New Study Shows Hypertonic Solution Cures Everything

Back in the 1970s, doctors frequently prescribed hypertonic saline (salt water) as a treatment. The idea was that the salty solution would draw water out of the airways, thinning mucus and making it easier to cough up. However, this theory was later disproved, and by the 1990s, hypertonic saline was largely phased out as an aerosolized treatment.

Fast forward to 2020, and a shift in medical thinking emerged: the longer the treatment, the better the potential outcome. This led to renewed interest in hypertonic saline, particularly for cases involving mucus plugging, often identified through X-rays or CT scans.

Common symptoms:  Excessive mucus production tied to conditions like asthma, COPD, or bronchiectasis—or sometimes, a vague “other” category when the cause isn’t entirely clear but the treatment is worth trying.

Frequency: Typically prescribed every six hours.

Effect: Designed to thin mucus by creating a hydrating, salt-infused "hurricane" in the airways. Even if no visible sputum is produced, the treatment is believed to work on a microscopic level.

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.

Instant Pneumonia: An Illness Doctors Just Made Up

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

Doctor's Creed: Update 10/1/2022

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 Please do not publish online, as we do not want respiratory therapists to have an opportunity to hack into our esoteric wisdom. 

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

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

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

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

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

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

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

Dr. Creed: One Budesonide Amp should cure stridor

Real Doctor's Creed: Appendix Z: Problem Solving

Section 982: Pediatric Croup.

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

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

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

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

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

So I ordered a one time dose of pulmicort.

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

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

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

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

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

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

Spousuterol proven to help spousal asthma

Have you guys ever heard of Spousuterol.  It's the latest in a long line of fake albuterol nebulizer solutions made to treat every ailment from rickets to asthma.

Spouseuterol is a neat formula specifically designed to produce a little extra mist so that family members in the room who have asthma can inhale second hand albuterol in order to get breathing relief that way.  In essence, it's a way of helping husbands and wives of patients breathe easier.

So, the next time you have a husband or wife who also has asthma, talk to your hospitalist about ordering spousuterol.  It's the best treatment for spousal asthma.  Trust me, it works.  It even helps respiratory therapists breathe easier, and I bet you didn't even know that.

Oh, and if that first one doesn't work, by God order four more to be give every 30 minutes if you are in the emergency room, or every four hours if your patient is admitted.  And, hey, if it doesn't work, at least it doesn't hurt anyone.

The Noninvasive Ventilation Creed

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

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

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Page99

(Section B-3)

Physician's Real Creed: The Noninvasive Ventilation Creed:

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

There are essentially NINE rules for NIV: 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Dr. Creed: Pulmicort: the new miracle medicine

To: Dr. Ven Tolin
Company: Doctors Creed Association of America
From: Dr. Sloof Lirpa
Date: 1/14/2013
Subject: Pulmicort

The planning committee for the 64th edition of the Real Physician's Creed met last night, and the hot topic was the use of Budesonide (Pulmicort) on all COPD patients.  Dr. John Carlton of The Royal London Hospital reported that he gave pulmicort to a COPD patient suffering from severe shortness of breath, and the next day the patient was better.  He tried this again a month later on a patient with a similar condition, and that patient got better the next day too.  So he recommended to the committee to add pulmicort as a front line medicine for all patients admitted with asthma, COPD, or pneumonia.  He believes that instead of waiting until the patient has been admitted for two weeks, that we start it right away. This way the patient will eventually get better and we can discharge him.  I personally would like to endorse Dr. Carlton's idea.  Certain pulmonologists in Europe have already begun their own experiments with the medicine, and I highly encourage us to send the memo to pulmonologists in the U.S., and then to add it to the Real Physicians's Creed for the next edition.  I would like to see this medicine used with increased frequency throughout the year.  I do not feel as though any further testing is indicated.

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Dr. Creed: Unrespiratory ailments treatable with B2 agents

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, yet explains the reason for needless bronchodilator for patients with no respiratory disorders.

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Page87

Section B8

We have listed previously the unresiratory ailments that are cured by B2 agonist therapy.  Here to for are the nonpulmonary disorders treatable with B2 agonists.  Yes, there is a difference between unrespiratory and nonpulmonary.

1.  Nonrespiratory: These are pathological dysfunctions whereby physicians know that symptoms observed are caused by changes within the body. 

2.  Unrespiratory: These are mytholocigal dysfunctions whereby physicians assume that the symptoms observed are caused by way of some theory concocted by Galen, a famous physician form the 2nd century A.D.  

Nonrespiratory disorders can be found on page 87 of this Creed.  

The following are unrespiratory disorders that are treatable with b2 agonists (bronchodilators, sympathomimetic, rescue medicine)

1.  Spleen/ melancholia (now known as depression): Occurs when the spleen secretes too much black bile, resulting in an imbalance of black bile in the body. Ventolin has been proven to induce the kidneys to secrete excess yellow bile, in order to maintain homeostasis of the four humors: black bile, yellow bile, phlegm, and blood. Speenobuterol works quite well.  

2.  Cold disease:  It's the converse of heat, a condition that often arises which visibly involves the extremities so that these, having necrosed, also falloff.  This is caused by the abstraction of too much blood during venesection, which was a treatment for many diseases.  It was also caused by a natural diminution of blood from the body by inexplicable means. It may also be caused by traveling long distances in the cold, and for those unable to find warm lodging during frozen weather. The condition may also occur with apoplexy (stroke symptoms), epilepsy, tremor, and spasm.  If the limbs do not fall off, or if the patient does not expire due to the initial recourse of this ailment, the victim becomes susceptible to the dark magic of the witches and wizards.  When copious supplies of extract of ventolin are in the blood stream, this creates an invisible vector field that protects the victim from the powers of dark magic. The vector stream likewise creates a negative pressure that sucks the dark magic from the body that is already floating in the bloodstream, thus nibbling and gnawing at extremity tissue.

3.  Venomous bites:  Black venom of snakus enomotous causes all humours to become dimunitive, thus making it difficult to sustain life.  Remedy postulated by Galen, among others, was similar to that of medicine men of the ancient world, and consisted of a second person placing his mouth around the bite and sucking out the venom. In 1992 a study was done by giving breathing treatments to said patients.  Following ventolin therapy many patients eventually got better and were discharged to home, and the theory postulated was that the ventolin acts as a fertilizer for the humours, allowing them to grow in to full and flourishing humours.  The medicine is called Galeonuterol. 

4.  Ailments of the eyes: Galen was very concerned with diseases of the eyes, such as glaucoma, which he considered the most common cause of blindness.  He offered a variety of herbal remedies to increase flow of vital spirit to the eyes in order to improve vision. While the methodology remains a mystery, retitobuterol is believed to likewise increase flow of vital spirit to the eyes to improve vision.  

5.  Ailments of reproductive organs: The testicles performed the job of heating the blood.  Since ventolin has the same powers of diminishing the blood supply and cooling the body as venesection, testiculobuterol is likewise believed to cool the body by slowing the heating properties of the testicles. The exact methodology this occurs remains a mystery.  

6.  Ailments of psyche: Psyche was considered the same as the soul, or the seat of consciousness.  It was housed in cerebrospinal fluid, the pneuma.  The pneuma is the substance in the air that contained the vital spirit, the substance necessary for life.  It traveled from the lungs to the heart where it was transferred from the veins to the arteries by pores between the right heart and left heart.  From their, arteries carried it to the ventricles of the brain. Symptoms of ailments of the psyche include delerium, psychosis, insomnia, anxiety, spleen (depression). Remedies that would purge the noxious humours affecting the brain and causing melancholic depression or psychosis ought to cure those disorders, though Galen.  Such remedies would be anything that diminished the supply of black bile in the blood. Speenobuterol works for well if the problem is limited to spleen, although of other disorders of psyche, Pneumobuterol Vital Spirit (Pneumobuterol VS) increases flow of vital spirit to through the body.  It has also been proven to act as a magnet to attract good pneuma to the body (which acts as an air purifier of sorts). 

7.  Fever:  Galen described fever as a disease entity of its own, as opposed to a symptom of many diseases. Fever causes a "burning heat" that causes insomnia, rapid heart beat, difficult digestion, rapid breathing, tension in the body, tremors, confusion, malaise, chills, vomiting, delirium, and lethargy. It is caused by the overabundance of flesh causing an increase in the humour blood.  Since blood is associated with heat of the body, an abundance of blood causes a fever.  A prolonged fever may cause the disease epilepsy or seizure. Since fever was an accumulation of blood, the obvious treatment was venesection, which was the letting of blood from a vein.  Venesectuterol works similarly, as it attaches to blood cells and directs them to the respiratory tract, where they are extricated through the bowel.  Note:  May increase blood in stool, and trick some physicians into thinking there is a GI Bleed. 

8.  Appoplexy: It's now called a stroke.  Galen defined it as a palsy (paralysis) of the whole body, followed by impairment of its leading functions.  It could also be palsy of a particular part of the body, such as an arm, let, face (cerebral palsy)or organ (cardiopalsy results in death). A victim may or may not maintain a level of consciousness, although appoplexy has a high mortality. Galen believed this was caused by something being inhaled that prevents the vital spirit (a substance in the air vital to life) from being transported form the arteries to the brain, thus impairing the nerves.  Modern physicians have learned that Appoplexolin enters the blood and assists the vital spirit cross the blood brain barrier into the brain.  It speeds up healing of stroke symptoms. 

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Dr. Creed: Here's how bronchodilators treat hypercapnea

Sympathomimetic medicine, once inhaled, lands on beta 2 adrenergic receptors, thus causing the bronchial muscles they are attached to to relax.  This causes dilation of these muscles, thus allows the patient to take in a deeper breath.  This deeper breaths allows for increased ventilation, thus increased exhalation of CO2 molecules.

That's what has been known since the 1st meeting of the Real Doctor's Creed Association of America in 1960.  Since that time it has been learned that sympathomimetic medicine also has the ability to get down into the alveoli, cross the alveolar-capillary threshold, and attach to CO2 molecules carried by hemoglobin molecules.  The new molecule that is formed is called GPSuterol.  The molecule is now super smart, and roams the blood stream looking for a well ventilated area of the lung, where it crosses the alveolar-capillary membrane to be exhaled.

There have been no scientific studies to prove that this is true, but it sounds so good it has to be.

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Dr. Creed: Here's how bronchodilators treat lung cancer

The scrubbin bubblin powers of Albuterol have been proven to scrub away all ailments in the lungs, except cancer.  However, the soothing soap like substance left behind following subsequent breathing treatments has been proven to decrease the spread of cancer.

Internist Richard Funk reported to the 53rd annual meeting of the International Conference of the Real Doctor's Creed Association of America that it has been discovered that cancer cells generate certain molecular interactions between cells and the scaffolding that holds them in place (extracellular matrix) cause them to become unstuck at the original tumor site, they become dislodged, move on and then reattach themselves at a new site.  He said this is a significant finding because only 10% of cancer deaths are caused by the primary tumor.

Dr. Funk likewise reported that a new theory proposed by himself is that a residue is left in the lungs after a good washing by ventolin scrubbin bubblin foaming action (a.k.a. albuterol).  The coating remains in the lungs for up to four hours, which is why it is very important that lung cancer patients receive ventolin therapy every four hours even when there is no evidence of bronchospasm.  

Cancer cells will still become unstuck from the original tumor site, yet the residue that now coats the cancer cells that are dislodged will not adhere to other places around the body.  This will help to prevent metastatic cancer.  This new theory, if it is true (which we know it has to be because it sounds good), will allow time for physicians to better treat the primary cancer.

Dr. Funk said that scientists from the Massachusetts Institute of Technology say that finding a way to stop cancer cells from sticking to new sites could interfere with metastatic disease, and halt the growth of secondary tumors.

Dr. Funk said the findings are especially important considering the medical community has believed for years that MalaNOmolin would get rid of cancer, as noted below from page 87 of the Real Physician's Creed:

Any Cancer: So you've tried everything, it's time to start the bronchodilator melaNOmolin regime you've tried for every other illness. Bronchodilator properties are known to break up unwanted tissue, at which time it is absorbed by Ventolin particles in the blood stream, screened by renal tissue, and excreted out the urethra. Note: see #6 below. It's important here to keep the renal system in tip top shape

Despite the application of melaNOmolin to lung tissue, cancer morbidity and mortality persists.
In 2007, cancer claimed the lives of about 7.6 million people in the world. Physicians and researchers who specialize in the study, diagnosis, treatment, and prevention of cancer are called oncologists.

Malignant cells are more agile than non-malignant ones - scientists from the Physical Sciences-Oncology Centers, USA, reported in the journal Scientific Reports (April 2013 issue) that malignant cells are much “nimbler” than non-malignant ones. Malignant cells can pass more easily through smaller gaps, as well as applying a much greater force on their environment compared to other cells.

Professor Robert Olin and team created a new catalogue of the physical and chemical features of cancerous cells with over 100 scientists from 20 different centers across the United States.

The authors believe their catalogue will help oncologists detect cancerous cells in patients early on, thus preventing the spread of the disease to other parts of the body.  The addition of ventolin scrubbin bubblin thereapy QID will further aid in the preventing of the spread of this disease.

Dr. Olin said "By bringing together different types of experimental and made up theories by intelligent Internists, expertise to systematically compare metastatic and non-metastatic cells, we have advanced our knowledge of how metastasis occurs and how to prevent it."

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DR. Creed: Updated for Obamacare

The following is an email intercepted discreetly by Doctor Ven Tolin, President Dr. Creed Association.  It was sent to Carl Breatheright, CEO Shoreline Medical Center:

Faux Sepsis

We learned earlier that faux pneuonia is a type of pneumonia that exists only for billing purposes.  To make sure insurance and government auditors don't catch on to the cunning ways of medical quality assurance analyzers, the medical community had conceived another faux diagnosis, this time called faux sepsis.

Surely no doctor would admit to the diagnosis of faux pneumonia, so he simply writes "pneumonia" as the admitting diagnosis.  The same is true with faux sepsis.  In this case, the physician would write "SIRS" as the admitting diagnosis.

The official name is Systemic Inflammatory Response Syndrome.  It was first described in 1983 by Dr. Wiliam R. Nelson at the University of Toronto.  He described it as an inflammatory state of the whole system, and that it precludes multi system organ failure or full fledged sepsis.  He said it was essentially the systems response to an infection, such as pneumonia.  It is a serious condition that must be taken seriously.

The condition is typically dealt with by a hospital's sepsis protocol.  Any person who has any two of the following meets criteria for the sepsis protocol:

• Heart rate greater than 100
• Respiratory rate greater than 20
• Fever greater than 101.4

The protocol consists of the following:

• ABG to check for pH
• Lactic acid to check for organ falure
• Breathing treatment, if pneumonia is the suspected cause
• Other

If the tests turn up positive, the person is diagnosed with sepsis.  If the tests turn up negative, but the patient looks sick enough to be admitted and you don't want to risk a lawsuit for sending a sick patient home, then you diagnose the patient with faux sepsis, or SIRS.  This assures that the patient meets reimbursement criteria. 

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New Study ignored in favor of Duoneb/ Pulmicort Neb Combination

A study presented today at the 53rd International Conference of the Real Doctor's Creed Association in Orlando shows adult pneumonia patients given a certain inhaled corticosteroid had a 29 percent lower risk of ending up back in the emergency department (ED) or being admitted into the hospital, following admittance with a diagnosis of pneumonia.

The studied drug, PULMICORT RESPULES(R) (budesonide inhalation suspension), uses a nebulizer to deliver the medication to children, making the delivery more consistent. It is the first and only inhaled corticosteroid approved for children with asthma 12 months to 4 years of age. 

A second studied drug was Duoneb, a medicine that most studies show is no longer relevant now that Spiriva has been proven to improve lung function better, and also to reduce air trapping in adult asthmatic and COPD patients.  A study of physicians show that 93% of us do not believe Duoneb is less efficacious than studies show, and 90% of whom continue to order it regardless.  

The recent study was performed using a control of patients who were given just Duoneb, and a study group given both Duoneb and Pulmicort.  The study showed there was no difference in outcomes, as both groups were eventually discharged to home.  Likewise, about 30% of patients in either group were eventually readmitted, some for a diagnosis other than pneumonia.  

Despite the study results, the physicians at the Conference voted to accept the belief that Duoneb is a much better medicine than Spiriva.  They also voted to recommend giving Duoneb and Pulmicort together as a standard treatment for pneumonia patients, for no other reason than to make the treatments last longer, thus giving respiratory therapists something to do.  

The following have already been approved for addition to the 2015 edition of the the Real Physician's Creed: 

1. Seizurebuterol sooths and relaxes the myelen sheths in the cerebral cortex to minimize spasms of the head and shoulders. May be alternated with headandshouldersuterol. The medicine should be given at a frequency of QID. Pulmicort should be given BID to lubricate the albuterol particles to help crossage of the blood-brain barrier.
2. Pulmilubricort: Should be given with any ventolin product whereby the desired action is to cross the blood brain barrier to generate some type of calming effect within the mind and body. This medicine smooths and lubricates albuterol products so that they can easily squeeze through the blood brain barrier without being seen by the blood-brain police.  May have best effect if given with abscondlin.  Some examples of 'olins that would benefit with the addition of pulmilubricort: Palbuterol, Hiccuputerol, Exorcistobuterol, Revivolin, etc.  It may also be trialed with Muchtolateagain in an effort to stimulate the brain of a patient in cardiopulmonary arrest.  

The theory of why Duoneb should be given with Pulmicort (Pulmilubricort) is that the Pulmicort molecules, when combined with Atrovent molecules, helps to further lubricate the ventolin molecules so that ventolin scrubbin bubble buddies can transport themselves into the smaller air passages of the lungs (or, rather, just slip right in), and even into the alveoli.  The deep scrubbin bubblin action of ventolin has already been proven to wash all lung ailments away.

Dr. Olin said, "We need to take heed of the fact that not sometimes what is observed in the clinical setting matches what is proven in the laboratory.  So it's hard for physicians with a long standing belief that Ventolin scrubs the lungs clean as the sink to buy into modernism.  It has, however, that in the presence of a respiratory therapists patient's are happier, so it would only make sense to keep the RT in the room for an extended period of time."

The results of this new recommendation has been emailed to all pulmonologists working as hospitalists. 

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Real Drs Creed: Hypoxic Drive Hoax Revisited

What follows is what will be added to the new addition to the Real Physician's Creed: How to take care of Pesky RTs. Again, this is TOP SECRET information for physician use only, and was never intended to be released among the RT community.
My source for this TOP SECRET information will be kept anonymous, because if his peers find out he is the leak, he will be banned from the medical community at best, or ridiculed at worse. 

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Page 10,400

Appendix 8

Real Physician's Creed: Hypoxic Drive Hoax Revisited

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

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

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

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

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

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

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

Dr. Creed: How to deal with Brovana

In light of my post, "So why is Brovana feared by RTs, RT bosses and doctors?," the medical director for Shoreline Medical Center, Dr. Hein Olin, sent a letter to the professor, physician and editor in charge of the Real Physician's Creed, Dr. Ven Tolin, who in turn sent the following letter to Hein Olin.  

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To: Dr. Hein Olin
From:  Dr. Ven TolinSent: Thursday, November 15, 2012, 3:50 P.M.Subject: New changes to the Real Physicians Creed

Thank you for your letter of concern regarding that pesky Rick Frea.  He has been nothing but trouble since he started his blog in October of 2007.  His lies about bronchodilators have many of us on the defense as we are receiving letters on a daily basis from respiratory therapists concerned that most of the treatments we order are a wasted of time.  We have made attempts to get his blog off the net, but unfortunately we have failed in our attempts.  If you would fire him that would make our job much easier.  So why don't you just do that?  Of course it's probably too late anyway, as he would just keep "doing what I love to do," as he says on his despicable blog.  

Yet I digress.  Regarding this new medicine called Brovana.  All it is is an attempt by the home care industry to get rid of Albuterol and Duoneb breathing treatments that we feel are necessary.  These home care people are just lazy, and trying to get out of work.  The respiratory therapists who think Brovana can just be given twice a day without any Duoneb in between are using fake science.  Phooey on them.  As we have discussed many times, what feels good and sounds good is much more valuable than science.  So we have decided long ago that it sounds good to give Duoneb to all patients with lung problems, so we will continue onward with this policy.  To change it would make us look like we are indecisive.  I suppose it's for this same reason the President (Bush and now Obama) won't get rid of secretaries who perform poorly.  We agree it would look poorly on them.  

In our 31st edition of the esoteric "Real Physician's Creed" to be released in January of 2013, we will add a new section on Brovana.  We will ignore the fact that Brovana is a fast acting medicine that works similar to the rescue inhaler Albuterol.  We will continue to deny that giving Duoneb at the same time as Brovana is similar to giving two Duoneb treatments at the same time, and not necessary.  We know it is necessary.  It's necessary because it feels good.  Who cares about science?

Yes we will deal with this Brovana nonsense in the new book.  Until then we recommend you simply ignore that evil respiratory therapist Rick Frea. He is nothing but a piddling fool.  
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Thankfully I have my sources for getting this information, and I will not reveal my source.  Ahahahahahahahahahahahahahahahaha

Dr. Creed: The feel good policy of oxygenation

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, yet explains the reason for needless bronchodilator for patients with no respiratory disorders.

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Page91

Section B8

Forget the passenger seats on a train theory, because it's all hogwash.  You know the theory, because respiratory therapists use it all the time to try to convince us oxygen isn't necessary unless the SpO2 is less than 90 percent.  

The passenger theory says that if there are 30 seats on a train, you can only seat 30 passengers.  It doesn't matter if you put 100 passengers on that train, only 30 will get seated.  They use this analogy when complaining about us placing supplemental oxygen on all post anaesthetic and patients suffering from chest pain.  

We physicians go by the feel good philosophy, where if it sounds good it must be true.  So we oxygenate whenever it sounds good to do so. So when a patient has chest pain, we must oxygenate these patients because, somehow, this must get more oxygen to the dead and dying part of the heart.

Now, sure it's true we're ignoring that dead tissue won't oxygenate the heart no matter what, but this ignores our "feel good" policy. 

Based on this new "fact," physicians must be taught to place all patients complaining of chest pain, or all patients post anaesthetic, on supplemental oxygen -- period.

If some future political faction, like ACLS or Medicare, decides to only oxygenate patients with an SpO2 of 90 percent or lower, we must be skeptical of these claims.  

Dr. Creed: Albuterol decreases work of heart

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, yet explains the reason for needless bronchodilator for patients with no respiratory disorders.

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Page89

Section B8

Surely we are aware that beta adrenergics, once inhaled, attach to beta receptors lining the respiratory tract.  If a patient is extremely dyspneic this may in itself reduce the work of heart.  Yet we must exceed biases and understand that such a medicine may reduce the work of heart in patients breathing normal as well.

Once the beta adrenergics are filled to capacity excess albuterol molecules are absorbed into the capillaries and are carried to the heart where they attach to beta 2 receptors.  Unbeknownsed to science, these receptors, once stimulated, relax cardiac muscle and, thus, reduce work of heart.

Indications for such therapy are as follows:

1. Chest pain
2. Suspected chest pain
3. Mycardial infarction
4. Stroke
5. Stroke symptoms
6. Suspected stroke symptoms
7. Heart disease
8. COPD
9. Heart failure
10. Cor pulmonale
11. Syncope
12. Heart disease
13. Family history of heart disease
14. Past cardiac complications

Based on this new "fact," physicians must be taught to place all patients with the above indications on supplemental oxygen as well.