Fit testing time again, and again, and again...

Ah, fit testing season is upon us once again—the annual ritual where we confirm that the mask we’ve been wearing all year still fits. Because, of course, logic demands it. Nothing says "efficiency" like repeating a test for something you already know the answer to. Bureaucracy at its finest!

This tradition is brought to you by none other than OSHA—the overlords of occupational safety—and their local enforcers, MIOSHA. These fine folks ensure that anyone donning an N95 mask to fend off airborne germs is officially deemed fit to do so. And not just once, mind you. No, we must endure this spectacle every single year. Why? Because... well, because.

Seriously, didn’t we just do this? Oh wait, that was last year. And now it’s time again, because seven people sitting in ridiculously expensive leather chairs needed to justify their existence. So, they came up with a rule: Annual fit testing! That way, when they visit our hospital, they have something to check off their clipboard.

But let’s not forget the hidden genius of this policy: It doubles as a convenient way for the hospital to deal with "that guy." You know the one—the person nobody likes but HR hasn’t found a good excuse to fire. Skip your fit test this year? Boom. You’re fired. Thanks for playing.

Now, let’s talk about logic. The only time fit testing should be necessary is when something significant changes—like if you’ve gained or lost a lot of weight or decided to embrace your inner lumberjack and grow a full beard. But apparently, common sense isn’t part of the rulebook. Instead, we’re stuck in a cycle of pointless repetition, because doing things the logical way would be far too convenient.

So here we are, dutifully squeezing into masks we’ve already proven fit us perfectly, all for the sake of compliance. Not like we have enough to do already... right?

Hypertonic Saline --- Blue Light Special

Doctors are ordering hypertonic saline for nearly every patient in the hospital these days, regardless of whether it’s actually needed. Most of the time, it feels like we’re just wasting our time.

“Step right up, folks! Come one, come all! If you’re admitted to our hospital today, you’ll be eligible for our blue light special: hypertonic saline!”

Don’t listen to those grumbling RTs complaining that it’s a pointless therapy. What do they know?

You might overhear a conversation like this:

"Are you having trouble coughing stuff up?" the RT asks the patient.

"No, I’ve been coughing stuff up all day," the patient replies confidently.

The RT raises an eyebrow, thinking, If that’s true, then why on earth did the doctor order hypertonic saline?

Ah, but the doctors know best. Hypertonic saline, our blue light special, is practically a miracle treatment. It works almost as well as Albuterol to scrub every bit of mucus—or anything else—right out of your lungs! COPD? Fixed. Asthma? Gone. Pneumonia? Cured. Even a microscopic virus doesn’t stand a chance. A little salt water solves it all!

"But," the RT protests, "this patient isn’t even short of breath."

No matter! Hypertonic saline for everyone!

Decoding the Nebulizer: How Hospitalists Choose the Magic Mix

The "REAL Physician's Creed" is a highly classified and esoteric document, designed exclusively for hospitalists. Through our covert and undisclosed sources, we have obtained access to this "document" and its latest update.

Please keep this information strictly to yourself—should your hospitalists discover that you’ve gained access, they may take steps to shut down this blog. Use this insight wisely, not just for your amusement, but to better understand the absurdity behind some of the orders we all encounter.

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To Whom It May Concern:

In the spirit of evidence-based medicine (or, at least, medicine that feels evidence-based), we at the Real Doctor’s Creed Administration have made some updates to our guiding principles. These are, of course, grounded in the timeless medical philosophy: "If it sounds reasonable, why waste time proving it?"

For instance, research suggests that water is good for the lungs. Rather than waste valuable time with studies, let’s simply agree this makes sense and get on with it. After all, we often ignore inconvenient findings from studies anyway. Consider nebulizers and inhalers. The research clearly states that inhalers with proper technique work just as well as nebulizers. Yet, in our infinite wisdom, we prefer to order QID nebulizers (or Q4ever, meaning "until discharge"). And if respiratory therapy dares to discontinue treatments using their so-called "protocols," we simply re-order them. Because why follow protocol when you can wield authority?

Now, in 2024, we’re embracing the same spirit of untested brilliance with a groundbreaking update to the Creed. We propose that the effectiveness of a treatment be directly correlated with the amount of solution poured into the nebulizer. A simple, elegant idea, isn’t it?

Here’s how it works:

1. If a patient with COPD, pneumonia, pneumovirus, influenza, parainfluenza, COVID, or heart failure hasn’t improved after two days of Albuterol, Levalbuterol, or Duoneb treatments, don’t bother considering other explanations. Instead, refer to the Creed.

2. Add more solution to the nebulizer. Not because there’s evidence to support it, but because it feels like we’re doing something. For best results, try:

   • 4cc of hypertonic saline (especially if mucus plugging shows up on x-ray)
   • Pulmicort, because why not?
   • Performist/ Formotorol (and don't bother d/cing the duoneb or albuterol as duplicate orders are okay with us
   • Mucomyst (especially if mucus plugging shows up on x-ray)
   • If the patient has been using Albuterol alone, switch to Duoneb. The irony of giving a muscarinic to dry out lungs and hypertonic saline and mucomyst to thin and increase secretions can be just ignored. 

3. Ensure treatments are ordered Q4 or Q6. The goal is to maximize the length of treatments, ideally to the point of inconveniencing respiratory therapists. If they’re annoyed, it must be working.

By adhering to this new protocol, we uphold our longstanding commitment to decisions driven not by science, but by intuition, tradition, and the thrill of making things up as we go.

Yours in medicine,
The Real Doctor’s Creed Administration

P.S. If this update creates any confusion among staff, refer them to the nebulizer for clarity. It’s bound to fix something.

Murphy's Laws Of Respiratory Therapy

I recently wrote a post for asthma.net called, "Murphy's Laws of Asthma." I figured this idea can be applied to our profession too. You know, what can go wrong will. So, without further adieu, here are Murphy's Laws For Respiratory Therapy.

When you're in a hurry to chart, that little circle will go round and round and round and round.

When you finally get a chance to sit, every person who could possibly annoy you will. 

As you approach the time clock, you'll realize you left your badge at home. 

If you forget your badge, someone behind a door you need your badge to get into will need you. 

When you get home after a long, hard days work, you'll realize you still have your work phone in your pocket. 

The day you're slow and have hardly any patients is when you're most likely to forget to do your treatments. 

If you get to work hoping for a good day, shit will hit the fan. 

If it's slow and your coworkers are sent home early, shit will hit the fan. 

Right at the moment you're hoping to go home early shit will hit the fan. 

After you get all gowned up and enter an isolation room, you'll realize you need something not in the room. 

After you get all gowned up and inter an isolation room, your phone will ring. 

You took your medicine out of the Pyxis. When you get to the room and get the nebulizer out of the bag you can't find your medicine. 

Your home and having a nice relaxing evening. You make the mistake of answering the phone and it's your work wanting you to come in. 

When you are in a hurry and need a piece of equipment STAT, it won't be where it's supposed to be. 

If you have the ETT ready expecting to intubate a patient, the patient will be fine. 

If you are called to be on standby because a patient in ER does not look good, and you do not have your ETT ready, is when you're most likely to need it. 

When the ER doctor you most enjoy working with is working, you won't be needed in the ER. But, when the ER doctor you least enjoy working with is working, you will be needed in the ER, and frequently. 

Feel free to add to this list in the comments below. 

The Dim Stethoscope

You see them in isolation rooms. They are usually referred to as Fake Stethoscopes. They are made by Fake Incorporated.

Sometimes they are referred to as "Dim Stethoscopes." It's because you can't hear lung sounds for crap. So, you find yourself just writing or clicking, "Diminished."

And sometimes you don't even bother using it. I mean, it's been in the same room as a MRSA patient for a week now. And the lung sounds have been the same since the patient arrived.

And so you just scan the patient. You start the treatment. And you just (if no one is looking, that is) go right to charting. And, without even touching the Dim stethoscope, you click: "Diminished."

There is one exception. If the patient is wet. That's the exception. Because, if that's why the doctor ordered it, it's mainly because of that audible cardiac wheeze. You don't need a stethoscope to here it. So, you can then click on "Wheeze"

So, that's your prototypical dim stethoscope. The patient is dim whether you use it or not, so you might as well just not. But, usually you do. But, still, it's dim and dimmer. Thoughts?

Exaggeration of Asthma (Staticus Asthmaticus)

How they present when you are in their rooms.

A diagnosis sometimes observed in the clinical setting is an exaggeration of asthma (staticus wheezicus). These patients often have a diagnosis of asthma/ COPD, although often learn to play it to their advantage.

Clinical Presentation: You can observe them from the doorway, such as while they are sleeping, and they are fine. But as soon as you wake them up, they have a forced, expiratory, almost stridorous wheeze. It is often audible. They may appear fine as you enter their rooms, although as soon as you pull out your stethoscope they start forcibly exhaling. Heart rate may be elevated slightly. Oxygen saturation is usually within normal range. (This section was submitted to me by a reader here at the RT Cave, and published with permission. )

Differential diagnosis.  The RT Cave sponsored a committee of 20 respiratory therapists and five doctors. During a meeting on January 27, 2017, they came up with three mechanisms for establishing a diagnosis.  They are:

1. Doorway Observations. It's  beneficial to observe them while they are sleeping from the doorway. If they are sleeping comfortably you can rule out asthma and rule in staticus asthmaticus. 
2. Pursed Lip Trick. Have patient breathe through pursed lips. You cannot fake a wheeze through pursed lips. If you hear a wheeze while patient breathing through pursed lips you can diagnose asthma. If you do not hear a wheeze, then the diagnosis is staticus asthmaticus.  (Note: Those who have a long history of staticus wheezicus learn this trick and generally ignore requests for them to do it.) 
3. Denials. Similar to Munchausen syndrome, these patients will never admit what they are doing even when called on it by physicians and faced with evidence. Adamant denial, and claiming that they hate the doctor that called them on their bluff, is the most common sign indicative of staticus asthmaticus. 

How they present once they are admitted and alone. 

Treatment. Our committee concluded that they usually have an actual diagnosis of asthma, so QID Duonebs are usually indicated. They are usually given systemic corticosteroids just in case they might be telling the truth. They also insist on anxiolytics or pain relievers. They would benefit from psychological consults, although they usually refuse this. Even though their oxygen saturation is normal, they often insist upon supplemental oxygen, either the nasal cannula or oxygen masks. The best treatment is early diagnosis and calling them on their bluff. Just be open and honest with them. What makes this tricky is the fact that most healthcare providers have tons and tons of empathy. Plus, there is always the fear that they might be telling the truth. So, this often leads to overtreatment.

Etiology. Our committee decided that their fake bronchospasms are usually psychosomatically induced, meaning that it's all in their heads. The exact cause may be stress, such as annoying family members, work, or school. It may also be attention seeking induced in order to improve self-esteem. The theory here is that the attention and empathy received in the hospital setting boost self-esteem. Some may also be drug seeking, although this is never confirmed.

Discharge. Our committee decided that they usually do not want to be discharged. As soon as they learn you are thinking discharge, they go on a strong, self-induced coughing fit. They may be fine one minute, perhaps even involved in an interesting discussion. Then, out of the blue, they embark on a serious coughing fit, which sometimes results in true bronchospasm. An alternative to coughing is sudden onset chest pain.

Consequences. Our committee noted that they sometimes suffer from overtreatment, and what is referred to as the accelerated side effect-effect. This is where one medicine is used to treat fake symptoms, and this presents with side effects. A second medicine is given to treat the side effect of the first medicine, and this second medicine also has side effects. A third medicine is given to treat the side effect of the second medicine, and this medicine has side effects and so on and so on. This can often result in an endless cycle of long hospital stays and repeated re-admissions, making these patients very costly. This condition is extremely difficult to treat, making an early diagnosis of staticus asthmaticus extremely important.

Prognosis. With early diagnosis and proper treatment, the prognosis is good. However, diagnosis is usually missed until the patient becomes a repeat offender. Other than accelerated side effect-effect, a secondary complication results from the difficulty of empathetic healthcare providers to call these patients on their faux asthma. This often results in lengthy and expensive hospitals stays and the inability for these patients to gain the psychological consultation that they truly need. (Note: This prognosis was submitted by a Pulmonologist. He gave us permission to use his name. The RT Cave has decided to keep his name anonymous anyway for his own protection.)

Disclaimer. The above is a facetious characterization drawn by the readers of the RT Cave and on conclusions by our committee. Any resemblance to actual patients is merely coincidental. Mr. Frea is not responsible for the content of this post, as all he did here was compile together comments from our readers and our committee. 

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Study: Ventolin Shown To Prolong Life

A new version of Ventolin, aptly termed "Keep-me-alive-olin," has been shown to prolong life. This is according to analysis of studies conducted by the Real Doctor's Creed Committee.

Keepmealivolin was listed as the #61 most popular version of Ventolin prescribed by doctors by our own experts here at the RT Cave.

This version of Ventolin was first recognized by Dr. Happy Lackluster in 1985. He t he ordered a respiratory therapist to give a Ventolin breathing treatment by mask to a patient who was terminally ill, who had an ejection fraction of 20%, and who was in otherwise poor health with terminal bone cancer, diabetes, and kidney failure.

Dr. Lackluster sadly passed away in 1998. However, the RT Cave was able to get ahold of Dr. Will Chambers, a longtime coworker of the beloved Dr. Lackluster.

"He was a fine fellow," said Dr. Chambers. "We were all so impressed with his discovery. I remember Happy  telling the story. He about keeled over laughing because, as he said, 'the respiratory therapist was so unhappy to be giving the treatment.'  He said the therapist said, 'He is not even short of breath.' But, in the end (no pun intended), the therapist was proven wrong, as the patient lived an extra day, long enough to say good-bye to loved ones who had to fly all the way into California from Great Britain."

Dr. Chambers added, "But we were taught in medical school back in the 1980's that if all else fails, order a breathing treatment. Little did we know that Happy stumbled on a new version of Ventolin now aptly titled Keepmealiveolin."

While we have never revealed the true history of it on this blog before, we called the wife of Dr. Lucky Happluster and she was more than happy to provide for us a study. It was performed in 1964, and involved an entirety of four whole patients. Two were given a placebo and two were given Keepmealivolin, and they all lived a little while longer. This was all the proof needed to convince the medical community of the efficacy of keepmealivolin. Two hundred studies since then seemingly proved this initial study wrong, but those studies never changed anything: keepmealivolin is still used to this day.

So, ever since that initial study was published, whenever doctors don't know what else to do when a patient is terminal and things don't look good, it's time to order Ventolin. And, likewise, during a code, when there is nothing else to do, it's time for Keepmealiveolin. If necessary, it can be given inline with the AMBU-bag.

And it's not like this is unusual. The hypoxic drive theory is based on a study of 4 COPD patients from the late 1960's. So, who's to say 4 patients can't prove that Keepmealivolin won't prolong life. It can at least buy a patient a day or two, perhaps an opportunity to say goodbye to loved ones who live 10 or more hours away who need time to travel.

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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

Study: Eating More Important Than Breathing

Breathing is important. As respiratory therapists, we know this more than anyone. But a new study conducted by the Bronchodilator Reform Committee of the U.S. Government purports to show that eating is even more important that breathing.

The study involved 100 patients at Shoreline Community Hospital, all of whom were prescribed QID breathing treatments with 3cc of normal saline and 0.5cc of albuterol. All of the patients had chronic bronchitis or asthma. They were all typically short of breath when their breathing treatments were due.

Treatment times were scheduled for 8 a.m., 12 p.m., 4 p.m., and 8 p.m. The patients were asked to order a tray of food about 30 minutes prior to the time their breathing treatments were due. This gave the cafeteria plenty of time to prepare the meals and deliver them. The patients were told they would be involved in a study, but they were not told anything specific.

The therapists were asked to enter the patient's room the same time the meal arrived. They were instructed to identify themselves and to say it is time for their treatments. They were then instructed to prepare the medicine and to give the medicine to the patient either with a mouthpiece or a mask. If the patient requested to eat first, the therapists were told to try to convince them the treatment was more important than eating.
Of the 100 patients involved in the study, a whopping 60% requested that the respiratory therapist hold the breathing treatment until the meal was completed. Of these, 48.5% were persistent that they preferred eating over breathing. One such exchange went like this.

Respiratory therapist: "Mr. Smith, I am John from respiratory therapy. I am here to give you your breathing treatment."

Patient: "I will take the breathing treatment, but as soon as my tray comes I'm going to take the mask off and eat."

At this point cafeteria lady brings in the tray of food. Seemingly ignoring the fact that the tray has arrived, the therapist says to the patient: "Are you breathing okay?"

Patient: "Well, I am a little short of breath. But I'm really hungry."

Respiratory therapist: "The breathing treatment will only take a few minutes. This way we can get you breathing better so you can enjoy your meal."

Patient: "I am really hungry right now. I need to eat."

Respiratory therapist: "Are you sure?"

Patient: "I am really hungry."

The study was initially published in the Doctor's Creed Magazine. Lead researcher, Dr. Ven Tolin, suggested that the results show the importance of eating. He said, "You need to eat to have the strength to breathe. So, it only makes sense that a patient, especially one with COPD or asthma, would prefer eating over breathing."

Dr. Creed: Rules for PEEP

Warning: What follows is top secret information surreptitiously leaked to me via one of the nations elite pulmonologists from an elite teaching hospital. Read at your own risk. This is not edited.

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Appendix 7

Rules for PEEP/ CPAP/ EPAPt:

So, when do you increase PEEP. To answer this we have to understand what PEEP is. 

PEEP is an abbreviation for Positive End Expiratory Pressure. When used on a ventilator it is called PEEP. When referring to noninvasive ventilation it is called EPAP, which is an abbreviation for End Positive Airway Pressure.  When used alone, it is referred to as CPAP (Continuous Positive Airway Pressure). 

Essentially, PEEP, EPAP, and CPAP are the same thing, only the terms vary depending on what type of machine is applying the pressure (ventilator, BiPAP, or CPAP machine). The unique terms help caregivers tell know what device is being referred to: Ventilator, CPAP, or BiPAP. 

Whether called PEEP, EPAP or CPAP, it is a constant flow during expiration to keep the pressure inside the airways above atmospheric pressure. It increases FRC, or Forced Residual Capacity. This is the amount of air left in the lungs at end expiration. By keeping some air inside the airways, it prevents them from collapsing. Essentially, it:

• Prevents muscles of the upper airway from collapsing. Some individuals develop flaccid muscles around the upper airway that may collapse during end expiration, resulting in upper airway obstruction. This causes obstructive sleep apnea. It may result in apnea and hypoxemia. CPAP alone may keep upper airways from collapsing to keep these airways open. Studies have confirmed this, so RTs will usually agree with this theory
• Alveoli may collapse at end expiration, resulting in V/Q mismatching and hypoxemia. CPAP, EPAP, and PEEP prevent these alveoli from collapsing, thus improving oxygenation. Studies have confirmed this, so RTs will usually support this theory too. 
• By keeping atmospheric pressure in the lungs above room air atmospheric pressure, this helps to push fluid out of the lungs. It also prevents the buldup of fluid in the lungs. So, if you have a patient who you suspect might eventually get fluid in the lungs, PEEP will prevent it. So, even if the ABGs are normal, PEEP, CPAP and BIPAP might be indicated. No study has ever confirmed this, so RTs will usually argue with you, and contest that all PEEP does is reduce cardiac output (blood pressure) which reduces blood flow to the lungs. We doctors go by what sounds good, not by what's proven. It sounds good, so it must be true. 

Conventional uses for positive expiratory pressure.

1. To keep airways open
2. To improve oxygenation

Unconventional uses of positive expiratory pressure include. 

1.  You have a patient in renal failure. His ABGs come back pH 7.37, CO2 48, PO2 90.  The patient has a history of pulmonary edema due to renal failure. In order to prevent pulmonary edema, order BiPAP.

2.  You have a patient on a ventilator with the following settings. PEEP 5, Vt 500, rr 12, hr 89, SpO2 94, PO2 87, pH 7.39, CO2 39.  The patient has had trouble with pulonary edema. So, what do you do? You increase PEEP to 10. RTs will cringe, but you know it works because it feels good. 

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.  

Dr. Creed: One Budesonide Amp should cure stridor

Real Doctor's Creed: Appendix Z: Problem Solving

Section 982: Pediatric Croup.

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

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

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

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

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

So I ordered a one time dose of pulmicort.

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

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

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

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

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

The eight stages of medical scams

Today's version is Ventolin

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

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

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

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

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

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

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

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

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

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

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

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

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

Further reading:

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

H.R. 3862: Obamacare Amendment

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

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

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

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

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

New Bronchowatch to set frequency of bronchodilators

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

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

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

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

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

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

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

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

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

'Olins: Part 3

The following is a continuation of our list of various types and forms of racemic and actual ventolin-tyes (o'lins) that we doctors keep esoteric from respiratory therapists so they continue to have procedures to justify their existence.  Oh, and the treatments actually do help for the various disorders listed below. Seriously, we are not making this up.

235.  Medicine:  Historolin

Diagnosis:  Asthma

Frequency:  Q4-6

Effect:  It is proven that keeping beta 2 receptors saturated with ventolin particles will keep asthma in remission.  Such therapy may be deemed profligate in the out of hospital setting.

236.  Medicine:  Abdomnolin

Diagnosis:  Had surgery on belly

Frequency:  QID

Effect:  Only works when prescribed by surgeon to prevent atelectasis and pneumonia caused by the surgeon.  Warning to physician: side effect to second hand ventolin types is respiratory therapy apathy and grumpiness, so stay out of their way. Still order it, though, we're just saying; they are lazy and will try to convince you it's pointless, but we know it is not pointless.  Yes, a study of 100 post op patients showed that, of 100 post op patients who were treated with QID ventolin, they all eventually got better.  So we know some form of ventolin must be ordered.  Note: not ordering Abdominoilin for post operative patients was not shown to decrease length of stay.  Side effect to patient may be increased desire to go home, agitation, and possible irritation with the therapist who continues to wake them up for breathing treatments when they already know they can breathe just fine.

237. Medicine:  Desatolin

Diagnosis: Aspiration Pneumonia

Frequency:  QID

Effect:  Once inhaled the ventolin particles join with a chemical called humidolin acetate to form H2O molecules.  As these accumulate over the course of many days the patient will become filled with increased fluid so that oxygen molecules can float to the surface of the lungs so they can be exhaled. May be tried with regular or faux pneumonia, although studies show that it works best for pneumonia that was caused by reflux of stomach contents. Helicobacter pylori (H. pylori), a common bacteria found in the intestinal tract, might actually plunge out of the water and be exhaled during the exhalation phase due to helicopter-like rotors that have previously eluded the vision of scientists but may be seen when the bacteria is attached to ventolin-like substances in the air.  It's a site worth seeing when hundreds, thousands, millions, even billions of H. Pylori escape their human captors in search of life on Mars.  The good news is they die within seconds of exhalation.

238.  Medicine:   HEALButerol®

Diagnosis:  Bone fractures

Frequency:  QID

Effect:  Rather than just giving albuterol to open up the air passages that are already open, this provides Orthopedic physicians a medicinal supplement proven to diffuse into the bloodstream once inhaled and seeps into bone material to cause fractured areas to rejoin and heal faster. The exact methodology is unknown, but a study showed that of 100 post op patients given HEALButerol® all eventually got better.  So this was indication enough to confirm that the medicine magically heals bones as well as opens up airways, even if the airways are already open.  You may also wish to try Knitolin.

Medicine:  Knitolin

239.  Diagnosis:  Bone Fractures, especially fractured ribs

Frequency:  QID

Effect:  It knits bones so they heal better and the patient breathes better at the same time.  If neither of those work, try tryagainolin.  It works best when given in tandem with an incentive spirometer  (IS)and acapella. Increased turbulence created by inhaling a deep breath with the IS pushes the knitolin particles deeper into the bone (sort of like hammer nail, so to speak) thus making the medicine particles work like a filling in a tooth to further supplement healing.  The acepella helps to loosen and free any bacterial particles that might collect inside the fractured portions of the bone and inhibit healing and/ or cause an infection.

240.  Medicine.  Trainwreck-uterol

Diagnosis:  Many, or Trainwreckeeeeism caused by the trainwreck virus that causes many of the organs of the body to become confused and not work right.  Trainwreck-ism is a another disorder caused by the trainwreck virus that causes nurses and respiratory therapists to make poor decisions that wreck things and people.  Trainwreckeeeism should not be confused with Trainwreck-ism.  Because trainwreckeeeism has a lot of e's in it, it can be treated the same way a wheeze is:  with an 'olin, particularly Trainwreck-uterol. Trainwreck-ism has no known treatment, and therefore you must not be anywhere withing 100 miles of such patients.  Usually they are not hired.  If they are, you should fire them immediately, because the disease is highly contagious.

Frequency:  Q4ever

Effect.  It has no effect on the disease processes, although it does attack to faux B2 receptors in throat muscles in and attempt to eeeeee-liminate the wheeze by soothing throat muscles (throatodilation) in order to make nurses and doctors happier.

241.  Medicine. Fusolin

Diagnosis:  Rib fracture

Frequency:  QID

Effect:  Increases tidal volume to prevent pneumonia and atelectasis.  Works similar to the way IPPB used to overinflate good alveoli.  May be alternated with Knitolin,  HEALButerol®, preventolin, postopulterol and tryagainolin.  May also try sputumolin to induce a cough.  Avoid using ventolin for its cough suppressant qualities, as this defeats the purpose.

242.  Medicine:  Lupisolin (aka Aligatoruterol, Sharkuterol)

Diagnosis:  Lupis

Frequency:  At least QID

Effect:  Ventolin particles go into the lungs and join with neutrophils to turn the ventolin particles into little critters that look like very sharp toothed alligators or sharks that kill and digest bacteria and viruses and other potentially harmful invaders so the immune system doesn't have to.  I guess you can say that the ventolin particles formed look and act sort of like Pac Man and Mrs. Pacman.  This works to suppress the immune system and to prevent inflammation caused by the disease, particularly in the heart, lungs, and brain (well, mostly in the lungs).

243.  Medicine:  Flapolin

Diagnosis:  Loose or damaged Mitral valve

Frequency:  Once

Effect:  Mitral valve may be heard flapping, meaning that the valve is leaky.  This form of ventolin causes an infusion of hardened, crystallized substances that are attracted only to the mitral valve to fortify it and assure the patient's safety until the valve can be replaced.

243.  Medicine:  Vasodilatolin

Diagnosis:  Hypertension

Frequency:  Q4-6

Effect:  Dilates vessels to decrease blood pressure. Will require frequent inhalations to assure a high enough dose of the medicine is in the bloodstream at all times. So this is why we recommend it be given Q4-6 rather than just QID.  A bonus is the patient will have to be awakened at least once, and this might make the patient mad and raise blood pressure that way.  It works the same as BiPAP, which has a benefit of increasing blood pressure.  May also place patient on BiPAP.  The more uncomfortable the settings the better the effect. Please, do not admit this to respiratory therapists. Oh, you did already: Doh!

244.  Medicine:  BiPAP-uterol DS

Diagnosis:  CO2 greater than 42 (boy, that's way too high, need to get it back down to normal)

Frequency:  QID, Q6, Q4, or just make something up

Effect:  Lubricates and soothes the vocal cords so you don't hear an audible wheeze (rhonchi, stridor). Works best if tried before BiPAP is ordered.  If doesn't work, order BiPAP.  Works well after BiPAP order too. If you continue to hear lots of noises in the lungs (especially if they annoy you), you probably should order BiPAP.  IN this case, the medicine mayu have a bonus of lubricating the lips and cheeks so you don't hear the BLLLLPPPPPLLLLLTTTTTTTHHHHHHHH due to the fact the seal is not tight enough.  It makes it so nurses don't keep calling respiratory because they don't feel like playing with the Velcro.  May alternate with BiPAPuterol (to ward off evil spirits so you don't have to eventually ventilate this patient).  Note:  For patients with a big scruffy beard, a double dose may be beneficial. Or, just get off your ass and tighten the mask might work just as well.  Or, if you're really brave, shave the beard)

245.  Medicine:  Normal Saline

Diagnosis.  Asthma, COPD

Frequency:  Q4

Effect:  Draws salt out of epithelial cells and Type-II alveolar cells in order to treat bronchospasm due to dehydration.

246.  Medicine: Retrospectuterol

Diagnosis. COPD, asthma, heart failure, pulmonary edema, kidney failure, lung cancer, etc.

Frequency: Q4-6

Effect:  The patient was short of breath greater than 24 hours ago, therefore albuterol is indicated today. The patient may have been short of breath yesterday, or may have experienced asthma symptoms (at the age of 6) 25 years ago.  Regardless, the retrospective qualities of albuterol-like particles have the ability to travel over the wrinkle in time scrub lungs clear of all past difficulties.

247.  Medicine. Keepmeinolin

Diagnosis. Respiratory failure, hypoxia, pneunonia, heart failure, dyspnea (all of which requires oxygen and IV medications to keep the patient alive)

Frequency. Q once

Effect.  Works similar to exercise in that it stimulates the brain to release a chemical called endorphins. They act like analgesics such as morphine to diminish the perception of pain, cause a sedative effect, reduce stress, ward off anxiety, ward off depression, boost self esteem, and improve sleep. It causes a sense of euphoria similar to that produced from morphine with out the risk of addiction.  Generally, the effect only lasts until the mist in the room clears, so it's usually only prescribed one time, as a last ditch effort, when a patient threatens to leave against medical advice (AMA).  The medicine should calm the patient down just enough to convince her that she really does need to be in the hospital.

247.  Medicine.  Transmitolin, Accousticsolin

Diagnosis.  CHF, Heart Failure, ETOH, Dehydration, old age

Frequency.  QID

Effect.  Prevents upper airway rhonchi from transmitting to other lung fields to prevent specious documenting of wheezes. It's a medicine that was concocted in the laboratory of Dr. Ven Tolin and his assistant, Paul RiTT, with the intent to discourage physicians from ordering breathing treatments due to upper airway noises confused for wheezing. The medical community generally has an aversion to this medicine, and so it has rarely been used to this point.  A Congressional Committee actually discussed this, and it almost made it into the Affordable Care Act in order to cut government spending, only to be cut from the bill at the last moment when it was discovered the individual hospitals have to absorb the costs of wasteful breathing treatments, and not Uncle Sam.

248.  Medicine.  Keepmeawakeolin

Diagnosis.  COPD, Sleep Apnea

Frequency.  Q4 ATC

Effect.  To a nerve cell, Keepmeawakeolin looks like a coffee molecule which looks like adenosine.  It then is allowed to attach to adenosine receptors, thus preventing adenosine from attaching to them.  So instead of adenosine slowing you down so you can sleep, Keepmeawakeolin keeps you awake.  Adenosine dilates blood vessels in the brain, presumably to keep your brain well oxygenated while you are sleeping and your breathing is more relaxed. Keepmealiveolin mimics this effect, thus causing vasodilation of the vessels in the brain to assure adequate oxygenation while you are not sleeping.  A side effect of this is that it may cause a headache, which is where caffeine comes in handy.  About three hours after dosing, keepmealiveolin starts to dissolve, opening up just enough adenosine receptors for caffeine to attach.  This should be enough, however, to constrict brain vessels, thus ridding you of your headache.  Still, once the rest of the keepmealiveoline molecules dissipate, the next dose should be due. A morning dose of coffee is highly recommended, although it should be given about an hour prior to the treatment is due.

A side effect is insomnia that lasts for the duration of this type of treatment.  It is typically not recommended to continue this treatment after discharge to home, as it often results in the viscous and never ending cycle of taking keepmealiveolin to improve oxygenation while you are sleeping and drinking coffee to offset the side effect of headache in the morning.  Another side effect is refractory headache, which is a headache caused by the medicine to begin with.  After doing all this reading (if you are still with me), the brain usually forgets about the bronchodilating effect.  Another idea is to only give the medicine at night, and allow the patient to refuse therapy while awake. Still, because respiratory therapists hate waking people up, an ideal order for this is Q4 ATC (Around The Clock).  This lets the RT know you mean business.

249.  Medicine. Alcurital (See Ad Here)

Effect.  This is the only medicine clinically not proven but believed to by nurses and... doctors (yes, doctors) to cure all that ails you And best of all It works even when You have clear lungsounds Hence the name: Alcurital.

Side Effects: Alcurital.for clear lungsounds. Side effects include anxiety, nervousness, headache, increased heart rate, death if consume more than 55 miligrams in a day, boredom, pissy RTs. However, studies show the medicine cures all ailments, but it has no effect on stupidity. Do not use if you have a wise physician or nurse.  Not expected to result in increased brain cells. Not expected to prevent accidents. While it can be used prophylactically, it will not prevent all ailments. Don't worry, as no studies were done to come to any of these conclusions, it's simply based on feel good: it looks good, sounds good, feels good, then it is a fact. One study of 100 post op patients given Alcurital eventually recovered, so now it only makes sense that it
works.

250.  Medicine.  Mucinexolinuterol

Diagnosis.  COPD, pneumonia, Cystic Fibrosis

Symptom.  Thick secretions; difficult expectoration

Efficacy.  The fact that the suffix olin and the suffix uterol are in the name means it has 10 times the ability to loosen thick secretions as Mucinex and albuterol alone.

251.  Medicine. Diverticulobuterol

Diagnosis.  Diverticulosis

Frequency. QID

Effect.  Bronchodilators have been shown to attach to fake beta receptors in the colon to relax smooth muscles that wrap around the intestines to help release trapped particles.  Similar to pneumonia, the medicine also magically reduces inflammation and smelling to ease pain and suffering caused by diverticulitis.

Further reading:

1. Fake 'Olins Part 1
2. Fake 'Olins Part 2
3. Faux Physician's Creed

Study: Secondhand albuterol linked with side effects

A new report published in the Journal of the Respiratory Creed suggests that second hand albuterol has side effects that may include grumpiness, apathy, burnout, a dry sense of humor, increased wisdom, and the ability to differentiate pneumonia and heart failure from bronchospasm without even seeing the patient.

Researchers followed 1,600 newly graduated respiratory therapists over a period of ten years between July 7, 2002 and July 14, 2012.  Six hundred sixty of the therapists gave an average of 10 albuterol breathing treatments in a given day.  A control group of 720 therapists was given a placebo to give to their patients.  But they were told to just sit in the RT Cave and watch movies on Netflix or play on their iPhones.  Six hundred twenty therapists were disqualified for already having been diagnosed with respiratory therapy apathy syndrome (RATS).

The results showed that 100% of the therapists who gave albuterol breathing treatments developed the symptoms, with 75% experiencing increased incite within the first year doling out treatments (a minimum of 36 hour work week was required of all participants), and 82.5% developing a dry sense of humor within the first eight months.

Level of IQ was tested using a typical IQ scale, although adjusted for respiratory therapy wisdom.  A typical question might entail, "Is heart failure treated with Ventolin?"  Members of the control group were too bound to their fantasy world's to have time to answer the question.  Members of the non-control group all answered the question correctly, with one scratching a comment in the margins of the test (taken on paper because because), "Are you kidding me!  Of course not."

The study was the first ever study to study the study abilities of respiratory therapists and the possible impact that ventolin may have on their demeanor.

"It was just amazing the results that we discovered by doing this simple scientific study," said Dr. Carl Olin of Westbrook University where the study was conducted.  "Who ever would have thought that people with only an associate's degree could actually know more about respiratory therapy than physicians?"

Cal Tripper, Medical Director of Respiratory Therapy at Buterol University, said, "It has been observed for years that respiratory therapists display a unique wisdom, particularly regarding respiratory therapy, although it was tough to put a finger on the reason before this study.  I highly recommend to other physicians to talk to a respiratory therapist, ask them if they have an opinion or a recommendation, the next time a patient has respiratory complications.  The truth to the matter is, even though they only have associate's degrees, they may actually know more than we do about how to manage respiratory therapy.  And it's all because of second hand albuterol."

Study: EKG goo soothes like VapoRub

The goo on the back of these stickers
 proven to work like Vick's VapoRub

A new study that was conducted at the University of Medical Creed Hospital showed that the goo on the back of EKG stickers works similar to Vick's VapoRub and makes breathing easier.

As a part of the study, 8 people complaining of shortness of breath and chest tightness were given an EKG upon admission to the emergency room, followed by two more every two hours, followed by one each morning until discharge.  The control group of 2 patients all did not have EKGs done, except for the initial one in the emergency room.  

All the patients who had serial EKGs eventually got better, except one male who developed nosocomial COPD and was disqualified.  Both the patients in the control group developed physician acquired pulmonary edema and were both disqualified.  

Not these!
These don't resemble
Vick's VapoRub

Dr. Bill Senseless, who heads the Faux Pulmonary Research Project at the University, said, "The only conclusion we could make from this was that EKG therapy works to open up airways by osmosis through the skin to the airways.  It works similar to Vick's Vapor Rub, only it's more profitable for physicians as we get $40 for just looking at the interpretation already on the EKG."

This study verifies the newly formed belief among the medical community that serial EKGs actually have therapeutic effects.  It was for this reason that many health organizations have recommended a minimum of three minutes door to EKG time for all patients complaining of chest pain.  

Further studies will not be performed to verify the results.  However, a future study will be eventually prove EKG goo has real or perceived cardiac benefits.  

Nausea, arm pain, hang nails, and rancid smelling patients are generally treated the same as chest pain and tightness. ACLS recommends a door to EKG time of 10 minutes for chest pain. The Real Physician's Creed recommends a door to EKG time of 10 seconds. Based on these recommendations, the Keystone Collaborate has succeeded in increasing the door to EKG time to three minutes so they have another reason not to pay if they don't want to.

Vick's VapoRub
Not recommended.
Makes stickers not stick

Dr. Senseless said that he has already sent a recommendation to the Real Physician's Creed Association to look into adding an EKG as a top-line treatment for all patients who come to the emergency room complaining of shortness of breath.  This should be performed immediately before or immediately after a bronchodilator, repeated Q2 times 3, then Qam.  

"And this is the minimum we require," Dr. Senseless added, "If it makes a doctor feel better, more can be ordered.  We actually had one nurse recommend an EKG because a patient had a stuffy nose, and it worked like a charm. She said the respiratory therapist complained about wasting his time and that this only worked because it made the patient feel like something was being done.  We're used to such sniveling by RTs.  We just know it works because because of the Vapo Rub Effect."

The Four Types of Pneumonia

A 1930 edition of the Real Physician's Creed.
It's now so huge it's non-photogenic.

In medical school, most physicians learn from the Real Physician's Creed, which by now is about 300,000 pages and still growing. I only found out about it because one physician is a friend of mine who used to be a respiratory therapist. But he is now retired, so he has given me permission to release some of the contents thereof.

On page 304,403, of edition 4,432, is a note describing the three types of pneumonia.  Listed they are as follows:

1.  Walking Pneumonia:  Don't have it but something must be ordered to make everyone happy.  

2.  Pneumonia.  They really have it and you can see it on the x-ray and everything.  Or, as noted, sometimes you can hear it via crackles before you can see it on x-ray.  Or, the white blood count is elevated, indicating there is an infection somewhere so it might be pneumonia.  It is generally lobal and caused by a bacteria. Treatment is antibioitic to treat the infection and systemic corticosteroids to treat the inflammation.  However, you may also treat it with ventolin because one study showed it enhances sputum production which, uh, somehow is twisted into making some doctors think it... well, it does help, errr, bring up the pneumonia... IT JUST DOES!!!

3.  Faux-pneumonia.  The patient doesn't have it, but you need a better diagnosis than walking pneumonia in order so that the patient may meet criteria.  You can see it on the x-ray only if you have the superior vision abilities only taught in medical school, which can be found on page 3,133 of the Creed.  (I at present do not have a copy of that page, as this part of the book I have has been destroyed by too many coffee stains).

4.  Double Pneumonia.  They have twice as much pneumonia than the average person who actually has a diagnosis of pneumonia, which some call real pneumonia as compared with faux pneumonia.  It is generally caused by a virus and is deadlier than regular pneumonia.  Treatment is to hit it with everything, including systemic corticosteroids to treat inflammation, antibiotic to treat the infection, ventolin to help the patient cough up the pneumonia, and anything else you feel like throwing at it. Usually it involves treating the symptoms.  Treatment is generally supportive.

Further reading:

1. The real physician's creed
2. 999 types of ventolin