What Determines Success?

Prepare for the worse and hope for the best. 

We are health care providers. We are nurses and respiratory therapists. Our success is not determined by how many sick people we care for. Our success is determined by how many people don't need our services.

Look at asthmatics as a good example. Back in the 80s, it was common to have sick asthmatics. In fact, it got so bad that asthma organizations were formed. Heads of these organizations, along with many of the top asthma research physicians in the world, put their heads together. They created asthma guidelines.

Today, regional asthma doctors are educated on how best to treat their asthmatic patients. Asthmatics themselves, in turn, are well educated how to stay healthy and out of hospitals. And it was a huge success. Today, we don't see a fraction of asthmatics we used to.

See, that is a success. The fact that most asthmatics are able to stay out of hospitals is a success. If they were still being admitted at record levels, that would not be a success. Sure, we would make more money if asthmatics were filling hospital beds. But, that they are breathing easy and avoiding us is a good thing, not a bad thing.

COPD right now is at epidemic levels. There are COPD patients getting admitted every day. There are also many COPD patients that become regulars. They are discharged and readmitted on a regular basis. That, my friends, is not a sign of success. It is a sign that we are failing them.

Let's talk intubation.

You don't want to intubate people. Sure, it's very profitable when we have ventilators. Sure, it might stimulate your excitement level. But, it's not something that's good. It's a last-ditch effort to save a life. It's nice that we have that skill. It's nice that we know how to save lives this way. It's great that we manage ventilators.

But it's not something we should look forward to. Someone comes in the door of the ER, we should be praying that they don't need us. We should be hoping they get better. But, I'm afraid there are many of us who hope, maybe even pray, that we get to intubate.

That is a sign of failure, not a success. Success is not needing to intubate.

Obviously, some people LOVE intubating. That's understandable. You want to do it to keep up your skill level. And Managers WANT ventilators. In most instances, they are very profitable for respiratory therapy departments.

But hospitals, especially the not-for-profit variety, are not in the market to make a profit. That's the whole point. We are here in case we are needed. We are the cost of being in the healthcare business.

Doctors die with grace and dignity

Most non-medical people develop a false belief that modern medicine can prolong the quantity of days a person will live, and that "doing everything" to prolong life will result in a high likelihood of a good quality of life thereafter.

For this reason, I think that every person should spend a minimum of six weeks shadowing a respiratory therapist, nurse, or doctor. Doing so would cause people to learn three things:

1. Everybody dies
2. Death does not always come easy
3. Bad things happen to good people
4. You cannot take the risk out of life

Everybody dies.  As recently as the turn of the 20th century most people dealt with death on a regular basis, as the life expectancy was not that great.  Today, however, thanks to better medicine, people are living longer. This has made it so people don't see death often, and so they develop this false perception that people don't die, or that they will live forever.  

Death does not always come easy.  So they develop this false perception that modern medicine can keep them alive longer.  Sure we can do that. We can intubate you and put you on a ventilator.  We can put a pacemaker to keep your heart beating. We can artificially feed you.  We can clean your bottom. But you may not like the quality of your life once we start doing all of this. 

Bad things happen to good people.  You can be the best Christian in the world and still get sick and die young.  Yes, there is truth to the song, "Only the good die young."  It happens.  

You cannot take the risk out of life.  There's a serious effort in this nation to get people to eat healthy, exercise, get in shape, and lose weight.  Surely there are people who don't take care of themselves and end up as regular patients in hospitals and nursing homes.  Still, there are many people live unhealthy lives who live long lives, and there are people who live perfectly healthy lives who still die young.  So, no matter how much we can try, you cannot take the risk out of life.  You will have 41 year old otherwise healthy men get lung cancer.  It happens. 

CPR works, but not as well as most think

Doctors die with grace and dignity.  Actually, anyone who works with sick people for any length of time develops the skills necessary to die with grace and dignity. This is not always true of the general population, especially in a world where people are not exposed to death, and are exposed to the fantasy world of Hollywood where CPR works an amazing 64% of the time.

There are many examples of CPR being performed in a movie or TV show and the person living.  One such incidence that is fresh on my mind occurred in an episode of "Walker, Texas Ranger," which starred Chuck Norris from 1993-2001.  I described it n my post "No Vent, DNR, or Full Code: What's Your Choice?"

What might confuse people is what you see in the movies. There was one episode of "Walker, Texas Ranger," where Chuck Norris's character was having chest compressions performed on him, and his friend who broke his arm was watching on. Then Chuck woke up, the ambulance arrived, and the person who was taken away on the ambulance was not Chuck, but Chuck's friend with the broken arm.

A recent study performed at the University of Southern California Davis School of Gerontology showed that the survival rate for CPR was actually as high as 37%, although the survival rate of CPR performed on TV was a whopping 70%.  No wonder people get a warmed view of what modern medicine can do.

The study also revealed that:

The depictions show CPR mostly being performed on adults age 18 to 65, when in reality more than 60 percent of CPR recipients are older adults over 65... Also, trauma was behind nearly 40 percent of the CPR instances in the shows, even though traumatic injury cases only account for 2 percent of all CPR usage in real life.

When comparing these results to a similar study conducted in 1996, accuracy rates of television CPR depictions appear to not be improving. And though they seem like harmless entertainment, widespread inaccuracies in medical dramas could have real-life consequences.

Harmless indeed! Some experts speculate that the false perception of what medicine can do has lead many to falsely believe doctors can fix any problem, prolong life by "doing everything" including CPR, and that after "doing everything" quality of life will not be impeded.

This is not harmless.  It causes people to delay dealing with end of life care.  It causes people to avoid discussing with their loved ones, with their doctors, how they want to die.  And considering the difficulty of the discussion, doctors tend to avoid the subject altogether.

Just to provide an example, a 67 year old lady with end stage COPD was rushed to the emergency room by ambulance. The first question the doctor asked her was, "What do you want us to do if your heart stops."  She said, "I want everything done."

An hour later she was intubated and put on a ventilator.  Then her blood pressure dropped so low we couldn't feel a pulse.  Now we are forced to begin full blown CPR with chest compressions.  Yes, this did result in ribs cracking.

The chances of her surviving this are not good.  If she does survive, she's going to still have end stage COPD, meaning she is going to feel dyspneic. Only now she is also going to have some pretty bad chest pain due to the chest compressions.

Did we do the right thing.  Well, the emergency room doctor had no choice.  We had no choice but to follow the wishes of the patient, even though we all knew full well that this patient had set a path to a death that was not going to be very pretty.  She was not going to die with grace and dignity.

What can be learned from this.  Doctors must talk to their patients about end of life care.  They must be honest with their patients.  "Hey, you have end stage COPD.  If you should end up in an emergency room in respiratory failure, what do you want done? How far do you want us to take you with our medicine? Do you want CPR?"

Of course this discussion must progress to a definition of what CPR is.  It may progress to a discussion of what intubation is, and of what a ventilator is? It may progress to a discussion about the difficulty of getting a patient with end stage COPD off a ventilator? It may progress to a discussion of recent studies that show that ventilatory support has yet to be shown as useful in patients with chronic respiratory failure?

Options must be discussed. Hospice must be discussed. It must be explained to the patient that choosing to be a DNR, or choosing hospice, does not mean giving up: it means dying with grace and dignity.

Further reading:

• Wall Street Journal: Why Doctors Die Differently (or find full article at zocalopublicsquare.org)
• RT Magazine: CPR: It's Not Always A Lifesaver, But It Plays One On TV
• RT Cave: No Vent, DNR, or Full Code: What's Your Choice?
• RT Cave: How do people die?

Breathing Treatments: The ideal way verses the real way

When I have a respiratory student I can't help but think of the two different worlds we live in side by side, at the same time, and these are the ideal world and the real world.  We as therapists try to live as though we are in the ideal world, although ultimately find shortcuts, we need shortcuts, to help us adjust to real life situations, and so we end up working in the real world.

For the purposes of discussion, allow me, once again, to define the two worlds we live in.

The ideal world:  The ideal world is the one concocted in a lab, it's the fake, world. It's euphoria. It's the place where everything is supposed to work as designed. It's where everything is perfect. In this world you walk into the room, identify the patient, and then leave the room to go to the pyxis to get the medicine. Then you go get the computer, log in, find the patient in the computer, click on the patient, and log into the emar. Then you grab the scanner and scan the patient. Then you scan the medicine. Then you assess the patient, and chart your assessment. Only now do you open up the medicine and start the treatment.  Then you ignore the patient (because in the ideal world the patient doesn't need you) and you chart. Then you look at the patient, maybe talk to him or her while you wait for the treatment to be done. And of course all this time no one else needs you, because in the ideal world you can pay 100% of your attention to just one patient at a time. Then the treatment is done.  You stop the treatment. You take the nebulizer to the bathroom where you take it apart and rinse it out in sterile water. Then you assess the patient again. Then you do your post treatment charting. Only now do you leave the room and move on to your next procedure. In the ideal world everything goes according to plan, and every solution is manufactured, as if in a factory.

The real world:  This is how things really work.  This is reality.  This is where things do not work as planned, because in the real world you never know what to expect.  In the real world there are outside forces placing pressure on you to take shortcuts so you can get done with this faster so you can move on to another task.  In the real world the patient wants to talk to you, or the patient may need you for some other reason, like walking to the bathroom or setting up a tray.  In the real world the patient matters.  In the real world you might need to talk to a nurse during the treatment.  In the real world all sorts of stuff happens that you cannot plan for in a factory, things that might pull you away from the patient and the computer.  It is the real world all the solutions manufactured in a factory (or in the case of medicine, in leather chairs in Washington D.C.) do not work.  In the real world you walk into the room, identify the patient , and start the treatment. Then you assess the patient. Then you log into the computer and scan the patient and the medicine. Then you chart the pre and post assessment and log out of the computer real fast.  Then you sit and pay attention to the needs of the patient.  You might have a discussion about how much the healthhcare profession is messed up.  Then you do you post treatment assessment and then stop the treatment, coil it up in a bag and set it on the windowsill.  Then you move on to your next procedure.  You jot down a few notes, maybe, and later (when you have time, if you get time) you log back into the computer and chart your post treatment assessment.  This shortcut, real world, way of doing a treatment is the only way that works in the real world, otherwise you would be so far behind you'd never get all your word done.

Of course, if they ask, you did it the ideal way.  You are, in this way, a trained politician; a trained liar.

You see, this is a perfect example of how everything in this world, including medicine, is politicized.  It's not based on science, it's based on politics. You have these people sitting in leather chairs, the so called experts, who think they can fix all the problems of healthcare with their pens and their papers, and then what they do is they create this ideal, fiction, euphoric world where everything fails to work as planned and chaos ensues. Their attempt is to increase safety and reduce costs, and what ends up happening is they make things less safe and more costly. This, my friends, is socialism at its best.  What we have in 2015 is a healthcare system based on socialism.  That is why it is failing. That is why nurses and doctors are so frustrated with it.

So, anyway, that is the difference between the ideal world of doling out breathing treatments and the real world way of doing it.  Surely, you want to do it the ideal way.  But in the real world, nothing ever works out as planned.  In the real world you play it by ear and use common sense, because nothing else works. If you sit and try to be ideal, you will fail to be a good respiratory therapist.  The trick is to find a way of being real and safe at the same time.  It is hard, and it takes effort.  And it can be done.  It would probably drive prices down too.  In fact, I know it would.  Because the only thing that has never been tried in healthcare is capitalism.

Further reading:

• Articulating Ideas: Idealism versus Realism
• RT Cave: Real World Versus Student World

Understanding stupid doctor orders, or SEE I TOLD YOU SO

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

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

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

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

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

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

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

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

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

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

Further reading:

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

Healthcare: Quality -vs- Quantity

As an advertising student at Ferris State University, we learned about quality versus quantity.  We learned that you could reach a lot of customers a few times with your ads, or you can reach a few customers many times with your ads.  You cannot do both.  You can either have quantity or quality.

Justin Williams, in describing the dilemma of quality versus quantity in marketing, said that "In a perfect world, a brand sends the perfect number of perfectly composed emails to elicit the maximum response possible. In the real world, email marketers must balance between quantity and quality."

I think about this often as I'm doing my work as a respiratory therapist.  On some days I have only a few patients, and they get 100% of my attention all the time.  Sometimes I'm able to sit and talk to them, and this type of social interaction brings joy to both me and my patients.  Other times I can spend more time assessing my patients, resulting in them getting better care.  

On these days, when the emergency room calls, they have my undivided attention right away.  When a nurse or hospitalist needs my services, they have my undivided attention right away. This results in better patient care, better coworker satisfaction, and better satisfaction for myself too.  

On other days, however, I have many patients, and doctors are writing many orders.  On these days I'm hard pressed to get my work done in a timely manner.  I usually get it done, yet at the end of the day I'm often left wondering if I could have given better care.  I never feel satisfied at the end of these days.

On the other hand, some say that we as RTs accomplish more on the busy days, and therefore should feel good about ourselves.  It's being busy like this that results in us keeping our jobs and the hospital making money.  Yet what those people fail to see is that such busy days result in quantity at the expense of quality. You see, you can't have it both ways.  

I think of this when my coworkers complain when it's too busy.  I think of this when my RT friends online tell me how overwhelmed they feel at work.  I think of this when nurses complain that they have too many patients due to poor staffing.  

Keep in mind here that sacrificing quality for quantity is not all the hospitals fault, nor the physician's fault. For instance, it's not their fault, on certain days, weeks and months, every person with a chronic disease gets sick and requires the services of a hospital.  Technically speaking, there's no way to plan for these busy days.

An ongoing conundrum of the healthcare industry, as well as any other industry, is finding the perfect balance between quality and quantity.

Yet in healthcare, this is a time tested challenge that may never be overcome.  For instance, store managers can look at sales from April to May last year and plan for this year based on last year's sales.  It's not so easy to do in healthcare, mainly because it's impossible to know when people will get sick.  

To twist Justin William's words for our own purposes:  "In a perfect world, a hospital staffs the perfect number of perfectly performing physicians, nurses, and respiratory therapists to elicit the maximum care possible. In the real world, staffing is a balance between quantity and quality."

How to succeed in life

If you want to succeed in life, then you need to avoid people who are failures.  You need to avoid hanging around people who have negative attitudes.  You need to avoid people who incessantly complain about their work.  Because these people will never succeed.  They will never be better than what they are today.  

If you want to succeed you need to talk to people who have succeeded.  Any person who has succeeded will tell you this.  If you hang around negative people, people who are not happy with their jobs, then that is the attitude that you will pick up.  So if you want to succeed, hang around happy and successful people.  

That's not just something I'm making up, it's true.  If you hang around the failures, you're just going to become negative, and you are going to lose hope, and you are going to become apathetic about your job.  Once apathy sets in, chances of you moving up the ladder will probably be thrown out the door.  

Once you become apathetic and sit around the RT Cave complaining about this or that, or complaining about this person or that person, then you are going to trapped where you are right now.  If you want to succeed, if you want to move up the ladder, for instance, you will have to get away from these people.  You will want to rise above them.  

Don't hang around people who tell you you can't succeed because they didn't, because then you won't succeed.  You don't want to hang around people who are bitter.  Find the successes and learn from them.

If you want to be a writer like I am, you used to have to be ambitious and try to get some newspaper or magazine to like your writing.  One day I was sitting around trying to figure out how I could become a writer, and my wife introduced me to the Blogosphere.  I started writing.  At first I wrote to no one, as I has no audience.  Then people started discovering my blog, and they realized that I had something interesting to say.  

Then one day I received an email from a producer.  She said, "I love your blog.  I love the way you write in a pithy manner, and how you describe your profession accurately, and how you write about asthma.  I love how you write about smart people and stupid people.  I think you are a great writer, and I want you to write for me."  

I responded to this email, and now I have been successfully writing about asthma and COPD since 2008 for healthcentral.com.  I love doing this.  To me, it's not work: it's fun.  I have succeeded.  You can too.  But you will have to take advantage of opportunities, and you'll have to stay away from the complainers, or at least not listen to them. 

I'm not even saying you can't complain, because Lord knows I do.  I'm honest about my job.  However, I talk about it in a generic way, without blasting any person.  I might honestly discuss a situation that isn't going well,  and I might even disagree with doctors and bosses, but never at the expense of respect.  

People do things for a reason.  Doctors order useless breathing treatments because that's what they were taught, and telling them they are "idiots" will not solve anything.  Many doctors even admit that they order 'useless" treatments because they have to in order to get patients admitted.  

You might look at me and say, "You are a small town respiratory therapist and you have a couple blogs, but you are not successful."  To that I say, "It depends how you define success.  I define success by how satisfied I am, and I'm very satisfied." 

Believers tend to be better patients

He was dying and he knew it.  Yet still he continued to read his history book.  I entered his room, and he smiled at me.  He told me stories of his past.  He enlightened me about what he was reading about.  He was a very smart man.  He was a good man.

I got to know him quite well over the course of a few days.  Then one day I sat down in a chair, and he said, "You know that I'm dying and it doesn't bother me. You want to know why?"

I nodded and watched as he picked up his Bible.  "This is the reason I don't worry about death.  I know that death is not the end but the beginning."  He smiled.

I truly believe that people who believe in God die better than those who don't believe.  Believers are happy all the way to the end because they know death is not the end.  They know that what they learn in this life can be used in the next, and so they continue to produce and to show joy.

I used to wonder why it was that someone who knew he was going to die would be reading a book.  What's the point? But the more I learn, the more I realize that most folks who know, and are reading, have a Bible on their side table.

I'm not saying that all people who know they are dying and don't believe are bad patients, nor that all believers are pleasant.  Yet I am saying that, based on my own observations, that believers tend to be more pleasant.

Prayer

So I'm standing with a nurse in the hallway, and we are watching as a group of our coworkers attempt to save a young man's life.  She turns to me and says, "I think this is a good time to start praying."

I said, "I already began."

She said, "I knew when I saw you standing out here that this man was going to be prayed for."

It's kind of a neat feeling when someone tells me that seeing me reminded them of God.  It says a lot about the image I portray, and shows the importance of a good Christian upbringing.

It wasn't obvious that I was praying, as I was not on my knees or anything like that. She knew it because I told her one night that I pray in such situations. As a Christian I know that death is not the end but the beginning.

The two types of healthcare workers: Over-functioning and Under-functioning

I have observed that there are two types of healthcare workers.  For the case of simplicity we will call them June and Tom.

June manages anxiety at work by over-functioning.  What this means is that when stress hits, she moves in quickly in an over-responsible fashion to take charge and fix the situation.  She walks fast from room to room and patient to patient, and gets her work done as fast as she can.  She takes charge, often telling people what to do  The higher the anxiety, the more she functions harder and harder, and the more she focuses on others who do not (in her eyes) fulfill their responsibilities or accomplish things.

People who are fond of June admire her competence, maturity, and reliability. Those who don't like her call her bossy, strict, overly assertive, and demanding.

Tom manages anxiety and stress by under-functioning.  What this means is that when stress hits, he slows down in a less responsible fashion.  The higher the anxiety, the more calm he becomes.  He tends to take his time, speak less, and gets his job done in a calm demeanor. He heeds orders, even those he doesn't agree with, and just does them to keep the peace. Rather than rushing from room to room in a panicked fashion, he steadily walks, rarely taking charge.

People who like Tom admire his warm, laid-back, charming, and relaxed style. Those who aren't fans of his think he should grow up and become more reliable and thoughtful toward others. They think he appears relaxed and uncaring, which is not the case at all. Chances are, even while he appears calm, he's already working on three things.

June might see in Tom a person who should grow up.  Tom might see in June a person who should calm down and relax.  Yet, as with marriages, the two opposing personality types are essential.

Toms are necessary in order to keep the peace and create an overall calm and peaceful work environment.  Yet too many Toms in one place may result in not enough stress to get all the work done.

Junes are necessary in order to take charge and get the work done in a timely manner.  Yet too many Junes in one place may result in too much stress, which might ultimately make it so even less work is done.

By working together, and with an appropriate combination of the two types of healthcare workers, an ideal environment can be created within a hospital setting.

The secret then is the two types of people learning to get along.  Obviously Tom's friends will side with him when there is a disagreement, and June's friends will side with her.  Yet through it all, there are rarely moments when either is truly at fault for conflict.

There is nothing wrong being a June or a Tom, as they can both be competent workers with many friends.  Yet they are different.

However, when the two get locked into extreme or polarized positions, they begin to operate at a cost to both self and other.  For example, say Tom gets a STAT page to the emergency room, and he calmly walks down.  When he greets the patient he calmly jokes with him as he is doing what the doctor ordered.

June, who happens to be a nurse in the room, thinks Tom is too calm and uncaring.  She sees his coolness as him not caring, and not working hard enough to get the work done.  So she says something to Tom.

Anxiety caused by June's "controlling" statement causes Tom to back away, and he becomes even calmer.  He says nothing to June, and continues to get his work done as he feels comfortable. He continues to jibe with his patient while he whistles while he works.

The patient likes the way June is taking the necessary actions to help him feel better, although he might agree that she is being a bit harsh to Tom.  He also likes Tom, because he makes him feel comfortable and easy in an otherwise stressful environment.

Many times Tom might approach the patient in a manner that June feels is late and too slow, although she says nothing.  Yet the tension in the room is so thick that anyone else in the room can feel it.  After the patient is fixed June will be on the phone calling Tom's supervisor to let her know how irresponsible and immature Tom was, and how worried she was about his influence on the patient.  June has all but lost her ability to focus on and relate to Tom's competence as a healthcare worker.

Tom, of course, did his full share to keep the intensity going.  Not only did he know exactly how to push June's buttons and keep her involved (like not stopping joking with the patient), but he was also highly reactive to June.  For example, when his boss came to him telling him that he was too relaxed in an urgent situation, Tom might say, "What do you want me to do, stop on the way to ER to wipe water on my face so I appear more stressed?"

June might want the two to get together to work out their differences.  Tom might see this as her trying to control him even more.  So the drama continues.

Ultimately June doesn't change and neither does Tom.  Despite any therapy or counseling that might take place, June will continue to over-function when under stress, and Tom to over-function.

Of course Tom and June may support each other, and learn to work together, for the benefit of the patient.  They may even be good friends under normal circumstances.  Yet there will be times when the two will not see eye to eye. That's just the way it is.

The many faces of death

I have been doing this long enough to know what death looks like.  I have seen death more often than the average person, and I have seen every kind of death.  I know how people die.  I am, shall I say, a default expert on dying.

How many different ways are there to die?  I cannot say.  I had one elderly man die while I was talking to him.  He said, "I don't feel good."  He became suddenly anxious and walked to the recliner, where he simply stopped breathing.  I had been having a nice discussion with him just prior to this.

There was this other elderly man with a heart function of less than 10 percent.  He was a happy man, and he said to me, "I'm not afraid of dying at all.  I am ready.  I have said good bye to my family and friends.  Whenever God wants to take me, I'm ready."

He was one of the neatest old men I ever met.  A nurse and I were sitting at the nurses station watching the telemetry units, when we saw his rhythm change.  We both got up to look at him, and saw that he was sleeping sound with what appeared to be a smile on his face.

We saw his heart stop.  The way he went out, in his sleep that way was therapy for us in a way, because, by the line of our work, we too often see people die among a burst of pain and agony, and then we call a code and make un-Godly attempts to reverse God's call.

It is never pretty when this happens, and we never succeed.  And then we feel bad because things usually do not go as planned.  Sometimes we feel guilty, thinking we could have done more.  Yet after seeing a few of these events, a healthcare worker generally grows numb to death.

I don't think growing numb to death is such an odd thing, though.  I think in today's day and age where medicine keep people alive so long, we tend to see death seldom.  This was not the case prior to the 20th century, when death was a common occurrence.

How many people died just because they got appendicitis, something that is now treated with a simple surgery?  How many people died due to their their throat swelling up because they contacted a disease that is not exterminated by modern science?

There was a time when 50 percent of infants died in birth, and many died in childhood due to one disease or another.  Most kids never got to see their grandparents because most people did not live past 40.

Death is not common anymore, so we fear it.  Yet this is not the case if you work in healthcare, particularly as a physician, nurse, or respiratory therapist.  You will see death for what it really is.  You will accept death as just another part of life.

But this is good, I think.  As the Bible says, we never know when our time will come.  We never know when God will call for us.  And for this reason we should heed the words of Mark 13:33:  Beware, keep alert; for you do not know when the time will come."

I think that people who believe in God tend to go out with grace and dignity.  And healthcare givers who believe in God do a better job of dealing with it.  For we know that death is not the end but the beginning.

The cost of healthcare rises yet again!!!

Most of us who have health insurance have an incentive to not seek help unless we truly feel we need it.  Most of us with healthcare plans are forced to pay co-pays, or a minimum price for seeing a physician.

I think the idea of paying a co-pay is good. It forces people to think twice about seeking help for common sniffles and sneezes and bumps and bruises.  Yet this co-pay should not be so much that people are discouraged from seeking help at all.  

However, as of January, 2015, the cost of healthcare for many of us has nearly doubled, if not tripled.  In my case, my co-pays have nearly doubled, meaning office visits are $30, urgent care is $75, and emergency care is $150. To me, at humble RT wages, this is a pretty steep price for healthcare. 

This, coupled with the fact that my healthcare premium that I am required to pay per pay period has doubled to $300 a month, makes for a major ouch!  That's $300 a month that I will not be spending on other things I need or want.  That's $300 I won't be spending on a car.  That's $300 I won't be spending on food and clothing.  That's $300 I won't be spending toward air conditioning I need because my kids have allergies.

Add into this that most people are in the same boat I am, and you can see why the economic situation in this country is far from any euphoria dreamed up by certain members of the Washington elite establishment. 

On the other end of the spectrum, people receiving medicare and medicaid do not have to pay anything.  They have no incentive to think twice about seeking help, and it's because of this that our emergency rooms are full of people with ailments that you and I stay home with. 

Economics 101 teaches that as the demand for a product (in our case healthcare) increases, and the supply stays the same (number of nurses, doctors and respiratory services) the price increases.  So it only makes sense that the cost of heathcare have skyrocketed since these programs were created. 

Yet instead of fixing the problem, politicians continue to make it worse by creating even more laws meant to fix it "for our own good."   

There is a reason that the co-pays are stacked the way they are, because a person should first, when the decision is made to seek help, call their family physician.  If the family physician is not available, urgent care should be the next logical choice. Emergency rooms, which are expensive, should be reserved for (drum roll please) emergencies.  

I completely respect that some people need governmental assistance, and I'm not against it, not even in the slightest.  Still, there should be some kind of incentive to force people on such programs (some call it welfare) to think twice about seeking help for common sniffles and wheezes and bumps and bruises.  

For instance, they should have to pay $5 to see a doctor, $10 for urgent care, and $20 to see an emergency room physician.  This way they would be forced to consider that there is a cost for health care services.  They would see that an office visit is the same as a carton of cigarettes or a 12 pack of beer.  

Now I know there are people reading this blog post who are thinking: "But many of these people don't have $5.  They can't afford to pay anything."  Look, I understand this.  But there has to be some sort of incentive to force people to think twice.  There should be some price to pay  Make it  a buck.  Make it 50 cents. Make it a pack of cigarettes.  Make it a weeks worth of cable TV or cell phone service. 

Likewise, the fact that governmental programs require no co-pays is part of the reason that my healthcare premiums and co-pays are so high.  Since the Affordable Care Act (Obamacare) requires that all people have healthcare, my fees have increased to pay for this, and I can't afford it.

Surely there are those who say that it's not fair for people to not have healthcare. What those people fail to see is that it's not fair to me.  I can't afford it.  That's why more than half the people in this country don't support Obamacare. It's not even that we don't want to pay for it, it's that we can't afford to.  

I understand Obama promised that my healthcare costs would not go up, but it was an "unintended consequence" of his "good intentions."  Many people in my position are having a tough time making ends meat as it is.  Yet double the price of healthcare, and now it gets even tougher.  

Ever hear the story of the forgotten man?  Some people think of the poor and needy as the forgotten man. But the true forgotten man is the man in the middle class.  The light has been shining on the poor and the needy for the past 60 or so, and the people asked to pay for it are us.  Sorry, but we can't afford it anymore. 

Stroking egos: The only way to succeed

Whether we admit it or not, we all have egos.  The most popular people around us, and the most successful, are those who excel at stroking egos.  

Look at just about any Chief Executive Officer, and the president is a perfect example here, and you will see someone who excels at stroking egos. They stroked egos all the way to the top.  

Les Giblon, in his book "How to Have Confidence and Power in Dealing with People," said that the central person in everyone is "YOU!"  When you feel good about yourself, it's because you have an ego.  You love it when someone makes you feel better.  Those who make you feel better are the people you want to hang around with.  You love it when someone strokes your ego. 

In other words, all people have an innate desire for acceptance.  The people who make us feel accepted are the people we want to be associated with. 

He said this works because the most important person in your life is YOU. And YOU have an ego whether you want to admit it or not. And YOU love it when someone strokes your ego. In other words, all we humans have an innate desire for acceptance.

So the best way to succeed in life is to become good at building up the egos -- stroking egos -- of those around you.  Nearly all great salespeople are those who excel at stroking egos.  

Some sales people may excel at speaking, although others do not.  So it is not the gift of speaking that determines success, it's what the salesperson says and does. Those who succeed say and do things that make other people feel good about themselves.  

Giblon said that if you want to succeed, you must understand some basic facts about people.  

1.  All people are all egoists

2.  All people are are more interested in themselves than anything else

3.  All people want to feel important and to 'amount to something'

4.  All people crave approval from others so they can approve of themselves

So whether you are loquacious, taciturn, or somewhere in between, you have the skills necessary to life egos and succeed, according to Giblon.  

Giblon provides us with an example.  

Say you walk into a hotel on the eveing of the 4th of July and you are in a hurry. You have just enough time to check into your room and get to the fireworks.  Yet the desk clerk says the hotel is full.

Now, easily you could become irritated here and start yelling obscenities at the clerk, but the expert ego stroking will have another technique.  He would say something like, "I know your hotel is full, but I bet if there is anyone in the world who can find me a room tonight it is you."

Some people succeed based on technical skills.  Some people succeed simply because of intelligence.  Yet even people with limited technical and intellectual skills make it to the top, and the reason is because they "have a way" with people.

He said:

There are millions of people today who are self-conscious, shy, timid, ill at ease in social situations, who feel inferior and never realize that their real problem is a human relations problem. It never seems to get across to them that their failure as a personality is really a failure in learning to deal successfully with other poeple."

Of course there are people on the other end of the spectrum too, those who are talkative, confident and "bossy."  No one wants to be around these people because they make people feel bad about themselves.  They do not boost egos other than their own.

Regardless of how hard they try, they cannot get people to listen to them, appreciate them, and cooperate with them.  In fact, these people usually have to force people to comply with their wishes.

Yet while they can force people to comply with their wishes, they cannot force people to like them.  They never really get what they want because they have never mastered the art of dealing with other people.

He said that when people have to force compliance it's because they have no confidence in their ability to deal with people.  Lack of confidence therefore results in a low self esteem, and a "low self esteem results in friction and trouble."

Thus, the best way of dealing with trouble makers is to help them like themselves better. They need to have their egos stroked, or they need to be fed ego.  So when you become the person to stroke their egos, you in turn become the person they like to be around.  They will treat you better than they treat anyone else.  

Give that person a reason to like you. Give him a personal reason to give you what you want. 

Bottom line:  Regardless of your personality, the way to succeed is to stroke egos. The way to stroke egos is to make other people feel better about themselves.  So get started!  Go stroke some egos today!

Keeping the peace

The mood of one person can effect the milieu of an entire household. All it takes is one miserable and unhappy person to create gloom and despair.  Yet all it takes is one content and happy person to create joy and comfort.

It can be said that anger is the most difficult of all human characteristics to overcome. The reason for this is we are born with the innate desire to fend for ourselves and to protect what we perceive to be our own. We protect our homes, our children, and our pride.

Thus, when someone inadvertently or intentionally treads on what is ours, we have a natural tendency to respond in a negative way. We lash out either verbally or physically. We become gloomy and unpleasant. And, hence, so too does our anger morph out into the room. It spreads like the plague and so too does the gloom.

Yet there is something unique about human beings over every other creature that roams the planet, and that is the ability to Adapt and to Control our environment. While we can succumb to our innate desire to defend, protect and become angry, we can also control this desire.

We as humans learn that the best way to control our lives is to create a happy, copacetic personality. Then we see for ourselves that not only are we happier, the people around us are happier too.

The Mayo Clinic lists a variety of tips to help cope with anger and frustration, such as thinking before you speak and taking a time out.  While all of us will find a unique method for dealing with stressful moments, perhaps the best of all is to realize that life has a greater meaning than this moment. 

Consider, if you will, the wisdom of Jesus (Matthew 5: 11-12):

Blessed are you when people revile you and persecute you and utter all kinds of evil against you falsely on my account. Rejoice and be glad, for your reward is great in heaven, for in the same way they persecuted the prophets who were before you.

So perhaps the best way of keeping the peace is to swallow your pride, take the hit, and move on.  The nice feeling of solace that follows maintaining peace might be the greatest gift we can give this Christmas season.

No political correctness on the RT Cave

In honor of this being the 7th birthday celebration of the Respiratory Therapy Cave, a respiratory therapy student recently asked me some questions, and requested I share them here.  So, here we go!!!

So how long have you been a part of the respiratory therapy cave and what is your involvement with it?  I started this website on October 13, 1997, and I am a regular writer.

What qualifies you to do this? I'm a registered respiratory therapist working full time since 1997.

Do you have any other writing jobs?  I presently also work for healthcentral.com/asthma as an asthma and COPD expert.  I usually write about two posts on each subject each month.

Do you have a writing degree?  Have you ever had any other writing jobs? Have you ever had your writing in print? I have an associates in journalism from Ferris State University.  I learned a lot about writing, although that career path never really interested me after I graduated.  I also have a degree in advertising, which I think helps me to keep my writing pithy.  I have had my blogposts published in the online versions of various newspapers around the nation, including the Chicago Tribune.  I was also a writer for answers.com for a while, although I wrote so much they couldn't afford to pay me.

How has your writing improved over the years?  My writing is more pithy now.

Do you get paid to do the RT Cave?  If not, would you like to? No.  I do not want to get paid to do this.  This is my hobby.  If I started doing this for the money it would become a job, and it would become something I would have to do instead of something I choose to do.  Plus, not being in it for the money makes it so I can say whatever I want, even what is politically incorrect.

But you do have Adsense on your blog, don't you?  You get paid for that? Not enough to make this a career.  Usually that money is enough to pay for a couple evenings out with my wife each month.  It's usually not much, and it's inconsistent money.  It's essentially just enough money to keep this blog going.

What is your favorite part of blogging? Why do you do it?  The answer to both questions is because I love to write and I like to educate, and I think blogging provides me an opportunity to do both.  I love writing for the RT Cave because I don't have to be politically correct, and I have no editor to tell me otherwise. I like that I don't have to say certain things, or write in certain ways, so that I don't offend certain readers.  I can actually tell my readers what I actually think, as opposed to what they want to hear.

What do you mean? When I began my writing career in the late 1980s, we were able to write the truth, write in a style we were comfortable with, and not worry about offending people. That all kind of changed over the years as writers have sort of been forced to write in a manor that doesn't offend.  Here all gloves are off. I think that's one of the reasons people turn to the blogosphere, because here we can give honest answers.  Writing outside the blogosphere, when answering a medical question, I might have to justify it by saying something like: "You should talk to your doctor." I think that's poppycock, mainly because, in some instances, a nurse or a respiratory therapist may be more knowledgeable than a doctor.  In many cases respiratory therapy is beyond the scope of a physician's knowledge.  And I'm not the first person to say that either, as you will find credible physicians saying the same thing as you read my history of difficult breathing. The blogosphere is great in that it allows real people like me to say what we mean and mean what we say.

Do you worry about saying something that might cause you to lose your job? Not really, mainly because I do not write about my place of employment and I do not write about my patients.  All RT Cave writers are instructed to write in generalizations and to stick to the facts.  For example, we are not to write about how albuterol affects a specific pneumonia patient, but how albuterol affects the pneumonia patient population.

But you have to be careful.  Absolutely.  There is definitely a line that cannot be crossed.  I have some writers who have noted fear that what they published might be taken the wrong way, and in such instances I encourage them to either not publish it or delete it if already published.

Do you have advice for other RT bloggers?  One of my top writers likes to say, "Write about the profession and not the individual."  Stick to that when blogging and you'll stay out of trouble.  Be honest, but be safe.

What is your worse part of blogging?  I'm just happy to have the opportunity to write. There really are no negatives to writing for the RT Cave.

Well, I hate to use this term, but do you have a pet peeves then?  I would never do this on the RT Cave, but I hate it when I'm writing elsewhere and I find myself writing cliches like "you can live a normal life with asthma and allergies if you are a gallant asthmatic."  I find that to be totally bogus.

Before I go any further, you are an asthmatic, right?  That would be correct.

And you have an asthma blog too, right?  That would be correct.  I created the blog hardluck asthma.

So you are a credible asthma expert then?  I would say so, by default anyway.  I have lived this disease in more ways than one.

What do you mean by that?  Well, I was diagnosed in 1972, I do not remember any part of my life where it has not affected me. Between 1976 and 1985 I had many asthma attacks, so many in fact that I sometimes would not tell my parents and would needlessly suffer.  By 1984 I was making unscheduled doctor visits on a regular basis, and made eleven trips to the emergency room that year.  I was admitted four times.  In 1985 I spent 6 months at National Jewish Hospital/ National Asthma Center, so, along with my RT experience, that sort of qualifies me as an asthma expert by default.   So asthma has affected every aspect of my life.

Okay, so we can't argue with the fact you are a credible asthma expert.  So, why can't you live a normal life with asthma?  Well, you can live a relatively normal life.  However, most asthmatics are forced to take medicine every day, which is not normal.  Most asthmatics are forced to avoid asthma triggers, which is not normal. Many asthmatics have to avoid certain jobs, which is not normal. Surely we try to be as normal as we can, but when we forget we have asthma and get overly ambitious, we too frequently get into trouble.  And every thing I just said also applies to people with allergies too.  Considering 75% of asthmatics also have allergies, that's a double whammy there.  I would also have to add that COPD patients cannot live a normal life either.

Do you write a lot about COPD:  I have written quite a bit on this blog, and so have other writers, although I started in February of this year as a COPD expert at healthcentral.com/COPD, and so I have been writing a lot about it over there.

How long will you be doing this? I will end this website when no doctor ever orders a breathing treatment that isn't needed.  I will end this site when no asthmatic and no allergic person suffers.  I will end this when there is a cure for difficult breathing.

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Political correctness and creative lying

I watched an episode of Girl Meets World with my kids that had Cory Matthews lecturing in class about how you should never tell lies. His daughter Riley was in attendance.  So when he got home and saw that this chicken plate was on the table that didn't look good, he was forced to be honest with his wife.  She kicked him out of the house.

As a Christian, one of the things that bothers me more than anything about healthcare is all the lying we are forced to do.  Allow me to give you some examples and you'll see what I mean.

1.  Clara Patient is an 88 YO lady and her son does not want her to know she has end stage cancer and she's dying. So you go into the room, her son is not in the room, and she says to you: "I know my son knows something he's not telling me. Will you tell me the truth. Am I dying?"

2.  Laboratory regulators insist that all critical values be called to the physician and read back by the physician.  The reality here is that no physician has ever read back a critical value to me, yet I still have to chart it.

3.  CMS declared that we must, in order to get reimbursement, rinse the nebulizer with normal saline after every treatment.  There is no science behind this, it just made sense to some man in a suit who works in Washington.  So a patient says, "Why are you rinsing out that cup?"  Do you lie and say its an antiseptic even though you know it's not?

4.  A patient says, "Why are you giving me a breathing treatment when I'm not even short of breath?"  Do you tell her the truth that the breathing treatment has no effect for her?  Do you tell her that it will help her get rid of her pneumonia?  Or do you tell her the truth that it's so the hospital gets reimbursed for her pneumonia diagnosis?

5.  CMS will only reimburse for a pulmonary function if the ordering doctor writes down a certain diagnosis.  Since they know asthma is one of them, nearly every person getting a pulmonary function test is diagnosed with asthma.  The problem I have with this lie is it screws up asthma statistics, making them look like they are on the rise when they are not. (See 10 reasons asthma rates are still rising)

I know there is a reason some regulations, but they should be made by people who work in healthcare, not people in Washington.  Still, there's going to be times in any job where a little white lie is necessary.  It's just the way it is.  It's what confession is for.  "Father, I have sinned."

The episode of Girl Meets World ended with Cory talking to his children how sometimes it's necessary to tell white lies when it comes to making people happy.

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My thoughts on Robin Williams and suicide

The world has become so politically correct now that we can't even say the truth about suicide.  It used to be that the "default" thing to say when someone committed suicide was that he "took the cowardly way out."  Sheppard Smith said that on Fox a couple days ago, and he had to apologize and retract his statement.

Now political correctness has consumed our culture. Before this heightened sensitivity to not offending anyone consumed our society, we used to be able to speak the truth.  When we turned on the TV we would get the truth  Now the only way to be sure we are getting the truth is to read a column, blog, or watch or listen to the many political commentaries.

The reason people said "it was the cowardly way out" was because most people commit suicide rather than face the challenges of life.  We said it because there are people that you leave behind when you kill yourself, and you are leaving them with the grief, agony and pain that you are gone.  Maybe you are also leaving them with all the burdens you didn't want to face anymore, be they financial or other.

When people wrote about suicide they talked about the torturous effect it had on the spouse, children, parents, and friends.  There was talk about "what did I do that might have caused that person to commit kill himself.  There is the regret that they should have noticed the signs and done something to prevent it.

As a Catholic, we believed that suicide was a mortal sin.  If you got to the point in your life that you had to kill yourself, you were doomed to hell.  This was the disincentive to do it.

Today suicide is glorified, and mainly due to social media.  Instead of walking around that Robin Williams killed himself, they seem to glorify it.  They talk about all the accomplishments in his life, and how the world around him was so bad that it forced him to do it.

The truth is, the world around us has never, is not, and will never be easy.  There will always be challenges that we have to face.  Suicide is a permanent solution to a temporary problem, but those who are sick with severe depression do not see that.

I had a friend commit suicide once.  He told me the day before he was going to do it that he was going to do it.  We were at hunting camp where we all joke around and have fun, and here he spawns this on us.  One of the campers was a counselor, and he talked with Jim.

I remember everyone taking pictures of Jim, just in case.  I remember Jim saying to me that his wife had her children living in the house, and he was so depressed about it."

I said, "Why don't you tell them?  Why don't you just leave?"

He said, "Because I can't.  They count on me.  I'm trapped."

I completely understand how he feels.  As a parent I often feel trapped.  Here my kids get all the attention, and all our money is spent on them, and what is left for my wife and I.  Sometimes I feel trapped.  Sometimes we all feel this way.  It's normal.

I think that one of the greatest challenges to our society is depression, mainly because you can't just look at someone and know they are depressed.  And when you are the person who is depressed, you feel embarrassed to say anything about it. So it goes untreated.  So I can see how it can spin out of control.

What if the fact that we have glorified the suicide of Robin Williams -- the world around him caused it, some reports claimed -- other people whose worlds are falling apart, people seeking attention, people who want to be the center of attention, take the same route and kill themselves.  They will be talked about as heroes among their community.

The solution, however, is not to get all politically correct about it.  The solution is to call it what it is: a horrible act of desperation due to a medical condition that did not get treated.

Further reading:

1. Depression alone rarely causes suicide
2. Mrs. Doubtfire did it?

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Discussing politics and religion at work

Your question: Do you think it's a good idea to discuss politics and religion at work?  I love to talk politics and religion, but I don't want to offend someone. What are some tips to talking about complicated, or often controversial, subjects at work.

My answer:  Good question.  Most people will advocate not talking politics or religion at work in order to not risk offending someone and potentially losing their business. Of course when you work in a hospital this is of utmost importance because you are in business of helping your patient feel better, not worse because of what you said.

However, I'm of the belief, that if you use common sense, you can talk about just anything.  The bottom line here is you must realize that life is stressful, and every person must do, or believe, what they need to in order to get through life.

The key is, you are best not to just walk into a patient's room and just start rambling about your political and religious beliefs.  It's best to let the patient invite you into a discussion, or find some creative way to encourage the patient to open the discussion.

For instance, if the patient doesn't open up the discussion, I usually look for cues in the room to start a discussion from.  For instance, if I have a patient who has a Bible on the table, that means the person probably believes in God.  So I might ask something like, "What is your favorite passages in the Bible?" Or, sometimes I ask, "If a non-believer came into this room, what one passage in the Bible would you recommend to convince him?"

What is the patient watching on TV?  If they are watching Fox News, chances are they are conservative.  If they are watching any other news channel, chances are they are a liberal.  Still, to make certain, you could ask a simple question about the news program that is currently on.  You might ask: "So, what do you think about that?  If the topic is Obamacare, you might ask: "So, what do you think about Obamacare?"

Of course you will need to be careful, because once you open this bag of worms, you might get an answer you don't expect.  Regardless, even if the person has polar opposite views as you, you can still safely tread these waters.  Just try to be open minded and noncontroversial, until you are invited to be controversial. If you adamantly oppose the person's view, you might say something like, "That's an interesting view."

The thing to remember is that most people love to talk about things that interest them, which means politics and religion should not be ruled out as topics of discussion.  Some people thrive off intelligent discussions, and that does not mean they have to be intelligent discussions with people they see eye to eye with.

Think of it this way, if you have an idea that will make the world better, or help someone feel better about life, what good would it do if you did not share that idea? It would do no good.  So, the only way ideas will be shared is in the arena of ideas.

Just be careful to tread lightly. Feel the waters and see how it goes.  Play it by ear. If the water doesn't feel safe, back away or change the subject.

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Should it be illegal to smoke in front of kids?

I have no problem with people smoking, so long as they do so in the privacy of their own homes or vehicles where no one else is being forced to inhale their stale, polluted air.  However, when little kids are involved, I draw the line.

This past spring and summer I attended many t-ball games where my 5-year-old daughter and her friends participated in a friendly we-don't-keep-score-and-just-play-for-fun game of t-ball.  Yet at every single one of those games some individual kept lighting up cigarette after cigarette after cigarette, forcing me and everyone else -- including the kids -- to inhale their smoke.

I have asthma too, and the smoke bothers me.  But I'm thinking of the kids first.  I have trouble fathoming the idea that an adult, addicted or not, can't go one hour without lighting up.

Liberty means to exercise  human rights in any manner a person chooses so long as it does not interfere  with the exercise of the right of others.  Going by this, all people have a right to smoke cigarettes, but that right should stop as soon as nonsmokers are in the room.

As an adult, I can easily avoid your stale, polluted air.  However, your children cannot.  For this reason, it should, by default, be illegal to smoke in front of children.

Seriously folks, I'm not a champion for more laws, as I believe every law takes away some liberty.  However, if that law would protect innocent children, then I'm all for it.  I think it is absolutely cruel to force children to inhale polluted air because you choose to smoke cigarettes.

There are already enough studies to show that second hand smoke is harmful, and especially to asthmatic children. When I was a kid I remember suffering heartily when adults smoked around me, and I make every effort to make sure that never happens to my kids.

Now, evidence suggests that even third hand smoke, the remnants of smoke that stick to carpet and furniture, can be inhaled with consequences.  Evidence suggests it may trigger asthma, and a new study shows that it may even cause cancer.

I don't like to judge people.  I don't want to make laws forcing people to take certain actions, or not to take certain actions.  But if people are going to continue to light up around people -- people who have a natural right to inhale pure air -- then it might be time to take action against it.

Further reading:

• 20 reasons to quit
• 10 tips to help you quit smoking

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How to create a successful blog

Your question:  You seem to have a pretty successful blog here.  Can you give some tips on how to start a blog and write good posts like you do?

My answer:  Thanks for the kind words.  There are a few keys to starting up a blog that I think other bloggers would agree with.

1.  Think of a pithy name for your blog that is relevant to your content.  For instance, I put "Respiratory Therapy" in my header so that it would come up in searches for "respiratory therapy."

2.  Create a header for your blog that will catch the eye of anyone who clicks on your blog and reveal what the blog is about.  You can actually create your own headers by going to Google documents, click on file, click on new, and click on drawing, and click on page set up.  In this space you will type in pixels the dimensions of your header.  These can be learned by right clicking on the top of your blog, clicking on "page elements" and the html of your header will appear, revealing the height and width of your header.  Type in these dimensions into "page set up."  Then you can go to Google images to to select pictures for you header, or take your own pictures.  You can then download the images to your header, separate into layers, crop as desired, and type in your blog name and subheading if desired.  Similar programs are also available on Microsoft Word and other programs you have to pay for, but this one is free and easy.

3.  Write content that is related to your blog name.  Since mine is about respiratory therapy, I try to make most of my content relative to respiratory therapy.  However, at times I expand this to medicine and hospital life in general.

4. Write a minimum of three posts every week.  If you write any less readers who discover your blog may lose interest.

5.  Keep posts pithy, which means that each post should only cover one subject.  Make a point, and, whenever possible, add your opinion to posts.  Surely people will come to your blog for facts, but they also want your opinion, which is the purpose of a blog.

6.  Tell people what they already know but never get to say or read about elsewhere.  Like Rush Limbaugh or not, what he does is tell conservatives what they already know and never get to read about in newspapers.  It is this approach that has made him the most listened to voice on radio.

7.  It's okay to write facts.  Facts are your friend. It's one thing to form opinions, but opinions based on facts are the most interesting and most reliable.

8.  It's okay to state your opinion, even if it's about politics:  While facts are important, people come to your blog to hear what you have to say about things. You can write about politics from time to time, and you can let people know what your political views are.  This will not throw people from your blog so long as you don't over do it.

9.  Keep old posts hot by linking to them:  Blogger makes it easy to link to older posts.  This also helps to keep your readers on your blog, making them more likely to come back and read more.

10. Link to other blogs, news items, studies, etc. that are relevant to your post.  This helps show your credibility and reliability.

11.  Use spelling and grammar checks:  You do not have to be excellent at grammar and spelling to be a good writer anymore.  All you have to do is use the tools that are available for free.  You can place your post on a Google document page, or you can just use the spell check provided by Blogger.  I recommend doing both.  Correct grammar and spelling sows you are serious. Besides, there are people who will tune you out if you have too many errors.

12.  Take the time and make the time  Take the time to sit down and write, especially when you have a good idea.  Keep a notepad on you at all times so you can write down your ideas and don't have access to your key board.  Then make the time when all your other chores are concluded and write.

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