Medical specialties are gift to healthcare

I just want to touch gently, ever so gently, on a subject today.  It's something that's near and dear to every medical professional.  It's called specializations in medicine. It's something that I think was a brilliant idea when it was first created in medicine over 5,000  years ago by the ancient Egyptians.

Yes it is true: specialization in medicine was started by the community of physicians in ancient Greece.  Even way back then they must have realized there is so much to know about each specific part of the human body that specialties were essential for adequate medical care. 

Of course the medical profession was a bit different back then.  Instead of neuro surgeons, and neurologists, and cardiologists, and nephrologists, and pulmonologists and Internists, there were heart doctors, anal doctors, surgeons, astrologists, and internists.  The surgeon, for instance, would suture a wound, but if the patient had internal disease, he'd refer to an internist. 

And there was a little overlap.  Back then, as is the case today, all physicians, no matter what you specialize in, learn the basics.  So just about everyone of them could perform as family practitioners.  But certainly you wouldn't want the family practitioner performing a major operation on you.  That, my friends, would be crossing the line. 

Today, other than physicians, we have many other medical specialties.  You have x-ray technicians, laboratory technicians, nuclear medicine technicians, MRI specialists, monitor techs, nurses, and respiratory therapists.  Each of these professions has a specialty.  While they all have basic medical knowledge, and all can perform certain duties, there are certain things that only the particular specialist is trained to do. 

For example, and this is what I'm getting at.  Nurses give all the medicine that a patient receives except respiratory medicine and oxygen.  The respiratory therapist specializes in respiratory medicine and oxygen.  Now, nurses surely know the basics of oxygen therapy, and some even know more than some respiratory therapists. BUT, when it comes down to it, the respiratory therapist is responsible for oxygen. 

Personally, I want and encourage nurses that work with me to put on a nasal cannula and tweak it up or down by 1 or 2 lpm.  I'm fine with that.  Whatever is needed to maintain that SpO2 of 90%.  But any major changes I need to know about right away. 

You know what I love most  about nurses.  I'll give an example here.  A nurse nurse set up a ventimask, and it's a nurse I trust really well, and that nurse pages me to call her.  So I call her, and she says, "Rick, I set up a venti mask in room 208, and I just want you to check it to make sure I did it right." 

"Awesome," I said, "I will be right there." 

To me, that's a major ego booster.  It's a nurse taking charge to help the patient when she knows I'm not around to do it (we RTs work solo where I come from), yet is wise enough to doubt herself in an area she is not an expert it.  I just admire that so much. 

On the contrary, recently I came across a situation where I entered the room of a patient on a nonrebreather, and the liter flow was at 2lpm.  I immediately turned it up to 15 lpm, and went to the nurses station to discuss this situation with the nurse.  The nurse was on break, so I turn to the chart.  Upon reviewing the doctor's notes, I realized that the doctor did it.  She even wrote about it in her notes: "oxygen mask turned down to 2lpm.  Wrote order to keep it there."

So, I'm sitting at the desk, and the nurse comes back from break.  I watch as she enters the patient's room, and then I hear her saying to the patient's family, "Oh, it looks like someone turned her oxygen up.  I better turn it back down." 

That's when I trudged intot the room, and just as she was about to put her fingers on the flowmeter, I said, quite bluntly, and in front of all seven visitors in the room and the patient: "Don't you touch that flowmeter!"

The nurse froze!  All the family members froze!  The patient didn't do anything because she was being oblivious due to her dementia.  The nurse was so stunned she started shaking.  "But," she said, "the patient's daughter wants it at 2lpm." 

I said, calmly, "I'm all for turning the oxygen down, but we need to do it the right way." 

Of course then I had to back track so I didn't look like a jerk to the family.  I made a teaching moment out of it actually; a quick five minute oxygen therapy made easy class.  I explained why the liter flow had to be at least 10lpm in order to blow off CO2 if the patine is on a nonrebreather. 

I later pulled that nurse aside and said something like "I have total respect for you.  I think you are an awesome nurse.  But please, please, please, don't be afraid to call me before making a major oxygen change."  So we hug, and no harm is done (or so I think).

Together we placed the patient on a nasal cannula at 2lpm because that's all she needed anyway.   

On the nursing specialist side, respiratory therapists don't touch IVs.  Well, again, I do sometimes.  Every time we get new IVs I make a point to discuss with the nurses what I'm allowed to do.  Most nurses encourage me to silence alarms and to inform the nurse that it went off.  I usually love to provide this service, because it saves the nurse from a lot of extra running around. 

It's also nice, because most of the time the IV alarms because of a distal occlusion caused by the patient bending her arm to hold the mouthpiece in her mouth.  So, once again, there is some overlap.  But, as a rule of thumb, RTs don't mess with IVs other that the basics, and vise versal for oxygen therapy.  Of course I place the exception for RTs specially trained in IVs, and nurses specially trained in oxygen. 

Again, I think the fact medicine is specialized is awesome.  I love working as a team.  I love when each specialist performs his or her duty to the benefit of the patient, and all goes well -- as it does most of the time.

Thoughts?

New DPI made just for CF patients

There is a new dry powdered inhaler (DPI) on the market tailored specifically for cystic fibrosis (CF) patients. The medicine is TOBI Podhaler (tobramycin inhalation powder), and it's made specifically for CF patients with Pseudomonas aeruginosa, according to rtmagazine.com, "FDA Approves First Dry Powder Inhalent for Some CF Patients."

The article notes that Pseudomonas aeruginosa is the main culprit among CFers in the loss of lung function, and presently the medicine to treat it, tobramycin, can only be taken by breathing treatment, which generally lasts from 5-10 minutes.  Supposedly, the new DPI would shake off 70 percent of this time.  The recommended dose is 1 puff twice a day.

The medicine is only approved by the FDA for patients aged six and over.  As usual, most researchers are too chicken to do studies on children because of fear of lawyers.  This does not, however, mean that physicians cannot prescribe the medicine for children under six however.  Obviously, physicians will have to weight the advantages with the risks. 

It's a democracy, so why are they taking away our asthma choices

Warning!!!! There are people who want to decide for you what is good for you.  They will say that you have a choice.  Yet what they will not tell you is it will be a choice between fewer options.  It will be a sort of control over you, yet you won't even see it, or feel it, or even know it's coming.

These people, many of whom already exist all over the world -- including right here in the good old United States of America -- think most people are not capable of making the right decision for themselves. They believe the American Experiment has failed.

So what is this American Experiment anyway?  Well, allow me to define it:

American Experiment:  Can man rule himself?

The American Dream:  Everyone has a chance to succeed no matter color, creed or station in life.  We are all smart enough to make our own decisions.  We are all smart enough to weigh the rewards against the risks.  We all have an equal opportunity to improve our lot in life.

Then there are two different types of people in this country:

1.  Equal justice:  These are those who believe in the American Dream, and believe the answer to the American experiment is YES.  They believe you are smart enough to rule yourself.  That you, asthmatics, are smart enough to make the right choices no matter how tough.  You are equally smart.  You are intelligent.

2.  Social Justice:  These are those who believe in the American Dream, yet believe the answer to the American Experiment is NO.  They believe you are not smart enough to rule yourself, and therefore not smart enough to make the right choices.  Their experts, therefore, must nudge you in the right direction.  One of the ways to do this is to limit your choices.  You are stupid.

They both call their system of government a democracy (they say this even though we are a republic, not a democracy).  The main difference is in equal justice you are allowed to weigh all your asthma medicines and decide what ones work best for you, and in social justice your choices are limited so you don't make the wrong one.

For the first 160 years of this Nation we were a democracy (republic actually)  run under equal justice, yet ever since about 1895 there have been people by insidious means who have been working hard to change this.  They believe that the Industrial Revolution brought about change in society that would require change in the way society was run.

Today, those who believe in social justice have gained much power not just in America but around the rest of the world.  Hitler ruled by the extreme measures of social justice, and so did Stalin and Mussolini.  Yet what few people know is that the term was coined right her in America during the term of President Woodrow Wilson. 

It has been a slow process.  After early failures they decided it was best to take baby steps.  They slowly worked to change the minds of Americans and those of the rest of the world.  After Wilson, FDR was their next great leader.  While Wilson planted the seeds, FDR created the regulations that allowed those seeds to grow into full, flourishing trees. 

They are trying to create a healthcare system that limits your choices, yet they will tell you otherwise.  They will trick you into believing that you have many choices, yet they know the choices are limited.  You will have fewer doctors to choose from, and fewer health insurance companies.  And you might even have fewer options of how you die and when you die.  Yet you won't know it until it's too late.  They'll just kind of slip by unnoticed.

They have already limited our asthma medicinal choices.  Remember when I wrote this:  Seven Classic Asthma Medicines To Be Discontinued.  The medicines you no longer get to choose from are:  Tilade, Intal, Alupent, Azmacort, Aerobid, Combivent, and Maxair.  You did not decide, they did for you.

These are all your CFC inhalers.  CFC destroys the ozone they say.  The ozone is more important than human life.  You aren't smart enough make and purchase medicines that don't destroy the ozone, so they had to "nudge" you in that direction. The market did not make this choice.  You did not make this choice.

I know you didn't because I read your cries that HFA inhalers don't work as well, or that you want to continue taking Intal and Combivent, medicines that have worked so well to control your asthma, or your COPD, or your cystic fibrosis for years.  You want control.  You want to decide what medicines you take.  Or you want your doctor to decide.

Yet in the new America, the new world, the one where social justice supersedes equal justice, and where you are "nudged" to make the "right" decision, you no longer get to decide.  It doesn't matter what works best for your disease, because the planet is more important than you. 

It doesn't matter whether you agree or disagree with theories that say man is causing global warming and destroying the ozone.  I'm in no way saying I don't respect these theories.  What I'm saying here is the government shouldn't be deciding what's best for you, YOU should be deciding what's best for you.  You are SMART.  Yet they think you are not smart enough to make the right decision.

A few years ago they tried to take away Serevent.   They even tried to take away -- or thought about it -- Advair and Symbicort.  They were scared about these drugs based on the belief that Serevent and Foracort were believed to make asthma worse, or kill asthmatics.

Yet even the FDA says Advair and Symbicort are safe for use, and that the benefits outweigh the risks.  Basically what this means is that your risk of dying of an asthma attack are far greater if you do nothing than if you take Advair and Singulair.  Yet YOU decide.

While I think Primitine Mist is a bad asthma choice, it has been available over the counter for years.  Many ashtmatics live by it.  It's their choice.  Yet recently the FDA banned all CFC over the counter asthma medicines, and any chance these will ever be available OTC again. 

I say they will never be OTC again because Primitine Mist has been on the market so long it was grandfathered in as an OTC medicine.  Yet any new HFA Primitine Mist will have to be prescribed, something no doctor will do.  Therefore it's not worth the investment to make an HFA Primitine Mist.

The market didn't decide this -- they decided it for us.  They had to because they believe we aren't smart enough to make the right decision.  They nudged you so now you have to see your doctor to get the best care.  You SHOULD in my opinion see your doctor and have a Ventolin in my opinion and the opinion of most asthma experts -- yet in a world of equal justice I wouldn't get to decide what's right for you.

More recently some wanted the FDA to ban Singulair  (also check these links).  It didn't matter what you thought.  They decided if you took it you were at an increased risk of suicide.  It didnt' matter there were no scientific studies to show this. 

The FDA did an extensive study on the Sinulair suicide risk, and decided there was no evidence.  They even reported this: FDA concludes there is no Singulair suicide risk.  Yet those who believe in social justice didn't care about the evidence, and there is a big black box warning on Singulair to scare people away from it, and perhaps from getting their asthma under control.

That's what black box warning do, you know, they scare people away from getting their asthma under control. 

Another example is more recent.  As of March 2, 2011 the FDA is ordering companies to stop making and shipping over 500 allergy and cold medicines.  Obviously since these are on the market they were being purchased by people like you, and I never heard one drop of a cry that these medicines were linked to any problems.  So why all of a sudden limit our choices?   Fishy, hey?  At least I think so.

In fact,  according to Web MD, Doctor Harold Nelson of National Jewish Health had this to say about this recent effort by the FDA:

"These are well-recognized drugs that have been used for decades and there is no reason to suspect that there is a risk involved. If there were risks such as hypertension or stroke with oral decongestants, it would be more appropriately addressed by eliminating the ingredient from all products whether those that are grandfathered in, available OTC, or FDA-approved.  These drugs haven’t cleared certain safety hurdles yet, but that doesn’t mean they are unsafe."

New medicines are studied intensely.  The FDA has such a rigorous screening process for approving new medicines that the chance of an unsafe medicine being approved is near zero.  I'm not implying mistakes can't be made.  That doesn't matter to those who believe in social justice:  YOU MUST BE NUDGED.

I'm not implying we shouldn't be careful when taking new medicines -- or old medicines for that matter.  Yet what I am implying is we need to make smart decisions, do our own research, and weigh the advantages with the disadvantages on our own, and not be pushed, bullied or forced into making a "choice" that is not truly democratic.

Yet that seems to be the direction we are going in.  It's scary to me.  I see it.  I hope other asthmatics do too, asthmatics with good, strong voices and pens that are willing to stand up and fight.
 
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He's refusing the one thing that would save her

"Hello, Mr. Smith?" Dr. Vanity was a heavy set man, messy dark hair on the sides, balding on top. As I looked down at him I could see sweat beads running down his scalp, which was the irony about it all considering it was snowing and blowing outside and I was wearing my lab coat because I was freezing.

"This is Dr. Steven Vanity from Shoreline Medical...

"Yep... Yes... that's what I wanted to talk to you about. Yep... Well, her hemoglobin has been about 6 for the past two weeks, but she seems to be taking a turn for the... yep... yeah... and that's what I wanted to talk to you about...

"You see, her hemoglobin has dropped now to 5. She has a temperature of 102 right now, and we're having trouble keeping it down. I hate to say this to you, but she's taking a backward step here, and, really, the only thing that's going to help her is if we give her some blood..."

He leaned back in his chair. He took a deep breath, wiped his brow. "I'm just to the point there's not much I can do for her if we don't give her blood....

"Hello... Hello..." He set the receiver down. He turned to look at me. "Well, I guess he wanted none of that."

"What, did he hang up on you," I said.

"Yep." He puckered his lip, wiped his brow again. "I told him she needed blood for me even to have a chance to save her, and he said, 'okay,' and hung up."

"Well, I guess you document that and do your best."

"It's unfortunate," he said, swinging his chair around and setting his feet on an empty chair. He wiped his brow again. "I really like that lady. I'd hate to see her go. She's only 51. She's young enough her body would have a fighting chance if only we could use the tools we have."

I placed my hands in my pockets, twiddling a vial of Ventolin in my pocket, and said nothing. The doctor sighed. That about says it all.

"My hands are tied," he said.