioners Pocket Guide to Respiratory Care," but who wants to carry an entire book around with them?  Not me.

(Here's my cheat sheets)

So a few years ago I created a cheat sheet of my own, shrunk it down to size, and carry it with me in my pocket.  I even created a key to help me decide what tidal volume is best for which patients.  Doctors love it so much they even request to see it often, and my coworkers all have one of their own.

The issue that I have is one day recently I updated my cheat sheet and set it out because one of my coworkers and I were trying to decide what color paper would work best.  My boss came out and said, "What you guys up to?'

It's not like we could lie, or felt we needed to.  I said, "We're deciding what color my cheat sheets should be."

"Oh," he said, and picked one up.  "This is some useful information.  I would have loved to have one of these when I was an RT."

"Then take one," I said.  "Or when we get these laminated you can have one."

He paused a moment, as though mulling it over, then said, "Well, you can't use these, you know."

He was joking of course, right?  I thought.  Then I said, "You're joking, right?"

"No.  ISO has a policy that only sheets approved by the forms committee can be used or in possession of any person who is working?"

"Why would they come up with such a stupid policy?" my coworker said.

"Because," my boss answered, "they wanted to improve quality.  This is a quality improvement polity.  If the hospital is sued because you used information on your cheat sheet, and what's on your cheat sheet is not approved by the hospital, you could be in trouble."

"Yes," I said, "but if the patient died because I relied on my memory to set a too high tidal volume on, say, a neonate, then we will all be sued and a baby will be dead.  So my cheat sheet is made to prevent such a thing from happening. My cheat sheet is made to prevent idiocy.  So by ISO telling me I can't carry my cheat sheet to improve quality may have a reverse effect:  It may create idiocy."

"In other words," my coworker said, "It's poppycock."

As it turned out, my boss could not get my cheat sheets approved by the forms committee because many of the formulas and calculators that I created and used are ones that I made up myself or found useful from other therapists.  Many aren't in Dana Oach's book.

So this is a perfect example of what would never happen if I were running the hospital, and it goes against rule #2:  Try something new. Often. Keep whatever works.  You can view my keys a successful RT Cave here.  You can view the old version of my cheat sheets here.  I hope to have the new one up soon (yet don't show your boss).  

STAT: A word that is often abused

The word "STAT" comes from the Latin word staim which means immediately.  So stat is essentially an abbreviation of the old word.  It's common for the English to be lazy with speech, and thus is how the word stat was formed.

Proper use of the word is either capitalized or not capitalized. 

Essentially, when someone is called STAT it means that person is needed immediately.  Unfortunately, however, the word "immediately" does not denote what the person is needed for.  So you can be called STAT because your services are desired to save a life, or  you could be called so the doctor can get his EKG results quick so he can see it before he goes home for dinner.

Ideally you'd think the word STAT would be used for life and death situations, such as the following. :

• RT STAT to ER..... we have a patient in respiratory distress
• RT STAT to 244.... we have a patient in V-tach
• RT STAT to ICU...  we have a patient with a heart rate of 27
• RT STAT to ER...  we have a patient who can't breathe

Realistically, the above plus the following are more likely to occur in tandem:

• RT STAT to ER.... EMTs are 20 minutes out with a cardiac arrest
• RT STAT to 244.... Dr. Jones wants an EKG done before he goes home, pt is fine
• RT STAT to ambulatory surgery... Dr. wants pre-op EKG done
• RT STAT to CCU... RN wants EKG to see what rythm patient is in

Actually, I have recent pages such as the following:

• STAT EKG in 2234 in two hours
• STAT ABG in an hour on the vent patient

With such a vague definition, and with such frivolous use of the word statim or STAT, the word has lost much of it's luster and RTs have become deconditioned to the word.  When an RT may be needed immediately, he may be inclined to finish his last bite of steak before sauntering to where he's needed.

He may also be written up for responding to a code overly relaxed and in a non-urgent manner.