Respiratory Therapy Cave

MCAT question #37

2012-05-26T15:50:00.000-04:00

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

Your phone rings at 2 a.m. and you are awakened from a sound sleep. The annoying nurse tells that Mrs. Ranger -- your infamous CO2 retainer -- is in respiratory distress with an Spo2 of 86 percent. She says the RT made the decision to place the patient on a 40 percent air entrainment mask and that brought the SpO2 up to 88 percent. The nurse says the CO2 on admission was 58. A prn ABG was obtained per protocol on the present O2 settings to reveal a CO2 of 65. The patient is now breathing fine, and she's only calling you because hospital protocol instructs the doctor to be called when a patient requires an increase in FiO2. Which of the following choices is the best statement to say to this nurse?

a. "Why do you call me for such B.S. at 2 a.m."
b. "Decrease the oxygen back to 2lpm."
c. "Decrease the oxygen back to 2lpm and tell RT to quit messing with oxygen on my CO2 retainers."
d. "You guys did a good job. Try to keep the sat 88-92 with the lowest oxygen possible. Call me anytime."
e. All of the above except d because RTs are a bunch of useless dummies

Do we learn too much in RT school?

2012-05-25T09:32:00.000-04:00

Your Question: Is it common that the things we learn in RT school are not what we deal with once we start working?

My humble answer: There's always going to be things we cover in RT school that we don't use in the real world. Yet I think this is a good thing. It's good because it helps you with critical thinking. It's better to know the why and the how rather just that it is. This additional wisdom is what separates the neb jockeys from the professional respiratory therapist.

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What is genetic emphysema?

2012-05-23T23:54:00.000-04:00

Other than smoking cigarettes, one of the most common ways a person can develop emphysema is by receiving bad genes from your parents. If you inherit genes that cause alpha 1 antitrypson deficiency you most likely will develop emphysema.

While studying this condition I was surprised to learn that 200,000 people have been diagnosed with this condition, and this makes antitrypson 1 deficiency one of the most common hereditary disorders among Caucasians in the Western world, which includes Europe and the United States. Yet it's believed many who have it are not diagnosed (1).

Alpha 1 Antitrypson is a protein that is produced by liver cells and circulates in the blood and generally effects the lungs and liver. Elastase is a component of white blood cells used to kill invading bacteria and "neutralize invading particles inhaled into the lungs," according to National Jewish Health.

Once the job of elastase is complete, alpha 1 antitrypson inactivates elastase so that it does not destroy lung tissue. In the absense of alpha 1 antitrypson, elastase destroys lung tissue and this results in genetic emphysema.

Once a person has genetic emphysema diagnosis and treatment is the same as for any person with chronic obstructive pulmonary disease (COPD), and you can learn more by clicking here. The only difference is there is a blood test to check for alpha 1 antitrypson and other blood test to check for the gene that causes this genetic disorder.

References:

How passionate are you about your job?

2012-05-20T00:37:00.000-04:00

A good morale is often the key to creating a good work environment. The higher the morale of each respiratory therapist the greater the customer service they provide. Hence, the happier the RT the happier the customer will be.

One study suggests that worker morale is directly related to worker satisfaction. Hence, study researchers might ask you which of the following describes your mood about your job. Are you:

Passionate about your work?
Satisfied with your work?
Engaged in your work?
Apathetic about your work?
Numb about your work?

Based on responses, studies showed the following:

10-29% are passionate about their work; they are completely engaged
60-80% are satisfied with their work but not engaged
10-20% are disengaged; they just work to get a pay check

Disengaged workers feel there is no hope no matter what they do, so they just do what they are asked to do and that's it. Disengaged workers tend to be apathetic, such as is the case with respiratory therapy apathy syndrome.

To keep workers engaged, it's best to involve each member of the department in tasks. Yes, that means that you might be asked to do a certain task, such as teaching oxygen therapy to nurses, or becoming a Basic Life Support educator, or making a presentation at your local respiratory therapy conference.

You also may be asked to write a protocol or hospital policy, or anything that keeps you enganged. Another technique is to have you write a blog such as the RT Cave. Surely you may have no control over your work, yet you will have control over your own projects.

The more you do, the more involved you are, the greater your morale will be. This has a direct impact on your satisfaction, and the happier you are the happier your customers (patients) will be.

Another way to improve your satisfaction is for your boss to ensure you have the best benefit package possible, make sure you get an annual raise for inflation plus bonuses if possible, and to involve you in departmental decision making.

It also helps to get praise. It also helps to be listened to. It also helps when you are respected when you make a recommendation. It also helps when you have automony to use your experience and education to do what's best for the patient.

Yet doing all these things isn't always possible. RT bosses get busy, and they get a lot of pressure from their bosses to mak your RT Cave look good on paper. The end result is you may not get the results you want, and you become apathetic and disengaged.

So, how passionate are you about your job?

(see natural progression of satisfaction)
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MCAT question #39

2012-05-19T17:50:00.000-04:00

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

In 1960, based on a study of four COPD retainers, the hypoxic drive was formed. Since then 300 studies have disproved this theory. At what point are you to admit the medical profession is wrong to continue teaching this theory?

a. Never
b. Never in a blue moon
c. Never in a million years.
d. Never in a million years unless that hot CCU nurse decides to go on a date with you

What is a slug patient?

2012-05-18T10:12:00.000-04:00

Have you seen this patient?

Slug: These are patients who are originally bedridden because they are lazy and unwilling to care for themselves. Yet ultimately they become dependent on the bed due to muscle fatigue.

Many are depressed, and most are obese and have a variety of maladies due to poor self care during their active years. They can be very demanding initially, yet as their body fades they will become completely dependent on you for all their needs, including butt wiping, rolling over in bed, scratching their faces, eating, drinking, and scratching their cheeks when they itch.

In the later stages you can do anything you want to them and they won't care, including putting the patient on a BiPAP mask or even ventilator. Most will even become deconditioned to the pain of needles, and you can put IVs in them without as much as a wince. You can draw labs and ABGs without much trouble from the patient, even though you'll often have trouble obtaining blood on the first poke due to poor circulation.

These patients are quite often full codes so you have to do everything possible to save them. Yet even if they have DNR orders the doctor will insist that you get an ABG even if it's physiologically impossible to feel a pulse and you've already missed 22 times.

They most frequently come from nursing homes. They can be very friendly early on, yet as their disease progresses they will only open their eyes and look at you and smile. It's sad in a way as ultimately you watch as a nice patient fades away due to her own laziness. However, most will not call her on it, not even her own doctor.

Most will also be ordered on aerosolized breathing treatments even though there is no evidence of bronchospasm and the patient never complains of dyspnea. The reason for the treatment is of one of the following reasons:

Doctors don't know what else to do and have to do something, so they order treatments
Audible annoying wheeze due to dehydration
Audible annoying wheeze due to over hydration
Audible annoying wheeze due to secretions in throat
Diminished lungsounds must be due to bronchospasm
In order for the patient to meet criteria for admission and reimbursement
To cover their bases (order sets)
The patient was diagnosed with pneumonia even though the patient doesn't have pneumonia because pneumonia is a reimbursable diagnosis. If patient has a lung diagnosis a bronchodilator must be ordered at all times at a minimum of every six hours.
The doctor wants the RT to assess the patient so he doesn't have to

As their body's slowly wade off they cease even watching TV, and simply spend their time either staring off into space or sleeping. However, they do cheer up and become quite loquacious whenever one of their friends or family members enters the room.

Synonym: A sluggish patient

Antonym: The Spirited patient

Note: This post is a generalization and not a description of any one particular patient. If you work in a hospital or nursing home you will meet many patients who fit this vague description.

What is bronchiectasis?

2012-05-16T23:51:00.000-04:00

Bronchiectasis is a disease that causes the air passages (bronchioles) in the lungs to become abnormally widened or dilated and inflamed or swollen. This makes it so the patient is unable to clear secretions from their lungs, these secretions become abnormally thick, and this creates a breeding ground for bacteria.

This is a condition commonly associated with cystic fibrosis patients as that disease progresses. Usually these patients have to take prophylactic antibiotics to prevent pneumonia, and during exacerbations of their condition IV antibiotics are often required to fight off lung infections.

Exacerbations generally include the following symptoms:

Cough
Increased sputum production
Sputum may be thick and chunky
Sputum may contain blood
Sputum may be colorful and putrid
Short of breath (dyspnea)
Wheezing
Sinus infections (often resulting in sinusitis)

This condition is caused as the result of an infection, often early in life, that causes the lungs to become inflammed and this inflammation becomes permanant. This causes permanant widening of the air passages and future exacerbations occur.

Since cystic fibrosis patients are prone to have this secretions this makes them susceptible to lung infections, and this is believed to cause bronchiectasis. Each progressive lung infection can make the condition worse, and this is why early diagnosis and treatment is essential.

While most cystic fibrosis patients have bronchiectasis, you don't have to have cystic fibrosis to have bronchiectasis.

It's usually the bronchiectasis component of cystic fibrosis that causes these patients to die at a young age. Yet thanks to modern wisdom, better antibiotics and prophylactic care, these patients are now living into their 30s.

Some people do develop this condition later in life, and these patients are also able to live longer with the condition thanks to modern wisdom and better medicines available to treat this condition.

Usually you'll see these patients come to the hospital at least once a year for their yearly recharge. Treatment usually consists mainly of:

Antibiotics to treat infection
Bronchodilators to treat bronchospasm
Mucus thinners to chop up thick secretions
Chest physiotherapy to help bring up secretions
Mucus clearance devices such as chest wall oscillators, Acapella and flutter valves
Underlying condition should also be treated.

Besides cystic fibrosis, there are other conditions that can cause bronchiectasis, including:

Viral infections
Bacterial infections
Tuberculosis
Fungal infections
Immune deficiencies (make person more susceptible to lung infections)
Aspiration (GERD, oralpharyngeal dysphagia)
Rheumatoid arthritis
Lupus
Primary ciliary dyyskinesia
Alpha 1 antitrypson deficiency
Lung tumors
COPD

Diagnosis may involve a patient assessment, medical history, cat scan of the lungs, and pulmonary function testing, and consideration of any underlying medical conditions such as listed above.

References:

National Jewish Health

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How can I manage asthma around smoke?

2012-05-15T11:54:00.000-04:00

The following Q and A sequence is from healthcentral.com/asthma:

Your question: How can I manage asthma around smoke? I am currently having trouble managing my asthma because of the brush fires that are around my neighborhood. Do you have any advice for management when there is a trigger you cant control?

My humble answer: That's one of the things that's kind of crappy about having asthma: there are certain things beyond your control. It's not like you can walk up to all your neighbors and tell them all to stop burning wood. The same can be said of backyard campfires and bar b ques.

The same can also be said of allergens. You can close all your windows and sit in a hot and stuffy house if you want, but tree, grass and ragweed pollen still have a way of getting indoors. And no matter what you do, you'll have to go outdoors at some point.

At least for allergies there's a few medicinal options that aren't avaiable to prevent smoke induced asthma

Of course another option may be to move to a neighborhood that bans brush fires, camp fires and the like. However, from my own personal experience, such asthma triggers will find you no matter where you live.

The best advice I can give is to try to stay indoors as best you can on days the air is filled with smoke. The only other really good option is to continue to do what you've already been doing, and that's work with your doctor to obtain good asthma control.

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Does McDonalds trigger asthma?

2012-05-14T08:42:00.001-04:00

The following post was originally published at healthcentral.com/asthma on May 16, 2011:

"Can eating high fat foods trigger asthma?"

American's love Big Macs, Whoppers, French fries, onion rings and deep fried chicken. These are convenient foods that are simply delicious. Yet the old saying goes, "If it tastes good, it's probably not good for you."

Now we already knew such high-fat foods are bad for your heart. Yet new evidence suggests they may also be bad for your lungs.

A study completed by Australian researchers in 2010 tested asthmatics before and after eating a meal, and determined that lung function was worse after eating a high-fat meal.

If that wasn't bad enough, the study also concluded that high-fat foods also made it so asthma rescue medicine (like Albuterol) worked less well.

Scientists aren't sure why this is, yet there are theories. One theory suggests that your asthmatic immune system might recognize saturated fat as an enemy and promptly acts to rid it from your system.

This response results in an increase in markers of inflammation such as leukotrienes and hystamine, and these increase inflammation in your respiratory tract. This causes muscles lining your air passages to constrict, and thus an asthma attack is the result.

Perhaps due to the increased inflammation, asthmatics who used their rescue medicine after eating a high-fat meal did not get as much relief as those who ate low-fat meals. Likewise, lung function improved less in subjects who used their rescue medicine after eating high-fat meals.

Obviously asthma rates have increased incrementally in the U.S. and other western nations over the past 20 years. This new theory suggests one of the factors might be the high-fat foods we put into our bodies.

I've also read other studies that suggest that if you're exposed to something that triggers inflammation in your lungs, and exposed to it often enough, the inflammation may become permanent. Thus, asthma is developed.

It's studies like this that remind us that the way we eat may determine the lives we live. If you want to prevent asthma, or prevent an asthma flare, it may be a good idea to eat a healthy diet.

Does that mean we asthmatics should never eat great tasting, convenient and high-fat foods? Absolutely not. Yet it's good to know the facts, and it's good to know what foods might not be good for us.

The natural progression of satisfaction

2012-05-13T20:16:00.000-04:00

I remember way back before I was hired as an RT, back when I had a new job every summer. I remember observing how the people who worked for five or more years tended to be apathetic and disengaged from their work. These people spent a lot of time complaining.

I saw the same thing when I was hired as an RT. My coworkers acted like they hated their work. They often complained and were slow to get up when their pagers went off. I didn't understand this because I was absolutely passionate about my work. I even remember thinking once I loved my job so much I could work every day.

What I observed was what is referred to as the natural progression of satisfaction. Most of the people who complained, I observed, were those who had worked for over five years of the same job, doing the same tasks, caring for the same customers.

Those who were the happiest were those who were new on the job -- like myself. Little did I know my own satisfaction would remain high for a while, yet it too would slowly dissipate. Yes, I too became infatuated with apathy and I too became disengaged in my work.

This disengagement results in a reduction in the quality of your work. It's something bosses want to reduce, and therefore it's been studied by experts.

When we first get a job there is a new excitement. We are learning new tasks and we are excited as we get better and faster at it. We feel as though what we do matters, and the better we are at it the more satisfied we become. The quality of our work is high. Our customers are satisfied with our work.

Yet then time happens. What was once challenging now becomes a redundant procedure. You become educated and learn some of what you do isn't needed. You learn shortcuts that make the job easier, and you start to simplify your speech so each customer hears the same things from you. Instead of treating each customer unique, you treat them all the same. You, in essence, become an automaton.

What happens is your job becomes routine. Routines result in shortcuts. Short cuts cause quality to be diminished. Instead of feeling the need to run to a code you walk. You are relaxed when you should feel an adrenaline rush. When a sense of urgency is replaced by routine this is akin to working in a factory spending the entire day wrapping paper around cigarettes.

Think back to when you first got your job as an RT. When your pager went off you were eager to see what your message was. You rushed to complete the job, and you were eager to provide your services. When you were done you were eager to discuss what you did with your coworkers. You cared about your work. You were proud.

Then over time, after learning that many of the patients you care for don't even need to be in the hospital, after realizing most doctors have no clue what a bronchodilator does, and after realizing most nurses want breathing treatments for all dyspnea, the thrill of your job wears out. You start working just so you can get a day off. When you do work you can't wait till the end of the day.

We still care about our patients, yet much of our concentration has shifted from what we can do to benefit our patients to just doing your job as fast as you can so you can get back to your game on the Internet. You are good at what you do, and too good. The task has become routine. You take shortcuts, and the quality of your work diminishes.

Many RT bosses have no clue about the natural progression of satisfaction. Many know about it because they were RTs once too, yet because they are now above it they don't care. Others learn about it and work hard to try to prevent it. They want to prevent it because they want quality to remain high.

Quality comes from pride. So the goal here is to keep RTs proud of their jobs. This reminds me of a recent encounter I had with my boss. I was called to assess a patient who had aspirated and was now short of breath, and I advised the nurse that a breathing treatment wouldn't be of any use.

Regardless of my recommendation, 20 minutes later my pager went off with the message: "Breathing treatment needed on that patient STAT!" My boss happened to be standing next to me when my pager went off, and I said, "Sometimes instead of thinking nurses just order breathing treatments."

"You should be proud of your job," my boss said. "You should want to do things you're asked to do."

I said, "I would be proud if my recommendations were respected. When I recommend one thing and the nurse completely ignores what I recommend, that makes me not proud. It makes me feel disconnected. It makes me feel that I don't matter."

So what can my boss do to keep RTs proud of their work? I think the simplest thing to do is to listen to what we say, and respect what we recommend. We all spent two years in RT school to become experts on the lungs and how to treat respiratory diseases. We spend every working day with respiratory patients developing skills.

I think all that is needed to make an RT proud is to respect us. All we want is to be treated like the professionals we are.

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MCAT question #40

2012-05-12T03:00:00.000-04:00

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

Which is the following cases presents the best example of the hypoxic drive theory:

a. COPD retainer on 100% FiO2 for six hours in the ER to maintain an SpO2 of 90%. The patient is AAOX3 and denies shortness of breath.
b. COPD retainer on 2lpm to maintain an SpO2 of 86%. The patient is cyanotic and complains of dyspnea.
c. The patient is on 35% air entrainment mask to maintain an SpO2 of 86. The CO2 rose from 56-62 after the mask was placed on the patient. The doctor instructs the RT to decrease the FiO2 on the mask to 30%
d. All of the above
e. Both b and c

What do RTs really do?

2012-05-11T12:00:00.000-04:00

The American Association for Respiratory Care (AARC) lists the following tasks that respiratory therapists do:.

Diagnosing lung and breathing disorders and recommending treatment methods.

Interviewing patients and doing chest physical exams to determine what kind of therapy is best for their condition.

Consulting with physicians to recommend a change in therapy, based on your evaluation of the patient.

Analyzing breath, tissue, and blood specimens to determine levels of oxygen and other gases.

Managing ventilators and artificial airway devices for patients who can’t breathe normally on their own.

Responding to Code Blue or other urgent calls for care.

This list is an ideal list of the tasks RTs do. For all you RTs out there in the real world, how accurate do you think this list is? Does this paint an accurate picture to prospective RT students?

Based on your responses I will update this list so that it is accurate if necessary. So what do you think?

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Misinterpreted study proves placebo effect

2012-05-09T05:46:00.000-04:00

Once again, folks, we have a medical study misenterpreted by the so called experts. They are now said to have proven "inhaling Albuterol helps asthmatic lungs work better, yet patients who get it don't feel much better than those treated with a placebo inhaler." That's the results of a study, and they have totally blown it.

Thankfully you have me to give you guys an accurate analysis of these study results, because they show something the researchers have completely missed.

So you have a patient come into the emergency room with dyspnea and wheezing, and the doctor automatically orders up an Albuterol breathing treatment. Upon your pre and post treatment assessment the patient neither looks better nor worse, yet then you pose the question: "Do you feel better?" The answer is almost always a resounding, "Yes! I do feel better." Yet you often wonder: Is the patient accurate?"

My theory has always been that many patients say they feel better when they actually don't. In fact, many times a patient will say something like, "Yeah, my breathing is better. My nose isn't as stuffed as it was before the treatment." Of course then you know the treatment only had a perceived effect.

A study was done recently and reported in the New England Journal of Medicine that studied the perceived benefits of Albuterol on subjects, half that were given actual Albuterol and half that were given a placebo. A good review of this study was written by Reuters "Treatment, not medicine, helps asthma patients feel better: study."

The test was only done on a small sample of 39 mild to moderate asthmatics. Of those who received Albuterol 50 percent reported improvement. Of those who received a placebo just about 50 percent reported improvement.

Thus, the researchers conclusion, as the headline to the Reuters post suggests, is that of the placebo effect, whereby just the mere presence of a medical care worker is all that's needed to help asthmatics feel better. They conclude that the presence of a doctor -- or in this case the RT -- is just as beneficial as acupuncture.

Yet I think the researchers have totally blown these results. I think these results tell a completely different story than the researchers are telling us, and this is not surprising. I think the conclusion we should be drawing from this study is that patients have no clue whether or not they feel better. I think these asthmatics only had a perceived benefit from Albuterol. I think what these results tell us is the patient is unreliable.

This goes back to common asthma wisdom that says that the only true way to determine if an Albuterol nebulizer has improved lung function is to either to a pre and post pulmonary function test or to have the patient use a peak flow meter. To go by what the patient says isn't enough.

Obviously if you have an asthmatic who is short of breath and the Albuterol provides instant relief in breathing then the patient is going to be accurate when he says, "I feel better." Yet if the patient's dyspnea and wheezing is caused by a cold, or heart failure, or pneumonia, or lung cancer, or rickets, the Albuterol will have no effect, and yet the patient will get the placebo effect.

As to be expected, the researchers got it all wrong. Yet your humble RT here is once again proven right. I've written before that Albuterol should be renamed Palbuterol because the medicine may not have any effect, but the presence of an RT will.

Once again the results of a study are misinterpreted. Thankfully your humble RT is on the job because these study results prove that Albuterol doesn't cure all dyspnea and wheezing.

Advair Diskus versus Advair HFA

2012-05-08T17:26:00.000-04:00

Your Question: The Dr. told me that there is now an arosol puffer for advair now. Can you tell me about it, please?

My humble answer: We have covered this topic to some extent, and you can read more here. Of the studies done so far regarding the new HFA propellant, it appears it takes the medicine deeper into the lungs than the old CFC propellent and the dry powdered version of inhalers. While studies are ongoing, and so the debate is ongoing, some asthma experts recommend switching to the HFA version of a medicine if you continue to have trouble with your asthma. Personally, I'd recommend trying the DPI first if you have uncontrolled mild-moderate asthma, and then if that doesn't work try the HFA version.

Yet the main reason for making an HFA inhaler, I think, is to provide another option for asthmatics who have trouble generating enough flow to suck in the medicine using a Dry Powder Inhaler. With the HFA inhaler you squirt the device and the flow is automatically generated, and all you have to do is inhaler.
Regardless, studies seem to show the medicine is at least equally as effective as the Advair Diskuss and is another option for us asthmatics to try. For more information regarding the Advair HFA check out this link.

What happens when asthma goes untreated?

2012-05-07T15:21:00.000-04:00

The following post was originally published at Healthcentral/ asthma on May 3, 2011:

What Other Medical Problems Can Occur When Asthma is Untreated?

It's said a gallant asthmatics can live a normal, active life. Yet what happens to the goofus asthmatic who doesn't treat his asthma?

The truth is, many goofus asthmatics are lucky and are able to escape without asthma trouble, yet far too often they end up making frequent visits to their doctor, or to the local emergency room for asthma flares. Sometimes they simply stay home and tough it out like our Martyr Asthmatic.

While it's rare, untreated asthma can lead to serious medical problems that can make asthma even harder to control. Consider the following worse case scenario.

Joe Goofus refuses to see his doctor, and he is too dog-gone lazy to take his Advair discus, or maybe he simply forgets to take his medicine. He also refuses to avoid his asthma triggers. He's simply a bad asthmatic patient.

So after sifting through dusty boxes in his basement, he makes yet another rushed trip to the emergency room. His asthma is so bad this time that he needs to be admitted to the hospital. He's put on systemic corticosteroids.

Finally after a couple weeks in prison he's released on good behavior, and he once again quits taking his asthma medicine. He's short of breath for two weeks before he finally decides to seek help.

He's readmitted to the hospital and put back on inhaled corticosteroids. The cycle continues.

The following are the risks of untreated asthma:

1. Severe Asthma: Asthma that is not diagnosed and treated agressively with asthma controller medicines can increase the risk for lung scarring. This is permanent damage to your lungs that can make you always feel short of breath. It also makes it so your asthma might not be reversible when you use your rescue medicine (Ventolin or Xopenex). This type of asthma is called severe, persistent asthma, Chronic Obstructive Pulmonary Disease (COPD) or what I like to call hard luck asthma.

2. Steroid side effects: If Joe needs systemic corticosteroids long term to control his asthma, serious side effects can occur that can make it even harder to manage his asthma, such as:

Fluid retention: Swelling in your legs
Increased blood pressure
Mood swings: Can effect how you manage your asthma
Weight gain: Chemicals released from fat can trigger asthma, plus obesity makes it even harder for you to get the exercise you need to manage your asthma, and keep your heart and lungs strong
High blood sugar: You'll now have diabetes that needs to be controlled
Infections: Can you imagine if you also developed pneumonia?
Thin skin: It easily bruises and is slow to heal.

3. Anxiety/ stress/ depression: These can make it even more difficult for Joe to manage his disease, although treatable.

4. Muscle wasting: His lungs become so bad he's unable to get the exercise he needs. This can greatly complicate caring for Joe. It can lead to obesity, which complicates things even

5. Respiratory Failure: If Joe doesn't seek help, his asthma attack might get so bad he simply poops out. This is a serious complication that must be treated immediately. It can lead to death.

While what I describe here is the worse case scenario, I've seen it. It's basically self-induced hardluck asthma. It's not pretty. It can also be avoided.

It's much better to be a gallant asthmatic. It's much better to be properly diagnosed and stay on a treatment plan.

Asthma experts have long said asthma is easiest to control when it's diagnosed right away and treated aggressively. Now you know why.

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The consequences of thought

2012-05-06T13:21:00.000-04:00

Quite often -- too often -- the process of thought gets us into more trouble than it's worth. Thought often results in judging. If you don't judge, then you'll be forced to accept the status quo. Yet if you judge you'll be judged in return as mean. So what do you do?

We RTs often "think" treatments are of no use. We are ordered to do one on a patient with an audible wheeze yet no shortness of breath, and we "think" to explain to the nurse why the treatment isn't needed. The process is like trying to drum a nail into a brick. By the time you're done you could have already been done with the treatment and back in the RT Cave.

Progress, thought, is never made without some form of thought, and then the reacting to that thought. Without thought we'd have no cars, no assembly line, no electric light bulb, no Ventolin.

Yet if everyone reacted to every thought ("boy, does she have ugly hair today!") peace and tranquility would be hard to keep. So some thoughts are best kept secret. If you don't believe me, just ask the person who can read minds. He went insane.

Thought can be good, and for proof just read about Ben Franklin, Thomas Edison, Henry Ford, Einstein, and Stephen King.

Yet thought can also get you into trouble. For example, I thought it was a good idea to talk to my boss about all the "useless" holter monitors that were being ordered in the ER. I thought it was a good idea to tell him holters are not an emergency procedure and shouldn't be ordered in the ER.

Yet, lo and behold, my thought got me into trouble. Instead of telling doctors that holter monitors were no longer to be ordered in the ER, our boss ordered 4500 new holter monitors to make sure we have enough to cover all the new holter monitor orders. Never again will we be able to get out of work by telling ER we don't have any holter monitors.

My thought got us into a heap of more work. In this way, it's often better to shut up and put up with than to think. It's better to think yet muzzle your mouth. It's better to do and shut up. It's better to just do the dog gone treatment than bitch and wine and educate. Yes, it's better to shut up thought than to teach facts -- sometimes.

I think through the course of life this is a lesson we all learn at some point or another. Yet the ones who ignore this lesson are the ones who are your inventors, your protocol creators.

You know what thought did. Thought believed he was on the pot when he peed in his bed. That's what thought did. Thought got him in trouble.

Thought could get you fired. Thought can get you a raise, thought can get you rich, yet thought can also get you fired.

So you thought it was a good idea to write a blog being honest about the profession of RT, yet if your boss ever finds out you could be fired. To heck with the first amendment. To heck with all the people who yearn to learn the truth. To heck with them all. Who cares about what's needed. Bah humbug on need.

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ISO bans use to RT cheat sheets to improve quality

2012-05-05T12:41:00.000-04:00

Would you believe I was told by my boss I can no longer carry with me a cheat sheet in my pocket. I was stunned, and I decided I was still going to carry it with me and just not tell my boss. It's this type of lying that's been deemed necessary by the International Commission of Idiocy.

According to my boss I can carry cheat sheets with me, but only ones that are officially approved by the powers that be. You can carry a book like "Dana Oach's Practitioners Pocket Guide to Respiratory Care," but who wants to carry an entire book around with them? Not me.

(Here's my cheat sheets)

So a few years ago I created a cheat sheet of my own, shrunk it down to size, and carry it with me in my pocket. I even created a key to help me decide what tidal volume is best for which patients. Doctors love it so much they even request to see it often, and my coworkers all have one of their own.

The issue that I have is one day recently I updated my cheat sheet and set it out because one of my coworkers and I were trying to decide what color paper would work best. My boss came out and said, "What you guys up to?'

It's not like we could lie, or felt we needed to. I said, "We're deciding what color my cheat sheets should be."

"Oh," he said, and picked one up. "This is some useful information. I would have loved to have one of these when I was an RT."

"Then take one," I said. "Or when we get these laminated you can have one."

He paused a moment, as though mulling it over, then said, "Well, you can't use these, you know."

He was joking of course, right? I thought. Then I said, "You're joking, right?"

"No. ISO has a policy that only sheets approved by the forms committee can be used or in possession of any person who is working?"

"Why would they come up with such a stupid policy?" my coworker said.

"Because," my boss answered, "they wanted to improve quality. This is a quality improvement polity. If the hospital is sued because you used information on your cheat sheet, and what's on your cheat sheet is not approved by the hospital, you could be in trouble."

"Yes," I said, "but if the patient died because I relied on my memory to set a too high tidal volume on, say, a neonate, then we will all be sued and a baby will be dead. So my cheat sheet is made to prevent such a thing from happening. My cheat sheet is made to prevent idiocy. So by ISO telling me I can't carry my cheat sheet to improve quality may have a reverse effect: It may create idiocy."

"In other words," my coworker said, "It's poppycock."

As it turned out, my boss could not get my cheat sheets approved by the forms committee because many of the formulas and calculators that I created and used are ones that I made up myself or found useful from other therapists. Many aren't in Dana Oach's book.

So this is a perfect example of what would never happen if I were running the hospital, and it goes against rule #2: Try something new. Often. Keep whatever works. You can view my keys a successful RT Cave here. You can view the old version of my cheat sheets here. I hope to have the new one up soon (yet don't show your boss).

MCAT question #41

2012-05-04T21:36:00.000-04:00

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

A nurse calls and says the patient in room 234 doesn't look good. You say, "Why are you calling me at 2 a.m. Two hours later the nurse calls and says, "The patient died because you didn't do anything." What do you do next?

a. Run to the corner market and grab a bottle of scotch
b. Drive to the liquor store and purchase a bottle of whisky and a 2 liter of coke.
c. Drink the 30 pack of Natural Ice in your refrigerator
d. Take a hit of the joint stuffed in your glove compartment
e. Be a man and admit you made a mistake.
f. a, b, c, d but not e because we doctors never admit mistakes.

The Tobacco Atlas: Smoking causes preventable deaths

2012-05-03T15:27:00.000-04:00

RTmagazine.com, "Globally, Tobacco-related Deaths Have Nearly Tripled Since 2002," reports on the latest tobacco statistics mentioned in the latest, and 4th, edition of The Tobacco Atlas. The following is the latest wisdom:

1. Tobacco is responsible for 15% of male deaths worldwide

2. Tobacco is responsible for 7 of female deaths worldwide

3. Tobacco is a risk factor for the four leading causes of death

Cancer
Heart Disease
Diabetes
COPD

It's interesting anyway. According to the article, the Tobacco Atlas is a book that documents the facts about smoking, and how the smoking industry is marketing a product that causes preventable deaths.

To read more check out the links above.

What is an Ambu-bag?

2012-05-02T12:05:00.000-04:00

A standard disposable AMBU-bag

An Ambu-bag is a bag connected to a mask and is used to breathe for a patient when the patient is not breathing on his own. The mask is placed over the patient's face and the bag is squeezed to provide a breath.

Ambu stands for Adult Bad Mask Unit. Other names include positive pressure ventilation or bag valve mask. When you are using the bag you are said to be bagging.

These devices are on every crash cart. (to lean what a crash cart is click here). They are also in many patient rooms where a patient might stop breathing. They are needed when a patient's breathing is inefficient to blow off CO2 or if the patient's lungs are inefficient at getting oxygen from the air to tissues of the body. They are also used during some surgical procedures during short operations.

The bags are usually connected to flow meters with oxygen tubing, and most deliver 75 to 100 percent oxygen. In hospitals these bags are used instead of doing mouth to mouth respirations.

The AMBU bag is actually one brand, although the name has become rather generic. The original bag was designed in 1953 by a German doctor. Stay tuned, because starting in 2013 I will publish the history of artificial respiration. You can get a sneak peak here.

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The link between high fat foods and asthma

2012-04-30T13:30:00.000-04:00

The following originally appeared at Healthcentral.com/asthma on May 16, 2011.

Can Eating High-Fat Foods Trigger Asthma?

American's love Big Macs, Whoppers, French fries, onion rings and deep fried chicken. These are convenient foods that are simply delicious. Yet the old saying goes, "If it tastes good, it's probably not good for you."

Now we already knew such high-fat foods are bad for your heart. Yet new evidence suggests they may also be bad for your lungs.

A study completed by Australian researchers in 2010 tested asthmatics before and after eating a meal, and determined that lung function was worse after eating a high-fat meal.

If that wasn't bad enough, the study also concluded that high-fat foods also made it so asthma rescue medicine (like Albuterol) worked less well.

Scientists aren't sure why this is, yet there are theories. One theory suggests that your asthmatic immune system might recognize saturated fat as an enemy and promptly acts to rid it from your system.

This response results in an increase in markers of inflammation such as leukotrienes and hystamine, and these increase inflammation in your respiratory tract. This causes muscles lining your air passages to constrict, and thus an asthma attack is the result.

Perhaps due to the increased inflammation, asthmatics who used their rescue medicine after eating a high-fat meal did not get as much relief as those who ate low-fat meals. Likewise, lung function improved less in subjects who used their rescue medicine after eating high-fat meals.

Obviously asthma rates have increased incrementally in the U.S. and other western nations over the past 20 years. This new theory suggests one of the factors might be the high-fat foods we put into our bodies.

I've also read other studies that suggest that if you're exposed to something that triggers inflammation in your lungs, and exposed to it often enough, the inflammation may become permanent. Thus, asthma is developed.

It's studies like this that remind us that the way we eat may determine the lives we live. If you want to prevent asthma, or prevent an asthma flare, it may be a good idea to eat a healthy diet.

Does that mean we asthmatics should never eat great tasting, convenient and high-fat foods? Absolutely not. Yet it's good to know the facts, and it's good to know what foods might not be good for us.

Delayed gratification

2012-04-29T07:43:00.000-04:00

I am one of many who will contend that one of the problems with our society, and why the economy is doing so poorly lately, is that so few Americans believe -- or even comprehend -- the idea of delayed gratification.

We live in a society where we want everything, and we want everything now. We want the best house and the best car and the best toys for our kids and the best toys for ourselves. Many of us are even willing to mortgage everything we have in order get all this stuff.

Delayed gratification, defined, means that you do just the opposite: you wait. You wait to buy something until you can pay cash for it. In this way, you can get twice as much and enjoy it twice as much.

Yet many of us can't wait. We think we need things right now. This was the topic of a research project completed in the 1960s and 1970s (and discussed here at science daily) where pre-school kids were given a marshmallow and told if they wait five minutes before they ate it they could have another marshmallow. "Some of the children resisted, others didn't."

A new study followed up with the kids tested in the original study and the results showed that the same kids who resisted eating the marshmallow when they were kids showed that they were still skilled at delayed gratification as adults.

Kids who couldn't resist the temptation to eat that marshmallow (or cookie, or candy bar) as kid were equally as likely to be unable to resist the temptation of immediate gratification as an adult. Which almost makes one wonder if the skills of gratification are inert and genetic as opposed to environmental.

Of equal interest, the study showed this:

Brain imaging showed key differences between the two groups in two areas: the prefrontal cortex and the ventral striatum.

Researchers say this is the first time they've found "specific" brain differences associated with gratification. This might help them, they contend, to learn more about and how to treat people with addiction -- like addiction to stuff.

I learned about the above study from this article in the Blaze.

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STAT: A word that is often abused

2012-04-28T02:48:00.000-04:00

The word "STAT" comes from the Latin word staim which means immediately. So stat is essentially an abbreviation of the old word. It's common for the English to be lazy with speech, and thus is how the word stat was formed.

Proper use of the word is either capitalized or not capitalized.

Essentially, when someone is called STAT it means that person is needed immediately. Unfortunately, however, the word "immediately" does not denote what the person is needed for. So you can be called STAT because your services are desired to save a life, or you could be called so the doctor can get his EKG results quick so he can see it before he goes home for dinner.

Ideally you'd think the word STAT would be used for life and death situations, such as the following. :

RT STAT to ER..... we have a patient in respiratory distress
RT STAT to 244.... we have a patient in V-tach
RT STAT to ICU... we have a patient with a heart rate of 27
RT STAT to ER... we have a patient who can't breathe

Realistically, the above plus the following are more likely to occur in tandem:

RT STAT to ER.... EMTs are 20 minutes out with a cardiac arrest
RT STAT to 244.... Dr. Jones wants an EKG done before he goes home, pt is fine
RT STAT to ambulatory surgery... Dr. wants pre-op EKG done
RT STAT to CCU... RN wants EKG to see what rythm patient is in

Actually, I have recent pages such as the following:

STAT EKG in 2234 in two hours
STAT ABG in an hour on the vent patient

With such a vague definition, and with such frivolous use of the word statim or STAT, the word has lost much of it's luster and RTs have become deconditioned to the word. When an RT may be needed immediately, he may be inclined to finish his last bite of steak before sauntering to where he's needed.

He may also be written up for responding to a code overly relaxed and in a non-urgent manner.

What is intubation?

2012-04-27T17:27:00.000-04:00

Intubation is where we insert an endotracheal tube into the airway of a patient to the lungs in order so that we can breathe for that patient. (to watch a video click here)

Indications for intubation may include:

1. During surgery. Your breathing may be stopped with anesthetic medicine and your breathing will be assisted with a ventilator.

2. Drug overdose: The patient took medicine that made him so relaxed that he is in danger of vomiting and inhaling that vomit (aspiration). In this way, intubation may be indicated to protect the patient's airway.

3. Neuromuscular paralysis: Some diseases cause the patient to be unable to breathe, and in these cases the patient will require intubation. If the disease is permanant or long term, a tracheostomy may be inserted.

4. Trauma: The patient has been in an accident and is unable to breathe on his own. In these cases intubation may be indicated.

5. Labored breathing: The patient has a disease like asthma, COPD, lung cancer, pneumonia, heart failure, etc. and is having severe trouble breathing. We can intubate these patients so we can breathe for them while we work our magic to fix the underlying cause.

6. Heart attack or head trauma: In these instances, we may need to assist the patient with their breathing so that we can rest their bodies in order to allow our medicines to work their magic.

Most intubations are short term, just in long enough until the surgery is complete, or until the disease process is resolved. When a patient is intubated the patient will either be ventilated (breathed for) by an Ambu bag or a ventilator.

When this tube is removed it is called extubation.

What is an ambubag? (coming soon)

What is a ventilator? (coming soon)
History of respiratory therapy (coming soon)

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Do Rapid Response Teams work?

2012-04-26T15:54:00.000-04:00

Hypothesis: I personally believe that the more people caring for a patient, and the more people assessing the patient, the better off the patient will be. It is for this reason I think Rapid Response Teams are a good method of preventing patients from going into respiratory and/or cardiopulmonary arrest, and thereby improving patient outcomes by preventing the need to transport patients to the Critical Care Unit (CCU).

Question: Do Rapid Response Teams really work? This was a question recently taken up by RTmagazine.com, "Are Rapid Response Teams the Answer?" The article, written by Michael V. Frey, RRT/ NPS, creates several good arguments that the answer to the question may be no.

What is a Rapid Response Team (RRT)? It's a team of experts who respond to the patients bedside when the patient doesn't look quite right to the attending nurse or physician. The team consists of CCU nurse, Nursing Supervisor, Respiratory Therapist, Physician (if one is available) and the patient's nurse. The goal is to be proactive and do what is necessary to prevent the patient from getting worse.

Why were RRTs believed to be a good thing? According to Frey

1. Most floor nurses lack critical care experience

2. Some nurses were hesitant to do proactive therapies without a physician's order. This is important because sometimes it takes a while for the physician to call back, and the patient needs something done right now. For our small town hospital, I think this was the key to forming an RRT. There were many times a nurse wouldn't treat the patient that needed immediate attention just because she didn't want to do something without an order. RRTs eliminated this, and the end result has prevented such patients from needlessly ending up in the CCU. This I would consider the most valid reason for an RRT.

The following studies seem to show RRTs work, as mentioned by Frey:

50% reduction in the occurrence of cardiac arrest outside the ICU
17% decrease in the incidence of cardiopulmonary arrests (6.5 versus 5.4 per 1,000 admissions)⁴;
Severe postoperative adverse events (ie, respiratory failure, stroke, severe sepsis, acute renal failure) reduced by 58%⁵;
Emergency ICU admissions reduced by 44%⁵;
Postoperative deaths reduced by 37%, and mean duration of hospital stay decreased from 23.8 to 19.8 days in surgical patients⁵; and
There has been a decrease in the number of unnecessary transfers to a higher level of care by a mean of 30%.⁶

The argument against RRTs: (According to Frey)

1. RRTs are a band aid solution to a bigger problem of nurses not understanding the needs of their patients.

2. Some patients are on the medical/ surgical floor, or step down unit, only because there are no beds available in the CCU. It's these patients who are at greatest risk for deterioration.

3. Due to cost cutting, some patients are moved our of CCUs and to step down units. These patients are also at high risk for deterioration.

Conclusion; I think the general conclusion is that RRTs work. My experience with them is they work, and I noted one very good reason above: At a small hospital, we don't have physician coverage 24 hours a day, and therefore RRTs sort of fill the gap between observation of a deteriorating patient and communication with the physician.

Surely, however, there are methods that could be improved. For example, if the CCU nurse already has several critical patients, it's difficult for that person to be pulled away from his already critical patients to care for a patient of another nurse. However, all in all, I think the teams are working, and the statistics show they are working.

What do you think?