Instant Pneumonia: An Illness Doctors Just Made Up

The following is an update to the Real Doctor's Creed. We have come upon this top secret (shared only with the medical community) information. We will continue to share these as we gain access to them. At the present time we have several spies in the medical community, making it possible to publish the Creed right here on the RT Cave. 

Doctor's Creed: Update 10/1/2022

Add the following to the pneumonia section of your booklets. Please do not publish online, as we do not want respiratory therapists to have an opportunity to hack into our esoteric wisdom. 

So, we know what pneumonia is. It is a condition caused by a virus or (usually) a bacteria. Walls of alveoli become inflamed. And this causes puss and fluid to fill alveoli. This renders the affected air exchange units less effective. And a may result here is soreness (especially with a deep breath), shortness of breath, and lowered oxygen levels. And, if severe and untreated, potential death. 

Now there is a new type of pneumonia. And it results from aspirating large doses of stomach contents. It is generally not caused by aspirating small amounts of stomach contents over time, as that would be diagnosed as GERD. But, if you aspirate large amounts of stomach contents (such as due to a drug overdose), then this is referred to as aspiration. 

A new study, one never performed by the fake left leaning scientific community, has now determined that aspiration INSTANTLY results in pneumonia. And this would help explain why we doctors are now able to diagnose patients with "Aspiration Pneumonia" instantly following aspiration. 

Respiratory therapists have often said things like: "Now, how the hell can someone develop instant pneumnonia? It usually takes time for alveolar walls to become inflamed." Or they say things like, "It should be called 'aspiration' not 'aspiration pneumonia'"

We in the medical community know better! We understand that unwanted fluid in the lungs from aspiration is "automatic" and "instant" pneumonia. Sure, there may be no inflammation right away. But, still, the aspirated contents fill alveoli meeting our definition of pneumonia. 

Besides, a consensus of doctors agrees with this author. And therefore it must be true. 

Also, insurance people love pneumonia and are willing to fully reimburse hospitals for pneumonia. So, adding the term "pneumonia" to the term "aspiration" shall guarantee the highest reimbursement potential for your patients admission. 

Dr. Creed: One Budesonide Amp should cure stridor

Real Doctor's Creed: Appendix Z: Problem Solving

Section 982: Pediatric Croup.

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

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

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

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

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

So I ordered a one time dose of pulmicort.

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

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

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

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

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

The Noninvasive Ventilation Creed

What follows is what will be added to the new addition to the Real Physician's Creed: How to take care of Pesky RTs. Again, this is TOP SECRET information for physician use only, and was never intended to be released among the RT community.

My source for this ESOTERIC information will be kept anonymous, because if his peers find out he is the leak, he will be banned from the medical community at best, or ridiculed at worse. 

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Page99

(Section B-3)

Physician's Real Creed: The Noninvasive Ventilation Creed:

Noninvasive ventilation (NIV)systems are complicated systems that require extensive training physicians don't have time for.  So, in lieu of spending thousands of dollars better spent on cigarettes and alcohol, allow me to simplify NIV so it's easy to memorize and requires little thought.  

There are essentially NINE rules for NIV: 

1. Know the types of NIV and when they should be ordered:

• CPAP: prescribed for observed apnea or just simply obesity
• BiPAP: for everything else

2.  Know the indications for NIV and how it works: 

• Pulmonary Edema: it forces fluid out of the lungs
• Respiratory Failure: it breathes for them
• Hypoxic hypoxemia: it forces oxygen into the lungs
• Hypercarbia/ CO2 >45:  It sucks CO2 out of the lungs.  Warning: Do not wait for CO2 to rise above 47.  If it's 46, it's time for BiPAP.
• Annoyed physician:  If either the patient or RT annoys you

3.  Know there are no contraindications, especially if you're too busy to consider intubation: 

• DNR: put it on anyway
• Unconscious/ Obtunded: fluid rarely builds up inside the mask, so it's well worth the risk.
• Restraints: same as unconscious
• Apneic: use BiPAP because it breathes for them

4.  Know that you can adjust the settings at any time without notifying a respiratory therapists. In fact, this can be done occasionally to boost your ego or tick off annoying RTs.  If they suspect you did it, deny, deny, deny.  

5.  Settings: Always order 10/4.  Increase settings aggressively to reach and maintain a pH of 7.40 and CO2 of 40.  FiO2 should start at 40% and adjust to maintain a PO2 of 106. Or, just pull any numbers out of your head and stick with them no matter what RT says. 

6.  Special considerations:  The increased pulmonary pressure will keep fluid out of the lungs and prevent pulmonary edema.  Works well for the following situations.

1. Unable to give lasix on dyspneic patient 
2. Need to give fluid bolus on dyspneic patient you are afraid to give lasix to due to hypotension (or any other reason)

7.  Length of time on BiPAP for effectiveness to be reached is two hours.  For this reason, it's important to talk patients into it, or have respiratory therapy force the BiPAP mask onto the patient, for at least two hours.  It's rare, although fine, for the patient to be anxious during this time. After the two hour time frame is up the patient may be allowed to refuse. A proper order for this is "Intermittent BiPAP." 

8.  May be indicated for low blood pressure.  Yes, we know that respiratory therapists keep saying that BiPAP is proven to decrease cardiac output and reduce venous return in order to reduce fluid in the lungs. When they say stuff like that just sigh and walk away. We KNOW that BiPAP can piss a patient off, and in this way raise blood pressure. It works well even better when combined with a continuous ventolin infusion. 

9. You do not need to order an ABG to prove BiPAP is necessary.  If the patient looks like a COPDer or CHFer, order BiPAP.  Here's what RT might say, "Dr. Do you want me to do the ABG before setting up BiPAP so we can verify that it's needed?"  To this you respond, "Do 'em in whatever order you want, just put the BiPAP on at some point so he can breathe better." So then the RT comes at you with the following ABGs: pH 7.4, CO2 40, HCO3 24, PO2 51, SpO2 86."  The RT says, "He says he's breathing great now that I increased his nasal cannula flow to 3lpm from 2lpm.  His SpO2 is now 95%."  Look, it doesn't matter what the RT says, nor what the numbers say, in this case you must stick with your initial hunch.  It's BiPAP all the way baby! 

10.  Know that BiPAP therapy is basically a glorified IPPB therapy. So, again, it may  be ordered as "intermittent BiPAP" for PaCO2 >45.  It also may be ordered as glorified BiPAP (i.e. Intermittent BiPAP) to ward off evil spirits. 

11.  CO2 Retention with normal or normalizing pH. So ABG results show a pH of 7.29 and a CO2 of 79. You know the CO2 is normally in the mid 50s. This is an ideal place to order BiPAP intermittently. This way you can gradually get the CO2 down to the patient's normal range. It's okay to order even if the patient is awake and alert and in no respiratory distress. It's okay to order this especially if the RT grumbles and gripes about it. 

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