Real Drs Creed: Hypoxic Drive Hoax Revisited

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 TOP SECRET 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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Appendix 8

Real Physician's Creed: Hypoxic Drive Hoax Revisited

Date: April 9, 2012
From: Dr. Al Buterol, M.D., President of physiciansrock.com
To: Dr. Ven Tolin, president of the Dr. Creed Association

Basically the hypoxic drive theory was created as an excuse to get physicians off the hook for when a patient dies of hypoxia.  It was originally intended to cover COPD patients, although we have extended it to include patients with severe asthma, lung cancer, cystic fibrosis, etc. It also includes every person who ever smoked, whether they are a CO2 retainer or not.

Since most people smoked in 1962 when Mr. Campbell gave his great presentation to the physicians of the American Medical Association, this theory seemed like a very good idea -- it made us all feel good.  And just think about it, if our own fake theories make us feel good, that's a bonus.  This new hoax pretty much got us physicians off the hook in most cases where we were sued for a patient dying of anoxia (for those who barely graduated medical school, that means lack of oxygen to the brain).  This new hoax pretty much got physicians off the hook in most cases.

However, the bimbo heads in Washington continue their quest to get people to quit smoking, and this has put a damper on our profession.  Since fewer people smoke today, this has resulted in increased litigation, and there be your reason for all the increased medical costs and all the warnings on medicine that most people ignore.  We owe it all to evil lawyers who now have an open door to suing us because our hoax is no longer valid as often as we'd like due to people no longer being ignorant.

Now it also appears that some incompetent physicians and nosy respiratory therapists are on to our hoax, and are out to expose our efforts. This would be terrible because it would make us out to be wrong, and you know the medical profession is always right.

So my effort by sending out this memo to all my fellow physicians is to remind you of the importance of the hypoxic drive hoax, and the importance of the efforts to ignore RT efforts to inculcate the idea the Hypoxic Drive Theory is really a hoax.  We know it is, but we don't want lawyers catching on to this, because that would result in lawsuits when when we intentionally keep COPD patients hypoxic.

Keep up the good work fellow Dr. Creed members.  We must continue our quest to keep anyone outside the medical profession ignorant.

Is it asthma, or croup?

I was called to the emergency room to give a breathing treatment to a 1-year-old who was having mild retractions with an audible stridor. Notice I didn't say I was asked to assess the patient, I was called because the nurses believed the doctor would want me to give a treatment, and probably a racemic epinepherine treatment.

The patient to me sounded quite diminished, and I suspected bronchospasm. I told this to the doctor, and he disagreed with me. He thought it sounded like croup, and he ordered for me to give a racemic epi treatment. I didn't have a problem with this on the grounds the race epi would also dilate the bronchioles if they were, as I suspected, truly spasming.

See, I have learned through the course of my experience that asthma sometimes sounds like croup. There are times, especially in children (yet occasionally in adults), audible stridor, coupled with diminished lung sounds, is sometimes indicative of asthma.

After the treatment the patient was obviously breathing better. The retractions were gone. And, when I listened with my stethescope, lung sounds were markedly improved, with much improved air movement.

Satisfied, I went upstairs, where I sat at my desk and the phone rang. It was the nurse of the baby. She said she thought I should set up a cool mist aerosol for the baby. "Don't you think that would help his croup," she said.

Again, I was thinking this was reactive airway and not croup, but I said, "Well, I think you better run that by the doctor, because every doctor has a different plan of action for croup." And this was true. As I set the phone on the receiver I almost made myself laugh as I thought, "Yep, every doctor believes in a different fallacy."

This is why I like to say medicine is an art more so than a science. It's based on science, although when it comes down to it medicine is an art.

We have a lot of policies, and order sets, and dogmatic doctors all that treat all patients the same, or from the same cookbook. Much of this, or so they say, is based on best practice medicine. This is great for most cases.

Doctors who treat all patients from the same cookbook often mistreat and over treat. A perfect example is my asthmatic patient here with stridor and no wheezes.

Yet there are fallacies too. For example, for croup one doctor likes to give race epi, and another xopenex, and another albuterol, and another likes to set up a cool mist, and another a shot of steroid (the actual only thing that really works). Worse, some doctors and nurses (and RTs) can't see outside the cookbook. They don't think.

It's almost funny the fallacies in medicine. It's even funnier that there is no consistency of fallacies, and it's this reason we RTs sometimes get vexed, are often apathetic, and why we call for protocols.

Thankfully the doctor on duty that night was not a cookbook doctor. He did not order a cool mist aerosol. In fact, later when I discussed with the doctor, he told me I was right. Later, as I was leaving the ER to the RT Cave, I couldn't help but to smile.

Doctors: Albuterol does not increase sats

I dare you to hang this sign on your bulleton board for doctors to see.

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Dear doctor:

A bronchodilator breathing treatment will not benefit a patient just because she has a low spo2. If the patient has normal lung sounds, good air movement, crackles in the bases, and is sleeping, chances are she is not having bronchospasms.

Likewise, upon further assessment, if a pre and post peak flows are the same, and the patient says, "I am not short of breath," before bronchodilator therapy and says, "I am still not short of breath," after bronchodilator therapy, the chances are the patient is not having bronchospasm.

If a patient is not having bronchospasm, then a bronchodilator is not indicated. A bronchodilator alone will not make the spo2 go up. However, the oxygen boost during the treatment might.

So, since the breathing treatment did not work, we would recommend you search for other causes for the low spo2 other than bronchospasm:

a) the patient's spo2 normally drops while resting, sleeping, or during shallow respirations, and increased oxygen is the solution.

b) the patient is slowly becoming wet due to all the fluid intake from surgery, IVs, etc. In this case, a dose of a diuretic like laxix or bumex is indicated.

Yes we appreciate the work, and we have no problem sticking a neb in someone's mouth. However, we would appreciate if, when you are not at the bedside, you respect the clinical judgement of the respiratory therapist as well as the nurse when deciding what is the best course of action for your patients.

We appreciate your cooperation in this area. Sincerely, your humble respiratory therapist.

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I dare you!

Dear doctors: don't abuse the word STAT

I dare you to hang this note on your bulletin board for doctors to see.

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Dear Doctor:

If the patient has been in afib for six hours, has a long history of afib, and shows no signs of respiratory distress, notes no signs of respiratory distress, has a normal spo2, and has no chest pain, then a STAT EKG is not in order.

Now, you may order an EKG as "Now" or "ASAP," but STAT is not appropriate. When we hear the word STAT we think that if we are not at the patient bedside in a matter of minutes the patient will die. If you abuse this important word, you diminish its value, and desensitize us to that word.

Thus, please, do not order a procedure STAT unless you actually mean you want us at the bedside immediately. If you order me to the bedside STAT because you don't want to wait, or because you're annoyed with the nurse, or because you want it before a surgery, I'm going to catch on and STAT to me is going to mean no more than ASAP or NOW.

So, please, from this day forth, do not order procedures STAT unless the word STAT is what you really want.

Thank you: your humble respiratory therapist

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I dare you.

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Word of the Day:Provocation: the act of provoking; something that incites, instigates, angers, or irritates

I imagine one might see this more as an act of provocation as opposed to educating.

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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."

My advice to physicians

Doctors are among the most respected profession on the planet, and rightfully so. Still, to continue to deserve that respect, doctors must earn it. There's nothing I hate more than when a doctor orders something that's not indicated, and yet a patient says something like, "Well, if the doctor ordered it, I must need it."

That's some pretty good respect. Literally, I've seen doctors order invasive procedures, and the patient just lets the doctor do it. I've seen suction ordered for a patient whose awake and alert, and the patient says, "Well, if the doctor ordered it."

I've seen BiPAP ordered on a patient with normal blood gases and no respiratory distress, and the patient said, "Well, if the doctor ordered it." Sure this is also a sign of ignorance among the patient community, but it may also be a sign that doctors, however well respected, must continue to better themselves.

That in mind, I've come up with a list of my humble advice to those among this greatly respected profession:

1. You ought to take a step beyond just assessing, diagnosing and prescribing.
2. By that, you ought to educate, educate, educate. Whether this is done by you or your staff, you ought to be sure that every patient understands fully their disease.
3. You ought to follow up with each patient to make sure they understand their disease and are following the treatment plan you prescribe.
4. If a patient is not being compliant, you ought to inquire of them as to what you can do as a physician to help them become more compliant. "What advice do you have for me?" Every doctor should ask that question of their patients.
5. You also must monitor prescription usage. If you see, for example, that an asthmatic is using three Albuterol inhalers a month, then you ought to be aware of this. If your patient has hardluck asthma, you need to know this. If your patient has poorly controlled asthma, you need to know this too.
6. You need to use common sense in your approach to medicine
7. You need to be open minded in your approach to medicine
8. You need to continue the education process yourself (for one thing, you need to read up on the real purpose of bronchodilators. You can learn about this by hanging around this blog, or clicking here).
9. You need to be proactive. Don't wait until a crisis hits to act.
10. You need to teach the people you rely on: such as RNs and RTs.
11. You need to learn to trust and rely on those who are with the patient: such as RNs & RTs
12. Other than that, continue doing what you're doing.

I understand that most doctors are the best at what they do. I respect most surgeons, because I know I'd never want that job. I respect Internists and family doctors, because I certainly wouldn't want to be bothered at 2 in the morning each night. Plus I wouldn't want the liability.

Still, I think all physicians, no matter how well you are at what you do, should take the next step at improving the patient/physician relationship.

Is BiPAP good for CHF?

As always I've been thinking too much lately. This time about BiPAP and CHF. The goal here is to make sure we are dealing with facts and not thinking BiPAP is doing something it's not.

So, that in mind, I created this Q&A. I did the research and then had a discussion with myself.

My Question: BiPAP is ordered for a patient who is labored, has a low PO2 despite 75% non-rebreather, and increased excessory muscle fatigue. Why does it work?

My humble answer: It works because the IPAP helps the patient take in a breath without having to use his excessory muscles. In this way it decreases muscle fatigue by decreasing work of breathing. The EPAP helps increase the patients FRC and thus increases oxygen delivery to the blood and to the tissues.

My Question: I understand that, but why is it every time I ask a doctor why he ordered BiPAP on a patient who shows signs of pulmonary edema yet has no signs of muscle fatigue and normal blood gases, he always says, "Because it pushes fluid out of the lungs?"

My humble answer: The idea that the BiPAP pushes fluid out of the lungs is a fallacy. It does nothing of the sort. I contemplated this and did some research. The best answer I could find came from Jeffrey Sankoff, MD, from Emergency Physicians. I will post what he wrote about his topic below and the next time you have a doctor say that you can show him this report:

Contrary to popular belief, NIMV does NOT push edema fluid out of the lungs. Patients with acute CHF have an imbalance in the CO (cardiac output) of the right and left sides of the heart. With the inciting event (detailed above) the left ventricle becomes compromised but the right ventricle usually does not. So the right ventricle continues to pump forward a normal volume of blood but the left ventricle becomes unable to keep pace. Fluid backs up into the lungs resulting in capillary leak and pulmonary edema. With NIMV, the resultant positive intra-thoracic pressure decreases venous return (blood flowing back to the heart). This reduces right-sided CO to a level that the left heart can equal or even exceed. Fluid ceases to back up and will even begin to be reabsorbed as left ventricular CO improves. Pulmonary edema ceases to worsen and may even diminish, often rapidly.

My Question: So does this explain why patients are still on BiPAP hours after their episode has been resolved and they are awake, alert, orientated, breathing normal, and irritated that they are still have the BiPAP mask strapped to their face?

My humble answer: I can't answer that for sure, but it's possible.

My Question: See, I have listened to doctors and nurses discuss how, "the BiPAP saved that patient's life." Yet I often wonder if it was the BiPAP at all but the medicine we use to fix the patient. What are your thoughts on this.

My humble answer: I think you guys are all right. I agree with you in that I have always thought of BiPAP as the machine version of Ventolin, that it does not cure, it treats the symptoms. A Ventolin treatment does not resolve the asthma episode, it merely treats the symptom of bronchospasm, thus buying time for other medicines (corticosteroids or antibiotics) to take effect. BiPAP is a treatment to relieve work of breathing and thus buy the patient some time while the medicines the doctor orders and the nurses give make the pump work better (Dopamine) and get the fluid out of the lungs (Lasix).

However, as you can see from the discussion we had above, BiPAP can also help decrease the amount of fluid in the lungs. Yet, still, it is just treating the symptoms while other therapies treat the CHF. Usually about 2-3 hours after treatment is started the patient feels great and the BiPAP is given credit for curing the patient. In this way, it is just like Ventolin.

Question: So, technically speaking, once the patients heart is stronger, the cardiac output improved, the fluid is off the lungs, and the patient is breathing better, the BiPAP can be discharged from the patient. Right?

My humble answer: Absolutely. When I was a student working at a larger hospital, back when these type of patients were put on Ventilators instead trialed on BiPAP, once the patient was better he was extubated. I work at a smaller hospital and the doctor won't extubate CHF patients who are intubated, and won't discharge the BiPAP now that this is the therapy of choice. That's just the way doctors work. It made the patient better and now they are afraid to take it off the patient.

Question: So are they being lazy, or is it because they think the BiPAP is keeping the fluid out of the lungs?

My humble answer: Your guess is as good as mine on that one.

So, while the main goal of BiPAP with CHF is to decrease work of breathing, it can also help increase cardiac output and decrease the amount of fluid in the lungs. It does not, however, push fluid out of the lungs. So we have once again debunked another RT fallacy.

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