Showing posts with label wisdom. Show all posts
Showing posts with label wisdom. Show all posts

Wednesday, November 6, 2013

Myth Buster: Mouth to Mouth breathing does not oxygenate patients

It has been a belief of mine that one of the reasons mouth to mouth breathing should no longer be performed was because exhaled air only contains 16 percent oxygen compared with inhaled oxygen containing 21 percent oxygen.  As it turns out, it was this myth that was one of the obstacles that was disproved just prior to its worldwide acceptance.

I'm going to give you a brief history of mouth to mouth breathing before I disprove the myth.  The most common cause of sudden death prior to the 1950s was drowning.  In the first century Galen believed a person inhales a vital spirit, and this vital spirit is absorbed and moves through the body to sustain life.  This theory was still believed in the 18th century.\

It also should be noted here that when a person died, the "vital spirit" left the body immediately.  It was probably for this reason that there were very few efforts to revive a presumably dead person.

In the ancient world, and into the 18th century, it was viewed as sacrosanct to touch a dead body except in preparing it for burial.  For this reason people were forbidden from toughing, let along performing autopsies, on dead bodies.

During the course of the 16th century men like Andreas Vesalius started inspecting the body, and therefore began doubting the words of Galen.  So it was in the 16th century that the science of anatomy was begun, whereby people started learning about the various structures of the human body.

During the course of the 18th century people started realizing that diseases were caused by changes within the body.  This began the science of pathology.  Realizing that changes within the body caused disease, some people started speculating that there was a reason a person suddenly dropped dead, and perhaps by rescue efforts a person could be brought back from the dead.

This was not a knew idea, although prior to this century it was not talked about much.  There were various efforts as far back as the primitive world where descriptions of artificial respiration were described, such as in Isaiah in the First book of kings, and Elisha in the Second book of Kings. Elijah pressed his body over a child three times to revive him (perhaps an early version of chest compressions) and Elisha performed mouth to mouth breathing to revive a child. Likewise, there were various stories of midwives providing mouth to mouth breathing to newborn babies, and the method working.

Yet in the 18th century, as people were learning about pathology, various efforts were made to save the lives of drowning victims.  And, lo and behold, some of the time these efforts worked.  Even though successes were rare, it was enough to inspire repeating of these efforts.

Noting success stories, in 1774 a British Physician named John Fothergill became impressed with accounts of successful efforts of mouth to mouth breathing, that he wrote about it as a safe and easy procedure that anyone could perform to reanimate a person in suspended animation.

Back then the term artificial resuscitation was not used, and instead it was referred to as resuscitation.  A person was suscitated at birth, meaning that he was given life.  Given the stories of some people being brought back to life, the period from when a person died and was reanimated was called "suspended animation."

Likewise, given these success stories, it was now believed that the vital spirit stayed in the body for a period of time after a person died.  However, it was not known how long before it left the body.  It was for this reason that you will read stories of reanimation attempts lasting for two hours or longer.  There was also no timetable for efforts to be started.

There were a variety of methods, that included mouth to mouth breathing, rolling a person over a barrel, hanging the person by his heals from a tree, performing chest compressions or abdominal thrusts, tickling his nose with a feather, covering his body with spirits, or breathing for him with bellows.

Mouth to mouth breathing was effective at times, although due to disease pandemics, it quickly went out of vogue.  It was replaced by using fireside bellows, which were readily available in most fireplaces.  Back then there were fireplaces in every house and place of work.

Mouth to mouth breathing made a brief appearance in 1909 when Dr. Robert H. Woods wrote about it, but people were so in love with other methods of resuscitation at the time, they ignored Wood's suggestion.  The preferred methods of breathing at this time were rolling a patient form side to side, providing abdominal or chest compressions, or applying pressure on the patient's back.

But during the 1950s Dr. James Elam and Dr. Peter Safar proved that mouth to mouth breathing was superior to any other method.  They proved that it was so simple that even a child could do it on an adult.  They even proved that it provided better tidal volumes.  The only obstacle that remained were critics who claimed that the 16 percent oxygen exhaled by the rescuer would be too little to oxygenate the victim.

This obstacle was hurdled by experiments by Elam and Safar.  I will allow Mickey S. Eisenburg, in his 1997 book "Life in the Balance, to explain the rest:
To prove the value of mouth to nose breathing (or mouth to mouth breathing), Elam first had to show scientifically that exhaled air was adequate to oxygenate a nonbreathing person.  It was widely believed that exhaled air, with 16 percent oxygen, was too low compared to air, which contained 21 percent... Elam needed irrefutable data collected in a rigorous fashion.  The year was 1952 and Elam was an assistant professor in the Division of Anesthesiology at Barnes Hospital in St. Louis.  he obtained permission from his chief of surgery, Dr. Evarts Graham, to do studies on post-op surgical patients before they recovered from ether anesthesia.  The endotracheal tube was left in place and succinylcholine (used ot keep the patient paralyzed) was continued as a drip.  By blowing into the tracheal tube with his expired air, Elam found that total arterial oxygen saturation could be maintained at 100 percent.  Nine patients were studies and the results were unequivocal: expired air was able to maintain adequate oxygenation.  In his scientific writings Elam called his technique expired-ari resuscitation, but he always thought of it as the "method of Elisha." 
 Surely this was a small sample, but this study was enough to convince the medical society that mouth to mouth breathing, when done effectively, was enough to provide adequate oxygenation. For those grossed out by the procedure, or worried about catching a disease, he invented what he called the Safar S-Tube.

The Safar S-Tube that was inserted through the oral opening into the pharynx.  On the opposite end (the end sticking out of the mouth) was a mouthpiece, whereby the rescuer would provide breaths.  The S-Tube, thereby, acted as both an oral airway and as a means of providing ventilation.

Now there were no obstacles preventing the method from being accepted.  By 1958 Elam and Safar had succeeded in convincing the experts of that era that expired-air resuscitation was far superior to other methods used, and it was accepted worldwide.

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Friday, August 16, 2013

Terms your kids use, but probably shouldn't

The following are terms your kids use, but probably shouldn't.
  • Like (like, I was planning on going to the fair): either you are or you aren't.  
  • Um (I, um, was thinking of going to the fair): It makes you sound unintelligent. 
  • Dude (Dude, I'm going to the fair): It is a lazy word.
  • Yo dog (Yo, dog, I'm going to the fair): people are not dogs
  • Awesome (The fair was awesome)
  • Literally (That fair was literally, like, awesome)
  • Anyway (Anyway, that fair was awesome)
  • Dumb (You are dumb): dumb means cannot speak
  • Idiot (You are an idiot): Idiot means non intelligent
  • Interesting (Wow! That was interesting!):  So what is interesting? What do you mean? I usually use the term "interesting" when someone shows me a painting I think is bad and I don't want to hurt the feelings of that person: I say, "it's interesting." 
  • Any curse word (you are a ________!)
  • Frickin or Fricking (You are a fricking liar!):  It's no better than a curse word
  • Jesus or Jesus Christ:  It's most often used as a curse word, and shows disrespect.
  • Hell:  It's most often used inappropriately
  • Pet Peeve (Saying "you are an idiot" is a pet peeve of mine):  You mean it irritates you?
  • Anyways (Anyways, I liked that movie): There is no such word. 
  • Ain't (You ain't going to the river): I know it's probably in the dictionary now, but it's not a word
  • Epic (Like, that was epic!): It's used incorrectly.  It's a generic term for awesome.
  • My bad (It was, like, my bad): In other words, you made an error.
  • I know (Dad, I know):  You did not know, because I just told you
  • Hate (I hate you): Do you really?
  • Touch base (We need to touch base.): So, what do you mean? phone call? email? text? in person?
  • Nerves (You are on my nerves.): No one can get on your nerves.
  • Yo (Yo, man...): It's the lazy man's way of saying, "May I have your attention."
  • Man or woman (Hey, man, will you come with me): Try "Would you come with me."
  • Sick (Yo, dog, that was sick): You mean 'that was disgusting?"
  • OMG and any other abbreviation (OMG!  Like, I am so disgusted!)  Makes you appear lame to any sophisticated adult.
  • Lame (You look lame, man!) Like, what's your definition of lame?
  • Cool (That roller coaster was way cool): It was in no way cold.
  • Way (That roller coaster, man, was way cool): That word way is way lame, man, and not used right.
  • That (The person that went to the fair was way cool): A person is a who, an animal or a thing is a that.
  • Pig out (At the feast I pigged out.): You mean you ate too much?
  • Fart (I farted): you mean you passed gas, expelled internal gases, or flatulated? 
  • Poop (I pooped): You had a bowel movement (and I did not need to know that) It's a term my 4-year old uses, I don't want to hear it from my older kids.
  • Took a dump (I took a dump): ditto for what I said about poop.
  • Ditto (Ditto what you said); you mean you agree with me?
  • Gay (That's so gay): So what does that mean, anyway? 
One patient of mine said he encourages his children to not say any of the above terms, and instead search for  a better vocabulary.  He says that "improving your vocabulary is easy and FREE; all you have to do is open any book, or look in a dictionary. Better yet, all you have to do is click on Google and do a search, any search (other than Facebook and YouTube)."

He says, "If you want to make a good impression, perhaps as to convince a sophisticated gentleman or woman that you are the best hire, have a decent vocabulary.  Do that and you will be fine. Do dat, and you will find yourself with a bum, low paying job."

This was just one of many interesting discussions I have with my patients.  What do you think?  

Sunday, May 10, 2009

RT Cave Rule #35: Wise Dr.s, Humble RTs

Wicked busy here at the RT Cave. I suppose it wouldn't be so hard if there were two of us here at night, but since it's just little old me all by myself trying to waddle between 17 patients, it makes for a strenuous night.

The short of breath patients, the critical patients in the ER, the one's who need BiPAP, the ventilated patients, and the one's who require a certain degree of RT expertise and critical thinking are the patients who bring joy and pride to the RT. They are the reason most of us chose this profession.

The frustration comes from the other 80% of the job. The frustration comes from the 16 patients who have no need for a bronchodilator every 4-6 hours around the clock. And once our feet are burning from trudging room to room trying to get all these done in a timely manner, the emergency calls us down for a lady in respiratory distress.

"Oh, come on!" The Rt grumbles. Yet he reminds himself that it is not this lady in respiratory distress, the one who requires his time and expertise for the next two hours, that he is mad at. She is the reason he loves his job. It's the critical thinking he does that saves her life that brings him joy.

And, yes, when the doctor wanted to intubate the patient, and the RT thought to say to the wise doctor: "How about if we try BiPAP first?"

But the BiPAP didn't make that CO2 of 89 drop. In fact, the CO2 actually rose to 92. The doctor called and asked to talk with the RT. He said, "If we can't get that CO2 down we will have to intubate. Do you have any ideas?"

The RT was impressed with the doctor. It's not very often a doctor utilizes the wisdom of the RT. And, seizing the moment, the RT knew exactly what to say: "We could increase the IPAP in an attempt to raise her tital volume and blow off the excess CO2."

"Go for it!" the doctor said.

An hour after the the humble RT called in the repeat blood gases to the doctor. The RT said, "Look, here's what I did. I increased the IPAP from 10 to 16 in an attempt to increase the tital volume and blow off CO2. The patient is now getting an estimated tidal volume of 550-600, which fit into the hospital tidal volume protocol of 6-10cc/kg ideal body weight.

"Then," the RT continued, "since the PO2 was fine with the last gas, I decreased the epap from 5 to 4 to get a pressure support of 12 and a little extra tidal volume. That said, the CO2 is down from 90 to 86, the pH is up from 7.29 to 7.31. Aside from that, the patient is awake and alert and orientated on or off the BiPAP. She is not longer in respiratory distress and states she actually feels great now. Oh, and she's also joking with us."

The good doctor said, "Good job! I think we averted a ventilator for now."

The RT's ego jumped from zero to one. But the humble RT had no time to savor the moment, as another page to the ER meant another treatment for a CHF patient. And, hence is the life and times of an RT.

Ego = +1. But the ego of the RT doesn't matter. A doctor being wise and admitting he needed the education, training and wisdom of his RT for a change does not matter. What matters is neither the doctor nor the RT panicked and needlessly intubated the patient.

This is a perfect example of what good can come from all the medical staff working together. And, since we haven't done this in a while, it's time for RT Cave Rule #35.


RT Cave Rule #35: A wise doctor admits when he is to the limits of his medical wisdom and seeks the education, experience and wisdom of RTs. A wise RT will be ready with a veritable option for the doctor, and stay humble if he is right.

Regardless: ego = +1. Current ego status = 1.