Cookbook medicine by demand or force?

I'm a big football fan.  One of the reasons I watch football, and I think other sports fans would agree, is because it allows me to escape life for a while.  I like sports because it's not real life, and its not politics.

But many of the top sports networks, particularly ESPN and CBS Sports, have forced us to endure politics while watching the pregame shows and even the games themselves.  I mean, it's to the point that sometimes I just turn the games on and watch them without sound.

Last Thursday, while I was watching the Redskins and the Giants with sound, I had to listen to James Brown say this:

Here in Washington last week US Senator Maria Cantwell of the state of Washington led a small group of senators that introduced legislation aimed at revoking the NFL's tax-exempt status if the league fails to force Washington owners Daniel Snyder to stop using the term "Redskins." Several prominent leaders in the Native American community, including Dennis Welsh of the National Congress of American Indians, the oldest and largest organization of its kind, have repeatedly stated that the Washington team nickname is derogatory.

I don't care if you agree that the Washington team nickname is derogatory or not, as that's not the point of this blog post.  However, what's key here is that this is the kind of stuff I don't want to hear when I'm watching a fun game for entertainment. It's the kind of stuff I expect when I tune into Fox News, or CNN or MSNBC and during episodes of CBS News Tonight, but not during sporting events.

Ironically, this was the same game in which former Giants quarterback Phil Simms attempted not to use the nickname "Redskins," instead opting, awkwardly at times, to refer to them as "the team" or "the Washington team."

Here's what he said at one point in the game:

The Washington team, they have a lot of weapons... They play a lot of man coverage, the wash -- the Washington team does. ... Let's see how the Washington team plays.

I don't know, it was kind of awkward, at least that's what I thought.

I'm digressing here, because what I really wanted to talk about was the comments by Brown, and I wanted to relate them to medicine. It's this that allows me, I think, to write about this here on this non politically correct health blog.  What Brown said is exactly what is broken with our healthcare system.

You see, there are some things people do not want. In sports, studies show most people are in favor of teams allowing Redskins to be called Redskins. Studies also show that 90 percent of Native Americans do not consider the term offensive either.  Most people do not see the name as derogatory and therefore don't care if the team changes its name.

Still, a small minority thinks native Americans should be offended, and so this minority is trying to force the team into changing its name.

But none of that is as important to us here in the healthcare profession except for the how they propose to do it.  Because we have a Constitution, they cannot force the Redskins to change their name.  So what they do is they say that if the NFL does not make them change their name, the NFL will lose its tax exempt status.

In other words, if this law passes Congress, the NFL will have no choice but to make the Redskins change their name.

The same thing has happened to healthcare.  Doctors for years have resisted cook book medicine that results from order sets.  However, in order to save money (or, as they referred to it, in order to save lives) CMS has passed regulations aimed to cut reimbursement to hospitals that don't comply.  In that sense, hospitals are essentially forced to comply.

It's by this reason we do too many EKGs, and too many breathing treatments, and too many smoking cessations.  It's why nurses and nurses aides do too many neuro checks, and IV starts.  It's why we all have to do too much charting, and why we have to chart when we should be taking care of our patients.

Of course, to make sure we're doing all this stuff, hospitals have to hire more workers to make sure we are doing it and doing it right.  In many cases, this comes at the expense of hiring one more therapist, or one more nurse, or giving raises. In many cases, while regulations are always created with good intentions, complying with them often comes at the expense of good healthcare.

This is what it's come to in healthcare.  Personally, I couldn't care what the team in Washington is called.  But the name should be changed because the owner thinks it's the right thing to do, not by a faux mandate by Congress.

Healthcare is no different.  Doctors and hospitals should not treat all patients with like diseases alike, but should treat all patients individually.  If a hospital or doctor chooses cookbook medicine, that's fine.  But they should not be forced by a faux mandate from Congress.

General George S. Patton had a nice quote that we can use here to conclude this post: "Never tell people how to do things. Tell them what to do and they will surprise you with their ingenuity."

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Stupid doctor order interpretation

Dr. Said:  "We'll just try an Albuterol treatment and see how it works."

Interpretation: "We'll order Q4ever nebs. 

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Is the false hope worth $120 a pop?

Your question: #1: do no harm. I can't speak for all rts, but most of my pts improve with the therapy given. Some pts despite all efforts whether mythical or not do not. I've never killed anyone with an albuterol. Sure, some docs think it cures everything, but it can make people feel better even if its just in their head. Now lets talk nurses overmedicating and rts having to fix their mistakes. Thoughts?

My answer: Actually it is a fallacy that ventolin causes no harm. We must not for get the s-isomer, which has been proven to cause inert bronchspasm. The more you take the medicine, the more you need it. It's an endless cycle.

I do see your point though. Patients do get the psychological benefit of thinking we're doing something, and the company of an RT.

Yet this has been a problem that has plagued the entire history of medicine, is that most medicine has no benefit other than psychological. Ventolin, like charms, amulets, prayers, and incantations of the primitive world, provides nothing more than the best remedy of all time: HOPE.

In other words, there are times when Ventolin has a real scientific benefit to the patients who receive it. The other 90% of patients receive nothing more than mythical benefits.

Does this "mythical benefit" and "false hope" justify the $120 it costs insurance companies for every treatment given?

Think of it this way, you give a treatment that's not needed every four hours, that's $720 a day, and $5,040 in a week. Is that price worth hope? Of course then you add all the prn treatments given in between because the patient got dyspneic on exertion to the commode, or developed an annoying wheeze, and the price only goes up even more.

Also, taking up a respiratory therapist's time giving a treatment that's not needed takes away time from someone who does need attention. This is a principle concept discussed often in economics 101 courses. It reminds me of the Broken Window Theory.

In the Broken Window Theory you have a boy walk by a sweater shop, and he tosses a rock through the glass. Some economists say this is good for the economy, because it creates a job for the glass maker. What is not seen is the effect on the sweater maker.

During the time the window is broken, the sweater keeper is not allowed to sell any of his sweaters. He therefore is out of a job until the window is fixed. He makes zero sweaters.  If he sells zero sweaters, the sweater maker sells zero sweaters.  Various other unseen people are also affected, such as the delivery man, and the man who sells little gadgets to support his family.

But the people don't see this aspect of the economy, all they see is what is obvious: a broken window and it being repaired. They see that the repairman is making money.  They think this is good for the economy. It is, but what they don't see is that the sweater company being closed greatly effects the economy in an unseen way.

So, I guess I'm comparing useless ventolin therapy with the sweater salesman. While the patient and the physician see the breathing treatment, what they don't see is that it did no good. Regardless, studies show that 50% of patients who received a placebo also said they benefited from the patient. So this proves that the patient is unreliable.

Likewise, in a similar scenario, while the breathing treatment is being given, the patient is given lasix. While the lasix is forming pee, and thus removing fluid from the lungs, thus making it easier to breathe, it is not seen.

In this way, lasix is also like the sweater maker. Since the ventolin is seen, it is given credit. It is also like the primitive medicine man getting credit for saving the live of a patient, when the truth is that nature did the same. But since he did something, he is given credit.

Also, and I'd like to see a study on this, when an RT is burned out at the end of a day due to too many frivolous therapies, it diminishes his ability to make good decisions at the end of his shift. A burned out therapist is not always at the top of his game.

This, in my opinion, may work to the detriment of good patient care. A burned out RT who is grumbling and griping at yet another useless ventolin order is probably not good for public relations either. And it's not like you can fire this RT, especially, as I've observed, this is common among all RTs. So you can't fire them all.

Now, these are simply thoughts. Although in all the years I've communicated such thoughts, I have never had anyone come up with a counter argument. Not one person has ever come up with any facts to prove that ventolin is needed for CHF, pneumonia, cancer, pleural effusion, and other lung diseases that provide asthma like symptoms.

I have had many doctors say things like, "I think that ventolin helps with heart failure." I ask this doctor, "Do you have the evidence to support this claim, or is it just a feeling?" Never has a doctor proffered any evidence. Usually they get mad as I offer my proof. They get mad at me for being honest.

Getting back to the broken window theory, as I'm giving the breathing treatment that isn't needed, what is not seen is that two rooms down is a man in the early stages of heart failure.  He is the man I would be visiting if I wasn't stuck in this room. Later on he will be intubated, and and only because of that breathing treatment that was thought to do no harm.

The idea that ventolin therapy does no harm, in my opinion, is no better than treating diseases the primitive way with a medicine man dancing, rattling his shakers, beating his drums, and chanting incantations. Since this is what the sick person sees, when the patient gets better the patient will say, "The miracles of the medicine man cured my sickness."

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Nebs at home? Well, then use them, you dummy?

So as I'm setting up the breathing treatment, I go through my usual rigmarole of questions.  You know, the questions we aren't supposed to ask, such as:

1.  Are you short of breath?  The patient says yes.

2.  Do you have these (nebulizers) at home? The patient says yes.

3.  Have you been taking treatments at home?  The patient says no.

So the treatment is finished, and I ask:

4.  Does your breathing feel better?  The patient says yes.

5.  Why didn't you take a treatment at home?  The patient says, "because I didn't want to self treat.

"Okay," think, "So you could have given yourself a treatment at home saved yourself a $1000 visit to the emergency room.  We're going to give you the breathing treatment that will make you better, plus to prevent the one percent chance of lawsuit we're going to do an x-ray on you, draw labs, and probably do an EKG. 

"And it's not self medicating if you already have the prescription at home.  The reason you have the medicine is so you don't have to go to the emergency room every time you get short of breath." 

There's an old saying you can't cure stupidity.  In fact, Ventolin itself is purported to treat everything except stupidity. 

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The rare, exceptional evil nurse

I'm the kind of guy who gets along pretty much with anyone. If you can't get along with me, chances are there's something wrong with you.  My parents pretty much inculcated into my head that things go so much smoother when, even during the toughest times, you are calm, cool, and polite.

I find that most of the people I work with treat me as I treat them: with respect and dignity.  On the few occasions I get irritated and show it, I generally apologize by bringing in cookies or some kind of treats.  Although it's rare that I need to do this.  Most of the people I work with are the same way: kind and generous.

As a rule of thumb, you almost have to be this way in order to work in a hospital.  However, for every rule, there is a person who breaks it.  We have one nurse that is very rude to patients.  I had this one patient say to me: "I hate that nurse."

He was surprised by my response:  "I don't really like her either."

We shared a good laugh and a good discussion.

This one nurse is rude, rude, rude.  If I could name her I would.  The fact that she's been divorced five times should say a lot about her.

The other day I left the EKG stickers on a patient, something I rarely, if ever do.  She said, bluntly:

"At this hospital we take stickers off patients."

She said once after I said albuterol is not indicated when a patient is not short of breath:

"See, that patient coughed.  That's why you give the treatment.  You need to just listen to the doctor and do what you are told." 

Today I asked a question:  "Hey, who has the patient in room 21?"

She said:

"Let's make this a teaching moment.  The tracker is right here.  All you have to do is look at it."

Tired of her poor behavior, I chimed:

"You don't have to be rude."

The neat thing was there were three other nurses right there that heard her be rude to me.  Later on one of those nurses came to me and said:

"I just want you to know that the rest of us love working with you."

I said:

"I appreciate it."  

We both smiled, and went happily about our business.

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What are the advantages of BiPAP?

I had a doctor today order BiPAP on a patient who was suffering from heart failure.  I walked into the patient's room and saw that the blood pressure was 65/20.  Based on my knowledge of BiPAP, I felt that it was contraindicated for this patient. 

So I sat down with the doctor.  I said, "The patient has a low blood pressure. Do you still want to use BiPAP." 

He said, "Yes!  He's a very calm patient, and if you irritate him with that mask it may help get his blood pressure up." 

After taking a couple deep breaths, I said, "Can you explain to me what BiPAP does for CHF patients?"

He said, "Yes.  It increases the pressure in the lungs so that it forces fluid out.  It helps decrease the pulmonary edema."

I said, "What I learned about BiPAP is that it decreases preload to the heart, thereby decreasing cardiac output, and thereby decreasing blood pressure.  In this way, it helps to decrease the patients work of heart.  That is how it helps with heart failure.  It does not force fluid out of the lungs."

"Well, put it on him anyway," he said, and stormed out of the room.

That occurred in the emergency room.  Up on the floor, a doctor ordered BiPAP on a patient who was septic, suffering from kidney failure, and in metabolic acidosis.  The patient likewise had a low blood pressure, but it was being somewhat controlled by dopamine. 

I asked the doctor why he was ordering BiPAP.  He said, "Because it will decrease the work of heart.  The patient is a DNR and I understand she's going to crash at some point anyway, but this will help delay the inevitable."

I asked, "So, how do you think the BiPAP will decrease work of heart?"

He answered me:  "Becaues it will force fluid out of the lungs and make it so the heart doesn't have to work as hard to breathe."

I took a deep breath, and said, "BiPAP will decrease the work of heart, but it does it by decreasing preload. This in turn decreases after load, and therefore decreases cardiac output.  This is what decreases work of heart.  Since blood pressure is an indicator of cardiac output, I'm concerned BiPAP will comlicate your efforts to control her blood pressure."
"So what do you suggest?" he asked. 

Impressed that he asked me, I said, "She's breathing normal.  So how about we don't use BiPAP."

"Welp!" he said.  He hymned and hawed a few minutes, then he said, "EEEEEEeeeeee, let's just put it on and see what happens."

Well, at least I tried. 

So, what are the advantages of BiPAP?

1. IPAP increases ventilation and helps to blow off CO2
2. CPAP increases FRC and therefore keeps the lungs open so the next breath comes in easier
3. Both IPAP and CPAP help to reduce work of breathing
4. Both the IPAP and CPAP help reduce work of heart as explained above

Apperently this is not what's taught in med school.  I'll have to investigate to see if this topic was covered in the Real Physician's Creed.

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The worse part of having 30 patients on treatments

The worse part of having 30 patients on breathingi treatments, with 28 who don't need them, is that I don't care about conversing with my patients the way I usually do.  My sole MO is to dole out nebs (yes, to be a neb jockey, or the nurses bitch).

The patient wants to start a conversation with me, and I feel guilty, but I'm so burned I can't even crack a smile.  My wife says I should be happy to do this, because I get paid to dole out stuff that's not needed.  But even that doesn't do it for me any more.  I just feel so pointless when I'm working like this.

Every room I go to, every doctor I talk to, every nurse I talk to, I keep coming up with ideas for my blog.  A doctor says, "I want to change that QID treatment to Q4 around the clock."  Why?  I just got done doing a treatment on that patient, and he was neither short of breath nor wheezy nor dim.  WT?.

A nurse comes to me and says, "I need you to give a treatment to the lady in room 33245234."

"Why?"

"Because she's wheezing."

"Is she short of breath?"

"No, but she sounds bad."

"She always sounds bad," I say.

If I walk away now the nurse thinks I'm lazy.  I once got written up because I didn't do what the nurse wanted.  So I go in the room and find a patient sleeping in no distress with an audible wheeze.  I say to the nurse, "If it's audible, it's not bronchospasm.  It's a cardiac wheeze.  It's in her throat."

But this is the 3,343,343,342,563,645,754 time I've explained this to this nurse, so I know this information is going to bounce off her gray matter like a rubber ball on cement.  So I do the treatment.  Yes, I'm this nurses bitch.

(Trust me, most nurses aren't this way.  Although when you're burned out is always (generalization) seems that such annoying nurses come out of the woodwork).

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The Chart Nazis

I think there is way too much emphasis on charting in healthcare, and not enough emphasis on the patient.  The longer I work in healthcare the more I realize this.

Just to give an example, my colleagues and I have maybe one or two experiences over the past 15 years where a patient, or patient family, complained about patient care.  Every one of those complaints was based on ignorance on the part of the patient or family member, and not on poor care by one of us RTs.

My colleagues and I get on average 2-3 notes a week alerting us to a charting error.  Once we master one area, the chart Nazis, as I like to call them, will find some other area of charting to focus on.  It's a never ending battle.

It's not just where I work either. I think even as you look at government regulations over healthcare, all, or most, of them tell a physician how to treat a patient with a given diagnosis.  There is no emphasis on the individual patient.

For example, all patients admitted with pneumonia must be sick enough to need one of the following in order to meet criteria for admission (translated means: criteria for reimbursement):

1. SpO2 of 92% or less upon admission, or an abg
2. Albuterol nebs or mdi every 6 hours
3. Antibiotic

There is no emphasis on the individual patient there.  There's this assumption that every patient is the same, or some kind of entity.  Individualism is lost in healthcare.  And this, my fellow RTs, is what is wrong with healthcare.  

Physicians are not encouraged to think outside the box.  For example:

• What if the pneumonia patient doesn't have bronchospasm?... too bad.
• What if the patient is too sick to go home but doesn't need oxygen or antibiotics... too bad. 

Personally, I think the current state of healthcare is unfortunate for the patient, because he's not going to get the care he really needs.  I think it's bad for the respiratory therapists and nurses, because the emphasis will not be on patient care, but whether those three things were done and charted correctly. Of course RT bosses will emphasize accurate charting, which is (ahem) where the dollars are.  

So when the chart Nazis come out in groves, now you know why.  

Low Information Doctors

The following is a guest post by our RRT friend Will Lessons.

Recently Obama received the Time Magazine "Man of the Year" award because he was, according to the magazine, "able to get the vote of the low information voters."  Playing on this theme, I would like to nominate for next year's prize the low information doctor.

Low Information Doctors don't know squat about respiratory therapy; it means they are not informed about Ventolin and Ventolators and BiPAP and Mucomyst and Atrovent.  Some low-information doctors don't care, to the extent that they care when they have a sick patient, but other than that, it's TMZ and the E! Entertainment channel.   You know, uninformed is not low informed.  Uninformed is not they don't care to be informed. The low informed doctor simply chooses to be informed about other things, like Claire Danes and what she did with Clinton after the Golden Globes.  Or Kim Kardashian's baby with Kanye.  I mean, they care more about that than they do the benefits of Ventolin or the truth about the hypoxic drive hoax.

Yes, you heard me right.  The low information doctor who may be the best doctor in the world, and yet he has no clue about respiratory therapy. Respiratory therapy is beyond the scope of their knowledge, yet they excel at making up theories about how ventolin ails every irritating lung sound.

Thanks. Will

Thoughts?

Note: The views of Will are not necessarily those of Rick Frea. 

Are Respiratory Therapists hospital's bitches?

The following may be a controversial topic among the respiratory therapy profession. 

However...

Considering the popularity of  questions I've received on the subject herewith, I have decided to publish the controversial post on the controversial subject. 

I humbly submit this with permission by said author, and by request of an anonymous friend from whom follows the RT cave from somewhere on earth but we do not reveal where as to not get him fired.

Note:  All names places, dates, periods, and capital letters are exaggerated as to not give away any reliable information.  Please consider this while pretenting to read said post. 

Hi Rick. At the hospital I work for we were so excited to finally have an emergency room breathing treatment protocol.  Man, this made me feel so good.  It was finally going to allow me to use the skills I learned in RT school, to decide who does and who does not need breathing treatments.  

Well, after about two years of implementing this protocol, it has resulted in zero fewer emergency room breathing treatments.  If anything, it's resulted in more -- many more. Thus has hammered RATS even deeper into my bones.  

I will give you an example as it occurred today.  I'm called to the ER for RT Consult.  The patient is not short of breath, but is diagnosed with pneumonia.  I'm asked to use my skills to decide if a treatment is needed.  

Nurse:  "You need to give a treatment."

Me:  "Upon my assessment no treatment is needed."

Nurse: "You need to give a breathing treatment."

Me: "No breathing treatment is indicated per RT Consult."

Nurse:  (Irritated) It's your job to give breathing treatments.  There's no reason you can't prepare one.  That's your job.  (right in front of the patient)

Irritated, I give the treatment.
Me: (to patient) "Do you feel any different after the treatment?"

Patient:  "No."

Of course then the patient coughs, brings up a loogy, and spits it into the sputum cup.  The nurse picks up the cup, and holds it up to me as she says, "And you said the treatment wasn't needed."

Me: (Rolling my eyes)(sighing)(leaving room)

Nurse:  (Writes letter to my boss complaining about how I'm lazy and trying to get out of work. Complains how I am grumpy with her.)

My boss then recommends that I take a customer service course, and give more treatments.  

Of course since the treatment is now "indicated" according to our protocol, I have to check up on the patient every half hour until discharge.  

Me:  irritated, go home and drink four Bud Lights, 2 glasses of wine, and one shot of Peppermint Schnapps.  

Sorry for the French, but as RTs, we've become the hospital's bitches.

Anonymous RT (with permission from RT Cave)

Keep in mind, here this is the perspective of the anonymous RT and not necessarily representative of the view of this blog.  However, the RT Cave does not deny it either.  

Now, we should have a raging discussion on this.  Thoughts.  

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Another frivolous use for Ventolin

I'm telling you you can't make this stuff up folks.  I was called to the recovery room to give a breathing treatment.  Upon arriving in recovery I said to the nurses:  "You need a breathing treatment, or want one?"

The nurses directed me to the patient.  "She needs a treatment," the nurse said.

The patient in question was sitting in high fowlers position and appeared to be in no respiratory disterss.  He was kid.  Right then the doctor arrived. 

"Oh, yeah," the doctor said, "His lung sounds are clear, but when his breathing slows down his sat starts to drop.  I figured a treatment might help."

I smiled and said, "So, what you want is for me to give a Ventolin breathing treatment to increase his tidal volume so his sat stays up?"

"Sure," the doctor said, confidently. 

I guess this is yet another example that proves my adage that instead of thinking just call respiratory. 

Here's how to be seen right away in an ER

So you know how it is in those big city emergency rooms: they are busy.  Sometimes you might have to wait over an hour to be seen for the wart on your penis that you decided you all of a sudden needed to see an ER doctor for, or the sniffles and sneezes that poeple who have to pay a deductable stay home and just deal with like your grandpa did. 

But, to be honest (and maybe I should keep my mouth shut here), there is one sure fire way that you can get your butt moved right to the front of the line.  Yes there is, and it's called chest pain.  If you have chest pain you will be seen right away.  There's no dinking around with chest pain. 

Yep, even faux chest pain results in immediate care.  Surely you might be overwhelmed by nurses and doctors, who are pent to strip off your clothing, poke you with needles, and do an EKG every hour until you are discharged. But somewhere along the way you can say to the doctor: "Oh, and by the way, I have a wart on my penis I'd like you to take a look at."

The down side to this is you might get admitted.  Well, you might get admitted because if you "had" chest pain you must get serial EKGs and have a stress test to make sure you're heart really is fine.  Even if you change your mind, or come clean about lying about chest pain, you won't be believed.  The hospital will make as much money off you as possible.

Oh, and if you don't get admitted, you'll probably need a holter monitor. Yes, we need to make sure you're not having irregular rhythms.  And we know that if we do this we probably won't get the holter back, but because laws say we have to treat you no matter how much of a dunderhead you are, we have to give you one of our $19,000 holters to take home anyway. 

And what the hey will you do with the holters you keep anyway?

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Don't be a dunderhead, get the flu vaccine

Every person should get a flu vaccine.  By doing this you will reduce your risk of getting the flu from dunderheads who don't get one by 60 percent (90 percent in most years, but his year it's 60 percent). 

If you are one of those people who think you get the flu from the flu vaccine, you are likewise a dunderhead.  I'm sorry, but it's true.  It is totally proven, and impossible, to get the flu from the flu vaccine. 

If, I say if, you had a reaction after the shot, it was not due to the inactive flu virus, but a preservative in the vaccine.  If this happens, the next time around request a vaccine with no preservative. 

If, I say if, you get nauseated after getting the flu virus, this is not, I say, this is not the flu.  If you get nauseated it is probably gastroenteritis.  It is not the flu.  The flu is a lung virus; it makes you sniffle and it makes you congested; it makes you have trouble breathing; it increases your risk of getting pneumonia.  It can kill you if this happens. 

Nausea can be a symptom of the flu, but it's rare.  So if you get nauseated after getting the flu vaccine, chances are it's just a coincidence. 

Most hospitals give the vaccine out for free.  You should definitely go out of your way to protect yourself from dunderheads.  If you do not, then you are a dunderhead too.  Got it!  Get it!  Good!

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

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

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

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

American Experiment:  Can man rule himself?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yet that seems to be the direction we are going in.  It's scary to me.  I see it.  I hope other asthmatics do too, asthmatics with good, strong voices and pens that are willing to stand up and fight.
 
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Signs that assume we are all stupid and lazy

Signs.  Notes.  You see them everywhere, especially at your work or office.  Most of them are written by choleric people who love rules and must have everything done their way.  And, yes, there is usually at least one choleric in every office.

They put signs up like the following:

• We do not have a maid service, clean up after yourself.
• Please shut off coffee pot when not in use
• This is a garbage, not a recycling bin
• This is for cans only, this is not a garbage!
• This room for employees and patients only! 
• This room is in use/ not in use
• Meeting this month is mandatory
• Label and date all food containers in refrigerator
• All unlabeled food will be tossed every Monday
• No drinking by computers
• No food in office

You get the drift.  These are signs written by people who have to have control.  Yet they don't realize that we are all people, and we all have different personalities, and we get busy.  These are signs written by people who think most people are stupid and lazy.

Some of us are lazy for sure, but the majority of us have more important things to think about than whether or not we leave a cup of water lying next to the computer, or have a container that's been in the fridge for two weeks.  Some people are clean and organized (the cholerics and melancholy) and some people aren't (sanguine and phlegmatic). 

I think a few signs or a few rules are good, but when you start to get a collection of them they become too hard to follow and too hard to enforce.  It's better just to have one really important sign, like this:

• Work hard
• Do your best
• We respect your hard work
• We know who the hard workers are, and we appreciate you

Yet communication in this positive way is rare and far in between, and usually comes just prior to communication that relays something you did that was wrong, such as a charting error that has nothing to do with the patient/ customer.

Signs are dumb.  I'd like to rip them down, and sometimes I do. Likewise, few of these prodigal signs say please and thanks.  I'd like to put my own sign up (just one) to put an end to such frivolity:

• Quit putting up stupid signs!  And Thanks

None of these signs are necessary.  If you're anal retentive and want to clean the fridge, clean it.  You'll be more respected that way anyway. 

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Yet another example of what's wrong with healthcare

It was kind of a culmination of all I've written about on my blog the past year was when our hospital Quality Analyzer came into the office and said, "I need to speak with Rick."

I spun around my chair and said, "Hi, Gerri, what can I do for you?"

"I was just wondering if you gave any breathing treatments to the kid in 310 today?"

"Um," so what was the right answer? The truth perhaps?  The kid in 310 was admitted with croup yesterday and was ordered to get racemic epinepherine breathing treatments prn. After an awkward moment of silence I settled on the truth.  "I didn't give one."

"Oh, I was hoping you did one and forgot to chart." She smiled. "The patient was discharged and now his insurance is refusing to pay for today because we didn't do anything today. If you did a treatment..."

"Do you want to to go in and chart a treatment I didn't do so we can get paid."  A provided her with an eerie smile.

She gave me the thumbs up.

Of course she was joking and so was I. Yet this is a perfect example of what is wrong with the healthcare industry. A patient needs to be admitted for observation, and yet because we didn't do anything the patient's insurance won't pay.

"Well," I said, "I guess for now on we'll be giving Q4 breathing treatments on all of Dr. Kipper's patients."

"Sure thing," she said, giving me the thumbs up signs again.

Dr. Kipper was new. The other pediatricians had already learned to order Q4 ventolin and racepic epi prn. That order makes no sense medically, and is a complete waste of time and money and results in RT apathy.

Yet that person sitting in a chair in Washington who makes all the laws was smiling somewhere in a leather chair in Washington as she unwrapped her paycheck.

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Doctors should treat patients, not insurance company

The doctor wanted to have the patient admitted for observation, yet the patient didn't meet criteria according to the insurance company. Still, the doctor didnt' feel comfortable sending the patient home.

So, what he did was write on the chart, "Recommended patient be kept for observation for best interest of patient."

That way, he said to me, the insurance company is liable if something happens to that patient and now the doctor. He also wrote on the chart, "Patient was sent home against my better judgement."

This is a perfect example of how cook book medicine does not work, and how doctors and nurses should be able to do what's best for the patient, and money should not be a factor.

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Fake side effects

It's funny how some people come up with the lamest side effects of drugs.

The most recent was when I finished a breathing treatment the patient said, "I don't want any more of those."

He belched.

"They make me burp," he continued. "It gives me gastric problems." He patted his stomach as to show me.

Of course we know that nausea is not an allergy symptoms, although more often than not when you ask someone why they are allergic to a medicine, they say it makes me nauseous.

Ventolin, for example, does not cause the allergy symptom of nausea. Although I've been ordered not to give it for this reason from time to time. Silly isn't it?

Smoking cessation good, but not if you don't smoke

At my hospital smoking cessation education is something we take very seriously. In fact, the order to do smoking cessation comes up on any patient admitted with CHF, COPD, MI, pneumonia, asthma and just about any other diagnosis under the sun.

This might sound like overkill, and it is. Yet our medical director wants us to do smoking cessation even if a person doesn't smoke. Thus, if they don't smoke, we're supposed to encourage them not to start, and we're supposed to inform them of the danger of not smoking.

I don't think this is a bad thing, yet where is the time do do all of this? If we're going to do smoking cessation on every patient, it's going to get to the point where the therapist dumbs down his presentation just to get it done and over with. In the end, a poor job will be the result.

Likewise, even while smoking cessation is deemed so important, we RTs have received no formal training to make sure we are providing the best education. Most RTs in my department that I talk to don't even know why we are doing it. I know because I ask around.

In fact, while smoking cessation is deemed so important, the hospital won't even splurge on a good smoking cessation packet. All they give us to give to the patient is a single sheet of paper with some basics about quitting smoking.

It's frustrating to me. It's frustrating because most of the patients who are ordered to get smoking cessation education have never smoked, or quit smoking years ago. So it seems quite frivolous and a waste of our time to HAVE to educate these people.

One man said to me, "I quit 75 years ago."

One patient has been admitted 4 times in the past month, and every time the order comes up automatically. I finally got irritated and started charting, "Smoking cessation done last visit." Yet I still, by hospital policy, have to bill the patient.

Of course the real reason we are doing all this education is not to help the patient. That's what we say, and that's what's said to us. But I know for a fact the real reason is because CMS reimburses for it, and when a patient is given smoking cessation, that helps to qualify the patient for reimbursement.

You see, everything in the new healthcare system comes down to money. No, it's not about saving the hospital money, because they (CMS) already only pay one lump sum regardless of how many things are done to the patient. In fact, it actually costs the hospital more money.

Yet our hospital wants to make sure the patient meets criteria and that the hospital is reimbursed for the patient's visit, and by charting smoking cessation for every patient admitted this is a step in assuring reimbursement criteria is met for that patient.

This is another perfect example of stupidity that results when we put the government in charge of anything.

Look, smoking cessations are good. Yet doing smoking cessations on people who never smoked or have already quit more than 6 months ago is a waste of time. IMO! Smoking cessation is good, but not if you don't smoke.

Argh!! A stupid doctor????

So I was teaching a class on neonatal resuscitation which so happened to have an array of doctors in attendance. So I thought this would be a prime opportunity to educate them about one of the myths about using 100% oxygen when positive pressure breaths are required on neonates.

So, I told this to one doctor. Then I set up a scenario where he was handed a blue and not breathing baby and told to use his skills to save this baby. When it came time to giving oxygen, he said, "I don't' care what the new studies say, ha ha ha!!!! I'm going to give 100% oxygen to all my neonate patients. So, give 100%!"

What do you do when that happens but smile, and cringe, and hope this doctor never has to take care of one of my kids.