Respiratory Therapy Cave

Singulair: A Medication That Works for Me, Despite the Controversy

2026-05-20T17:32:00.000-04:00

It’s honestly hard to write about Singulair.

Any time I’ve mentioned it in asthma groups, the conversation can turn quickly. People share heartbreaking stories about serious side effects, including suicide. Those stories matter, and they deserve to be heard. Losing a child is unimaginable, and I don’t take that lightly.

At the same time, those stories can make people afraid to try a medication that might actually help them. The concern around Singulair is real enough that it now carries a black box warning. But it’s also true that the research hasn’t clearly established a direct cause-and-effect link in every case. Like a lot of medications, it comes down to weighing risks and benefits.

All I can really do is speak from my own experience.

For me, Singulair has worked very well.

Before I started taking it, spring was rough every year. I was constantly sniffling and sneezing, and it felt like I was always trying to stay one step ahead of my symptoms. About 15 years ago, a doctor told me he didn’t think most people noticed much difference with it, so he suggested I could stop. I did, and for a couple of years I got by without it.

At the time, that was fine with me. It was still under patent back then and cost about a dollar a pill, so I wasn’t exactly eager to keep taking it.

Then one summer, my allergies hit hard again. I was going through Sudafed like crazy—probably a box a week—and still felt miserable. One night, I woke up feeling awful and realized I was out of everything. The only thing I had was an old Singulair tablet.

So I took it.

Within about 20 minutes, I felt noticeably better.

That was enough for me. I went back on it and haven’t stopped since.

I understand the concerns. I really do. But I also know what it’s done for me. What frustrates me is that some people who might benefit from this medication may never try it because the conversation around it has become so one-sided. Like anything in medicine, it should come down to an informed decision between a patient and their provider.

Dr. Creed: The Krebs Cycle Theory of Oxygen (2026 Edition)

2026-05-20T12:03:00.004-04:00

Warning: What follows is top secret information recently leaked to me from one of the nation’s most prestigious pulmonologists at a highly respected teaching institution. Read at your own risk. This is not edited.

The following is an excerpt from a lecture given by Dr. Ven Tolin, MD, PhD, MBA, at some point in the recent past.

Warning: What follows is top secret information recently leaked to me from one of the nation’s most prestigious pulmonologists at a highly respected teaching institution. Read at your own risk. This is not edited.

The following is an excerpt from a lecture given by Dr. Ven Tolin, MD, PhD, MBA, at some point in the recent past.

Transcript:


<pre style="font-family: Courier New, monospace; font-size: 14px; line-height: 1.4;">

Read at your own risk. This is not edited.


The following is an excerpt from a lecture given by
Dr. Ven Tolin, MD, PhD, MBA,
at some point in the recent past.


                         T R A N S C R I P T

</pre>

It has come to our attention that respiratory therapists continue to express concern when physicians lower oxygen on patients who appear, at least on the surface, to require it.

This is understandable.

RTs are trained to focus on things like oxygen saturation, work of breathing, and basic human survival. However, what they often fail to grasp is the deeper biochemical strategy at play.

Today I will once again explain why reducing oxygen remains one of the most effective ways to manage elevated CO₂ levels.

It all comes down to the Krebs Cycle.

You may remember this from your early training, although it is unlikely you fully understood it. Oxygen is required for aerobic metabolism, and aerobic metabolism produces CO₂.

So if you think about it:

More oxygen leads to more metabolism.
More metabolism leads to more CO₂.

Therefore, if a patient has too much CO₂, the logical solution is simple:

          Lower the oxygen.

At this point, the RT may begin to object.

They may say things like, “The PaO₂ is 47,” or “The patient looks terrible,” or even “They need oxygen to survive.”

These are surface-level observations.

We must think deeper.

By lowering oxygen, we limit aerobic metabolism and therefore reduce the production of CO₂ at its source. In this way, we are not just treating numbers—we are solving the problem at the cellular level.

In fact, one could argue that the most effective way to eliminate CO₂ is to eliminate the conditions required to produce it.

RTs often struggle with this concept.

They may quietly increase the oxygen when you leave the room. They may document concerns. They may even attempt to explain physiology.

Remain calm.

You are the physician.

If necessary, place a note in the chart stating:

          "DO NOT INCREASE OXYGEN UNDER ANY CIRCUMSTANCES."

This usually restores order.


A word of caution: do not attempt to fully explain this theory to a respiratory therapist. Excessive exposure to advanced medical reasoning may result in confusion, frustration, or spontaneous eye rolling. In rare cases, it may cause the RT’s head to swell to dangerous proportions.

We do not want that.


In conclusion, while RTs may continue to rely on outdated concepts such as oxygenation, ventilation, and patient comfort, we as physicians must remain committed to higher-level thinking.

Remember:

          Not everything that appears necessary... actually is.



                         END TRANSCRIPT



Editor’s note (RT Cave, 2026):

Sometimes the best way to understand a bad idea...
is to take it seriously all the way to the end.

Editor’s note (RT Cave, 2026): Sometimes the best way to understand a bad idea… is to take it seriously all the way to the end.

Weird Is Fine

2026-05-19T10:59:44.283-04:00

For a long time I thought being “weird” was something I needed to fix.

Too quiet.
Too anxious.
Too sensitive.
Too observant.
Too emotional.
Too interested in old things.

I spent years comparing myself to people who seemed more normal than me.

My brothers were outside socializing while I often stayed in my room reading, writing, collecting old photographs, or listening to family stories from my grandma. While other people threw things away, I saved them.

Letters.
Cards.
Old newspaper clippings.
Hospital paperwork.
Photographs.

At one point when I was a teenager at National Jewish Hospital in Denver, some of the staff even encouraged me to throw away old letters I had saved from home.

I refused.

At the time, maybe that seemed strange.

Now I’m grateful I kept every one of them.

Because years later, those same letters helped me reconstruct huge portions of my life and eventually helped me write my memoir.

The older I get, the more I realize something important:

A lot of people who create things were “weird” kids.

The kid who notices everything.
The kid who stays inside reading.
The kid who watches instead of joins.
The kid who remembers details nobody else remembers.
The kid who talks to grandparents instead of going to parties.
The kid who saves things everybody else throws away.

That was me.

My childhood honestly was a little weird.

I was often the kid sitting alone on the bench while everybody else played.

Sometimes the playground monitors even tried involving me because they felt bad for me. But most of the time I was honestly fine just sitting there watching everything.

Part of that was asthma.

Part of it was anxiety.

Part of it was simply my personality.

And honestly, asthma probably shaped some of that.

I was quiet.
Introverted.
Short.
Sensitive.
Always sniffling or congested from allergies.

And kids noticed.

So I got picked on sometimes too.

Honestly, that only made isolating myself even easier.

Back then, even I thought something about me was probably different in a bad way.

But the older I got, the more I slowly accepted something important:

This is just who I am.

And honestly, “weird” now looks a lot like this:

Sitting by myself late at night writing stories, preserving memories, researching family history, saving old letters, and trying to understand a life that once confused me.

When you spend a huge part of childhood sick, short of breath, anxious, or left out, you develop differently.

You spend more time inside your own head.
You observe people.
You listen carefully.
You notice details other people ignore.

At times in my life I hated that about myself.

Now I don’t.

Because the truth is, if I had been completely normal, I probably would not have a story worth telling.

I would not have saved the letters.
I would not have preserved the memories.
I would not have become a writer.
I would not have spent years researching family history.
I would not have created Respiratory Therapy Cave.
And I definitely would not be sitting here writing this today.

Weird is not always bad.

Sometimes weird simply means you grew in a different direction than everybody else.

And sometimes that difference becomes the very thing that gives your life meaning later on.

When I first started writing my memoir, part of me wanted to normalize myself.

Make myself cooler.
More social.
More confident.

Maybe give myself a girlfriend.
Make myself one of the kids sneaking off campus.
Make myself the tough funny guy always saying the smart thing at exactly the right moment.

But that was never really me.

Instead, I finally let the real story come out.

The awkward skinny kid.
The anxious kid.
The socially uncomfortable kid who often sat quietly watching instead of participating.

And honestly, once I stopped trying to rewrite myself, the story became much easier to tell.

Probably because it finally became true.

The truth is, I probably did have some strengths because I was different.

I noticed things.
Remembered things.
Saved things other people threw away.

But what finally made the memoir work was realizing I did not need to rewrite myself into some cooler version of a teenager.

The awkwardness mattered too.
The anxiety mattered too.
The loneliness mattered too.

Because that was the real story.

And honestly, if I had turned myself into the confident tough guy with a girlfriend sneaking off campus every night, the memoir probably would have become far less interesting anyway.

Not because my struggles made me special.

But because the things that made me different also shaped the way I experienced the world.

And maybe that difference is exactly what made the story worth telling in the first place.

How Do We Take the Power Back from Insurance Companies?

2026-05-18T16:39:00.001-04:00

One thing we do in this country—we see a problem and immediately say, “we’ve gotta do something.”

But sometimes it’s better to do nothing than to do something stupid.

And by stupid, I mean piling on another law, another regulation, another layer. That’s the default move. Problem? Add something. Fix it with more rules.

That’s the wrong approach.

Because most of the time, we don’t actually fix the problem. We just create new ones. Unintended consequences. More complexity. More people in the middle. More control.

And somehow, every time we “do something,” healthcare gets more expensive, not less.

We—the patient—we’re the ones who get squeezed. More rules, less access. More options on paper, harder to actually get what we need.

So how do you fix something like this?

Because let’s be honest—this thing is a mess.

Too many layers. Too many middlemen. Too many people getting between a doctor and a patient.

If you ask me, the first step is simple.

Get the middle out.

Right now you’ve got insurance companies, PBMs, and a maze of rules deciding what you can and can’t have. That’s backwards. The doctor should make the call. The patient should be able to get it.

If there’s going to be money in the system—especially taxpayer money—then put it directly in the hands of patients. Give people a fixed amount and let them choose their insurance. Let companies compete for your business instead of trapping you in a system where they call all the shots.

Competition works better than control. It just does.

Second, price transparency. No more guessing games. No more “we’ll let you know after we deny it.” If a medication costs $50, say it. If it costs $500, say it. If it costs $1700, say it upfront. Let people make decisions with real information.

Third, limit the gatekeeping. Prior authorization, step therapy, all of it. If a doctor documents that something is medically necessary, that should carry real weight. Not six phone calls, three faxes, and a denial anyway.

Now, when it comes to government, I’m not saying burn it all down. I want medications to be safe. Nobody wants unsafe drugs on the market.

But there’s a difference between safety and control.

Right now, the system leans heavily toward control.

A better balance would be this: government focuses on safety, transparency, and basic guardrails. Make sure drugs are what they say they are. Make sure they’re not dangerous. Then get out of the way.

Educate people. Give them information. Let doctors practice medicine. Let patients make decisions.

Because right now, we’ve got a system that says it’s protecting us—but in reality, it’s just making it harder to get treated.

More medications than ever. More options than ever.

And still…

Too many people walking away saying:

“I finally found something that works… and I can’t get it.”

We don’t need more control. We need less interference between the doctor, the patient, and the treatment.

2026 — The Many Types of Albuterol (According to Everyone But RT)

2026-05-15T16:51:00.000-04:00

If you’ve worked in respiratory therapy long enough, you start to notice a pattern.

Wheezing? Albuterol.
Short of breath? Albuterol.
Fever? …still albuterol.

At some point, you realize we’re not just giving treatments—we’re following tradition.

Over the years, a more accurate classification system has quietly developed.

1. 0.5cc Ventolin

Symptom: Wheeze / SOB
Diagnosis: Bronchospasm
Frequency: Q4 & PRN
Effect: Actual bronchodilation. The original. The reason this all started. It works great for asthma, but is used for all annoying lung sounds and when the patient is short of breath and the doctor doesn't know what else to do.

2. 0.5cc Preventolin

Symptom: Surgery
Diagnosis: General
Frequency: Q4
Effect: Prevents pneumonia, atelectasis, pulmonary embolus, MI, rickets, and possibly bad weather.

3. 0.5cc Mystolin

Symptom: Fever
Diagnosis: Non-specific
Frequency: Q4
Effect: A study showed that 100% of patients who received Mystolin eventually recovered.

4. 0.5cc Cardiacolin

Symptom: “Cardiac wheeze”
Diagnosis: CHF / Pulmonary edema / MI
Frequency: Q4 ATC
Effect: Even though fluid is the problem, the treatment remains the same.

5. 0.5cc Meetcriteriolin

Symptom: Vague complaints
Diagnosis: Pneumonia (despite normal X-ray, labs, and lungs)
Frequency: Q4 ATC
Effect: Ensures all boxes are checked. Outcome optional.

6. 0.63mg NoShakenex

Symptom: Shakes
Diagnosis: Side effect of albuterol
Frequency: Q4
Effect: Same medication, different name, same result.

7. 2.5mg Atrovent (Solo Edition)

Symptom: Anything or nothing
Diagnosis: “Allergy” to albuterol
Frequency: Q4–6
Effect: Backdoor bronchodilation. Also effective at testing RT patience.

8. 0.5cc Coolovent

Symptom: Fever
Diagnosis: Post-op
Frequency: Q4
Effect: Mechanism unclear. Provider reassurance high.

9. CVA-Albuterol

Symptom: Rhonchi
Diagnosis: Weak cough / poor airway clearance
Frequency: Q2–4
Effect: Followed by suctioning to eliminate concerning sounds.

10. 0.5cc Scrubbin-Bubblin

Symptom: Productive cough
Diagnosis: “Junky” lungs
Frequency: Q4
Effect: Bubbles imply progress. Doctors think the foaming bubbling action cleans out the lungs just like scribbin bubbles gets all the dirt and grime out of a dirty sink.

11. 0.5cc O-Buterol

Symptom: Mouth open, sleeping comfortably
Diagnosis: Existing in a hospital bed
Frequency: Q4 ATC
Effect: Maintains tradition. If a patient has an O they must need albuterol.

More to come…

Because this list didn’t stop at 11.
Not even close.

Source:

Inspired by an older RT humor piece, updated and expanded with real-world observations

Why I Always Have More Than One Albuterol Inhaler

2026-05-13T17:02:00.001-04:00

Every month, I pick up my Albuterol inhaler.

Not because I’m out.

Not because I’m using it every day.

I do it because I can only get one at a time now, and I’ve learned the hard way that having just one isn’t enough.

There used to be a time when getting a few inhalers at once wasn’t a big deal. That made sense. Life is unpredictable, and people who rely on rescue inhalers don’t keep them in one place. We carry them everywhere—pockets, cars, bags, work, nightstands. And when you carry something everywhere, it’s only a matter of time before it gets lost.

That’s really the issue. Inhalers don’t stay put. They get left in yesterday’s jacket or slip between the seats in the car. Sometimes they just disappear, and you don’t realize it until you actually need it.

That’s why I refill mine regularly, even if I’m not using it much. It’s not about overusing the medication. It’s about making sure I have one when it counts. I like having one at home, one in the car, and one at work. That way, I’m not stuck trying to remember where I last saw it if my breathing suddenly gets worse.

From the outside, it might look like I’m going through inhalers too quickly. But I’m not. I’m just staying ahead of a problem that’s easy to predict.

If you’ve ever had to stop and search your pockets or your car because you suddenly needed your inhaler, you understand this. It’s not about convenience. It’s about peace of mind.

And in a situation where breathing can change quickly, that peace of mind matters.

Every Couple Years — A Pediatric Airway Refresher (ETT Size and Depth)

2026-05-11T12:13:00.000-04:00

I work for a small-town hospital. I believe we only have 34 patient rooms upstairs. We no longer admit pediatrics—if they need hospitalization, they’re sent to the Big City. But we still have an ER, and every once in a while we get a pediatric patient—anywhere from a 1-week-old to an 18-year-old—and sometimes they require invasive procedures, including intubation.

So yes, we have the Broselow Tape. It’s a great tool. You lay it out, line it up with the child, and it tells you exactly which drawer to open. Everything you need is right there. Clean. Organized. Foolproof.

I was talking about this with one of my coworkers, and she said she just waits for the doctor to call out what size ETT he wants.

That’s not good enough for me.

Knowing and being prepared means staying calm myself. There’s always a bit of nerves when you’re dealing with someone’s child. That never really goes away—and maybe it shouldn’t. But preparation takes the edge off. It lets you stay steady when the room isn’t. It gives you something to fall back on when things start moving fast.

Every couple of years, it’s worth dusting this off. Pediatric airways are not something you want to be figuring out in real time with a room full of eyes on you. The Broselow Tape is great—and you should absolutely use it—but having a mental backup based on age keeps you one step ahead when things get loud.

Start simple. For uncuffed tubes, the classic formula still works: internal diameter ≈ (age ÷ 4) + 4. For cuffed tubes, subtract about half a size: (age ÷ 4) + 3.5. It’s not perfect, but it gets you close enough to act. A 4-year-old? You’re thinking around a 5.0 uncuffed or 4.5 cuffed. An 8-year-old? Around a 6.0 uncuffed or 5.5 cuffed. You can fine-tune from there based on leak and feel, but you’re not starting from zero.

Depth is where trouble sneaks in. A quick rule: depth at the lip in centimeters ≈ tube size × 3. Drop a 4.5, you’re thinking around 13–14 cm. A 5.5 lands around 16–17 cm. It’s a guide, not gospel—but it helps you avoid the classic right mainstem surprise while you’re still getting your bearings. You confirm with breath sounds, chest rise, end-tidal CO₂, and X-ray, but at least you’re starting in a safe zone.

And in kids, we’re talking lip, not teeth. Teeth are unreliable—missing, loose, or not even there yet. The lip becomes your consistent landmark. Say the number out loud. Document it. Make sure the room hears it. Tubes move, especially in small patients, and you want everyone on the same page.

A few quick anchors help when your brain blanks. Neonates usually fall in the 3.0–3.5 range, with depths around 9–11 cm depending on size. There’s also the weight trick: depth ≈ weight (kg) + 6. By about one year old, you’re typically at a 4.0 cuffed tube. From there, the age-based formulas carry you forward. By the teenage years, you’re basically in adult territory.

Cuffed versus uncuffed used to be a bigger debate. These days, cuffed tubes are common even in younger kids—as long as you respect cuff pressures and size appropriately. You get better control, less leak, and more consistent ventilation. The tradeoff is simple: don’t overdo it. Gentle inflation. Respect the airway.

The pediatric airway isn’t just a smaller version of an adult airway—it’s different. Bigger occiput, more anterior larynx, relatively larger tongue. Positioning matters. A small shoulder roll in infants can make all the difference. If your view is poor, it’s often positioning—not equipment.

The point of all this isn’t to replace the Broselow Tape. It’s to back it up. When things are calm, you use every tool you’ve got. When they’re not, you fall back on what’s in your head. Having a working mental model for tube size and depth doesn’t just make you faster—it makes you calmer. And in those moments, calm is everything.

Do people really die peacefully?

2026-05-10T09:11:00.001-04:00

We hear it all the time. “He passed away peacefully, surrounded by family.” It’s a comforting thing to say. It’s gentle. It helps loved ones, especially children, make sense of something that doesn’t make sense. I’m not saying it’s wrong. There’s value in that.

But I want to talk about the reality we see.

I’m an RT. Like most of you reading this, I’ve seen death many times. And yes, sometimes people really do die peacefully. I remember one patient who told me he was ready. He wasn’t dramatic about it. Just calm. He went to sleep, and I watched his monitor slow down and then go flat. No struggle. No panic. Just… done. That was peaceful.

But that’s not how it always goes.

You walk into a room and see a 92-year-old man who can’t get comfortable. He’s restless, shifting, breathing hard. You can tell he’s not okay. The doctor orders morphine or something for anxiety. You give it. He settles down. Not long after, he dies. And then the chart reads, “Patient passed away peacefully surrounded by family.” Maybe in that final moment he was. But right before that, he was miserable.

Then there are the diseases we know too well. Lung cancer. Pulmonary fibrosis. End-stage COPD. These are not easy ways to go. These patients feel like they’re suffocating, because they are. Air hunger is real. It’s one of the worst feelings a person can have. You can see it in their eyes. The panic. The fight for every breath. We give morphine. We give benzos. We do what we can to take the edge off. And sometimes we help a lot. But that doesn’t mean the whole process was peaceful.

So why do we say it?

Because it helps people. It softens the memory. It gives families something to hold onto that isn’t fear or suffering. And I get that. I really do.

But here, we can be honest about it.

Death isn’t always peaceful. Sometimes it’s uncomfortable. Sometimes it’s a struggle. Sometimes it’s a fight right up until the end. And sometimes our job isn’t to make it peaceful. It’s to make it less bad.

That’s the reality we see. The reality we treat. The knowing what few know.

Things Most Respiratory Therapists Have in Common

2026-05-08T11:17:00.002-04:00

Spend enough time in a hospital, and you’ll start to notice something.

Respiratory therapists don’t all act the same—but we think the same.

You can drop us into any room, any shift, any hospital… and within a few minutes, we’re doing things almost identically. Not because we were taught to follow a script, but because experience forces you into patterns that actually work.

Here are a few of them.

We listen to lung sounds bottom to top, side to side—and we don’t immediately tell the patient to take a deep breath.
Because we want to hear what’s really there first.
We know that the second a patient takes a deep breath, you’ll suddenly hear crackles and rhonchi that weren’t there before—and that’s not bronchospasm.
We understand that true bronchospasm wheezes are subtle.
You hear them through the stethoscope—not across the room.
If a wheeze is audible without a stethoscope, we’re already thinking:
upper airway noise, secretions, or fluid—not bronchospasm.
After checking for wheezes (which, honestly, aren’t present in most treatments),
then we ask for deep breaths—because that’s when the hidden stuff shows up.
We develop a kind of clinical detachment.
Not because we don’t care—but because we’ve seen enough to stay calm when things get weird.
Our sense of humor gets dry.
Sometimes really dry.
Sometimes only another RT will get it.
We quietly believe we know more about respiratory care than most people in the building.
And if we’re being honest… we usually do.
We definitely think we know more than nurses about respiratory.
(No offense. Different lanes.)
We can often tell the difference between pneumonia, CHF, and bronchospasm before the chart even loads.
We’ve given so much Albuterol (Ventolin) that we’re pretty sure it has granted us some kind of higher-level awareness.
We can walk into a room and know in about five seconds whether the treatment is actually needed.
We’ve mastered the art of doing a treatment… while also fixing three other problems no one asked us to fix.
We’ve all had that moment where we adjust the oxygen, step back, and think:
“This is going to be fine.”
And most of the time… it is.
We could probably run the hospital better than administration.
But we absolutely do not want their jobs.
When people in suits show up—administrators, inspectors, whoever—
we suddenly remember we have somewhere else to be.
We don’t run… but we definitely reposition strategically.
We become masters at bedside conversation.
One-on-one, patient to therapist—we know how to read the room, keep it real, and make people feel at ease in about 30 seconds.
Like journalists, we learn how to end conversations cleanly.
“Well, I gotta get to my next patient…”
(We’ve used that line a thousand times—and it always works.)
We can tell within seconds what kind of patient we’re dealing with—
talker, quiet, anxious, skeptical—and we adjust instantly.
We’ve perfected the art of looking busy…
because most of the time, we actually are—but it also helps when you need to avoid getting pulled into something unnecessary.

The Funny Part

Most of this isn’t written anywhere.

It’s not in textbooks. It’s not in policies. It’s not something you learn in school.

It’s what happens after hundreds—maybe thousands—of patient interactions. After listening to lungs long enough that patterns start to jump out at you. After giving enough treatments to know which ones matter… and which ones are just being done because “that’s what we always do.”

That’s when you stop just doing the job…

…and start understanding it.

Final Thought

If you know, you know.

And if you’re an RT reading this, you probably nodded your head at least a few times.

Because whether you’re in Michigan, Florida, or anywhere in between—
we’re all practicing the same unwritten version of respiratory care.

And somehow… it works.

Who Gave Insurance Companies All This Power?

2026-05-07T16:20:00.000-04:00

In my last post I talked about how insurance companies now decide what medications we get, when we get them, and how hard we have to fight to get them.

So who gave them that power?

This didn’t come from one law. It came from a series of laws—passed over decades—by both Democrats and Republicans.

Start with ERISA (Employee Retirement Income Security Act, 1974). That was passed by Congress and signed by a Republican president (Ford). It had broad bipartisan support. That law allowed large employers to run their own health plans and limited what patients can do when claims are denied. That’s a big one. Most people have never heard of it, but it quietly took power away from patients and states and centralized it.

Then in the 1980s and 1990s you get the rise of managed care. Not one single law, but a shift supported by both parties—Republicans and Democrats—pushing HMOs and cost control. That’s when networks, referrals, and utilization review really took off. That’s where the insurance companies started saying, “We’re not just paying—we’re deciding.”

Then you get Medicare Modernization Act (2003) under a Republican Congress and President Bush. That created Medicare Part D and locked in the role of pharmacy benefit managers (PBMs). It also specifically prevented Medicare from directly negotiating drug prices. That decision pushed more control into the hands of insurers and PBMs.

Then comes the big one everyone talks about—the Affordable Care Act (ACA, 2010) under Democrats.

No, it didn’t create prior authorizations or formularies. Those already existed. But it did a few things that made the system tighter.

It expanded coverage to millions more people. It added essential benefit requirements. It added regulations on insurers.

That sounds good—and some of it is.

But here’s what also happened.

More people in the system. More rules. More cost pressure.

And when you put pressure on cost, the system responds the only way it knows how:

It tightens control.

That’s where you see more:

prior authorizations
step therapy
narrower formularies
quantity limits

So no, Obamacare didn’t start this.

But yes, it added fuel to it.

Then you’ve got the role of agencies like the FDA and HHS.

Congress passes broad laws. Agencies write the rules. Those rules aren’t technically laws, but they function like them. That’s how our system works. Both parties have supported that structure for decades.

The FDA decides how drugs get approved, labeled, and brought to market. HHS oversees the system. CMS runs Medicare and Medicaid rules.

Insurance companies then build their policies around all of that.

So now you’ve got:
Congress writing broad laws
Agencies writing detailed rules
Insurance companies enforcing them
PBMs controlling drug access

And the patient stuck in the middle.

I’m not saying we don’t need regulation. I want safe medications. I don’t want garbage drugs getting pushed on people.

But somewhere along the way, it stopped being about safety and started being about control.

And both parties had a hand in building it.

Republicans pushed market-based systems, employer plans, and PBMs.

Democrats expanded coverage, added regulations, and increased system complexity.

Put it all together over 40–50 years and you end up with what we have now.

More medications than ever. More inhalers than ever. More options than ever.

And somehow it’s harder than ever to get the one your doctor says you need.

This didn’t just happen.

It was built.

How Many Inhalers Have I Used in My Lifetime? A Lot

2026-05-06T15:21:00.001-04:00

It started for me around 1980.

That’s when I was first introduced to inhalers. Back then it was simple. You had a rescue inhaler—mine was Alupent. Then that shifted to albuterol, which is what most people still use today. Same idea, different name.

Then came the inhaled corticosteroids. At first it was just one inhaler, one job—reduce inflammation. But over time, that changed too.

We went from single inhalers… to long-acting bronchodilators… to combination inhalers with LABA and inhaled corticosteroids… and now triple therapy with three medications in one inhaler.

And that’s just the surface of it.

Because then you add in all the generics. I’ve probably taken most of them at one point or another. Same drugs, different names depending on who made them. Beclomethasone, budesonide, fluticasone—brand name, generic name, back and forth. Albuterol alone comes in a dozen versions. Then different devices—MDIs, dry powder inhalers, mist inhalers. Then the propellant changes. Then patents come and go. Then years where there are no generics… and then suddenly there are again.

At this point, there are so many inhalers and combinations that it would be impossible for anyone to try them all. And there are probably more than I even realize.

So what have I actually used over the years?

Quite a few.

Vanceril—and all the versions of beclomethasone that came with it, usually that pink inhaler
Beclovent—another version of beclomethasone, brown inhaler
Azmacort—triamcinolone, white inhaler with a spacer
Aerobid—flunisolide, and yeah, that one tasted awful
Flovent—fluticasone, plus the generic fluticasone versions that came later
Serevent—salmeterol
Advair—fluticasone/salmeterol, and the generic versions of that combo
Singulair—montelukast (not an inhaler, but part of the routine for a while)
Dulera—mometasone/formoterol
Breo—fluticasone/vilanterol
Trelegy—fluticasone/umeclidinium/vilanterol
And now Breztri—budesonide/glycopyrrolate/formoterol

If you add in all the generics, the list is much longer:

Alupent, Proventil, Ventolin, ProAir HFA, ProAir RespiClick, ProAir Digihaler, Xopenex, Maxair, Primatene Mist, Primatene Mist HFA, Vanceril, Beclovent, QVAR, Azmacort, Aerobid, Flovent HFA, Flovent Diskus, Pulmicort Turbuhaler, Pulmicort Flexhaler, Serevent Diskus, Foradil Aerolizer, Intal, Tilade, Advair Diskus, Advair HFA, Wixela Inhub, , Symbicort, generic budesonide/formoterol inhalers, Dulera, Breo Ellipta, , Trelegy Ellipta, Breztri Aerosphere, generic albuterol sulfate HFA inhalers, generic fluticasone propionate HFA inhalers, , generic beclomethasone inhalers, generic flunisolide inhalers, generic triamcinolone inhalers

And on top of that, all the albuterol inhalers over the years—Proventil, Ventolin, ProAir, and all the generics that look slightly different but do the same thing. Heck, there used to be tons of albuterol generics, each one a unique color.

I switched from Trelegy to Breztri because Trelegy is a dry powder inhaler and it made me cough. Breztri is a metered-dose inhaler with a mist, and it’s just easier for me to tolerate.

When you step back and look at it, it’s kind of crazy. We went from a couple of inhalers to all these options, combinations, and delivery systems.

You’d think that would make things easier.

But somehow, it’s gotten more complicated—and in a lot of cases, harder to get the one that actually works for you.

O-Buterol: Because Everything Gets Albuterol

2026-05-04T16:39:00.001-04:00

When Did Insurance Start Practicing Medicine?

2026-05-01T15:20:00.001-04:00

There was a time—not that long ago—when this was simple.

You went to your doctor. They wrote a prescription. Your insurance covered it.

I remember getting three albuterol inhalers at a time. No hoops. No questions. Just care. Doctors had samples in the office. If you needed something, they handed it to you. You walked out treated.

Now it’s one inhaler, maybe. Prior authorizations. Step therapy. Denials. Appeals. Delays.

Somewhere along the way, the system flipped.

And I keep coming back to the same question: when did insurance companies start practicing medicine?

This didn’t happen overnight. It was a slow shift, and like most things in healthcare, it came down to money and control. Drug costs went up, insurance companies pushed back, and instead of working with doctors, they built systems to manage what patients could and couldn’t get.

That’s where formularies came from. Lists of approved medications. Not approved by your doctor, but by the insurance company. Then they added tiers—cheap drugs, expensive drugs—and suddenly what you got wasn’t just about what worked, it was about what cost less.

Then came prior authorization. This is where your doctor says, “My patient needs this,” and the insurance company says, “Prove it.” So now your doctor’s office is filling out forms, sending faxes, making calls, and waiting. Meanwhile, you’re waiting too. And after all that, you can still get denied.

And then there’s step therapy. This one is just stupid. “Try the cheaper drug first. If it doesn’t work, then we’ll consider the one your doctor actually wanted.” That’s not medicine. That’s a cost-control strategy pretending to be medical judgment. It delays care, frustrates patients, and puts barriers between you and treatment for no good reason other than saving money.

Behind the scenes, there’s another layer most people don’t even know about: pharmacy benefit managers, or PBMs. These are the middlemen. They decide what drugs are covered, what pharmacies you can use, and how much things cost. They negotiate deals and rebates, and they make money in the middle. So decisions about your medication aren’t just about what works—they’re tied up in contracts and margins.

Even the little things disappeared. Doctors used to give out sample medications all the time. That’s mostly gone now. Partly because of tighter regulations, partly because of liability, but also because the system has shifted toward tracking everything, billing everything, controlling everything. Free samples don’t fit well in that kind of system.

So here we are.

We’ve moved from a system where doctors made decisions and patients got treated, to one where insurance companies decide what gets approved, how much you get, and how long you have to wait. Doctors still make recommendations, but they don’t have the final say anymore.

And patients notice. You feel it when you can’t get the medication your doctor prescribed. You feel it when you’re stuck waiting for approval. You feel it when you’re told to try something that doesn’t make sense just to check a box.

That’s why people are starting to go around the system. Cash pay. Online pharmacies. Compounding pharmacies. Not because they want to be difficult, but because they’re trying to get treated without jumping through a dozen hoops.

I’m not saying the old system was perfect. It wasn’t. But it was simpler. It was faster. And in a lot of ways, it made more sense.

Now we’ve got a system where the people paying the bills are calling the shots, and the people actually taking care of patients have to ask permission.

And that’s the part that doesn’t sit right.

Because at the end of the day, it shouldn’t be this hard to get something your doctor says you need.

Before Pulse Oximeters, We Guessed. Then We Knew.

2026-04-29T17:13:00.001-04:00

I was in the hospital for asthma a lot in the 1980s.

Back then, in the ER, they’d put a nasal cannula on me—little prongs in the nose, oxygen flowing. The problem was, I didn’t feel fine—I was having trouble breathing—but that thing on my face made me feel restricted.

So as soon as they left the room, I’d take it off. They’d come back in, put it back on. They’d leave, I’d take it off again. We went back and forth like that more than once until they finally gave up. And I would always be admitted -- if I was admitted -- on room air.

At one point, someone decided, “If you won’t wear the cannula, we’ll try an oxygen tent.” So they did.

That lasted about an hour.

I didn’t like that either.

So there I was—being put on oxygen, clearly supposed to need it—and I didn’t want it. Which raises a fair question:

How did they even know I needed oxygen?

The honest answer is—they mostly didn’t.

Not the way we do today.

Back then, you were looking for signs. Blue lips. Blue fingertips. Work of breathing. How you looked. How you sounded. If you wanted a real number, you had to draw blood—an arterial blood gas (which they did a few times). Accurate, but not something you were doing every few minutes.

And then, everything changed.

When My Finger Told the Story

I didn’t see it until 1991.

Another asthma attack. Another ER visit. And this time, they clipped something onto my finger.

No needles. No blood. Just a clip.

I stared at it and started asking questions.

“What is that?”

They told me it was measuring my oxygen.

That didn’t make sense to me. Up until that point, oxygen was something you guessed at, or something you pulled out of an artery with a syringe. Now this little device was just… reading it?

It felt like science fiction.

But it wasn’t.

Pulse oximetry had been around in development for years, but it really took off in the 1980s when the technology finally caught up. Suddenly, you could monitor oxygen continuously, noninvasively, in real time.

No needles. No waiting. Just a number.

At first, the machines were big. Expensive. Not something every room had. But as the technology improved, they got smaller, cheaper, and more reliable. By the 1990s, they were becoming standard. By the 2000s, they were everywhere.

Now?

You can grab one for $25 at Walmart, a pharmacy, or Amazon. Toss it in a drawer like a thermometer.

That would’ve blown my mind back in that ER room—when I was taking off my oxygen and they were trying to decide if I actually needed it.

Because today, there’s no guessing.

You put the clip on the finger…

…and the finger tells the story.

So What Is It Actually Doing?

Here’s the simple version.

A pulse oximeter measures how much oxygen your blood is carrying. Not the oxygen in the air. Not your breathing rate. Your blood.

And it does it with light.

Inside that little clip are two lights:

one red
one infrared

They shine through your finger. On the other side, there’s a sensor catching that light.

Now here’s the trick:

Oxygenated blood and deoxygenated blood absorb light differently. One soaks up more red light, the other more infrared. The device compares the two and uses that difference to estimate your oxygen saturation—your SpO₂.

It also times it with your pulse, so it knows it’s reading fresh arterial blood, not just everything sitting in your finger.

No blood draw. No guesswork. Just physics.

From Bulky Boxes to Your Fingertip

The early machines weren’t sleek.

They were big. Expensive. Wires everywhere. You didn’t carry one around—you rolled it.

Then they got smaller. Handheld units. Clip-on probes.

And now, the whole thing is the clip.

You slide it on your finger, wait a few seconds, and there it is:

your oxygen level
your pulse

Something that used to require a needle and a lab can now be done in your living room while you’re watching TV.

You put the clip on the finger…
and the finger tells the story.

Why Was Green Chosen for Oxygen?

2026-04-27T16:35:00.028-04:00

At some point, someone decided oxygen should have a color.

Not because oxygen itself needed one—but because people did.

And it probably didn’t start with oxygen alone. It started with a bigger problem. Hospitals were full of gases—oxygen, nitrous oxide, anesthetics—and they all had to be delivered through the right lines, to the right places, every single time. If you mixed them up, it wasn’t a minor mistake. It could be catastrophic.

In the early days of surgery, that wasn’t just a theory. Operating rooms used flammable anesthetic gases like ether. Add oxygen to the mix, introduce a spark from cautery equipment, and you had a real risk of fire—or worse, an explosion. Because of that, some older hospitals placed operating rooms on lower floors, sometimes away from the main patient areas. It sounds extreme now, but it wasn’t. It was precaution.

So systems were built to eliminate the guesswork. Connections were designed so they physically couldn’t be mixed up. Equipment was standardized. And one of the simplest, most effective solutions was color coding.

Make it obvious. Make it fast. Make it something you don’t have to think about.

In the United States, green became oxygen.

And once that decision was made, it stuck. Green tanks. Green flowmeters. Green outlets. You walk into a room, see green, and you know exactly what you’re dealing with—no hesitation, no second-guessing.

So Why Green?

So why green?

Was it chosen because oxygen glows green in the sky?

That would be a great story.

And the wild part is—it’s actually true that oxygen glows green. Just not here.

If you’ve ever seen the Northern Lights, that eerie green curtain in the sky isn’t just “energy.” That’s oxygen. High above the Earth, where the air is thin and spread out, solar particles come screaming in and slam into oxygen atoms. They don’t just bounce off—they transfer energy. It’s like winding a spring.

And when those oxygen atoms release that energy, they don’t do it quietly. They emit light. A very specific wavelength. Green.

Up there, atoms have space. Time. They can hold onto that energy just long enough to let it out as light. That’s why you get that haunting, almost unreal glow.

Down here, it’s a different story.

The air is crowded. Oxygen atoms are constantly colliding with other molecules—nitrogen, water vapor, everything. So instead of releasing energy as light, they just dump it into each other as heat. No glow. No show. Just business as usual.

So oxygen still “has” that green in it—it just never gets the chance to show it.

Which makes the whole thing kind of ironic.

The same gas we treat as invisible, as background, as nothing special… is capable of lighting up the sky in one of the most vivid displays on Earth.

So no—green wasn’t chosen for that reason.

But it might as well have been.

That would be a great story.

But like most things in medicine, the real answer is less poetic and more practical.

Green was chosen because it stands out. It’s easy to recognize. It doesn’t get confused with other gases. In a room full of equipment, wires, alarms, and people moving fast, you don’t want subtle—you want obvious. Green cuts through the noise.

And once it was chosen, it stuck. It became the standard. You see green, you don’t think—you act. That’s the whole point.

But even if the reason was practical, it’s hard not to see something more in it.

Because green already means something to us.

It’s life. Growth. Go.

It’s the light that says move forward. It’s the color at the end of Gatsby’s dock—always just out of reach, but pulling you ahead anyway. It’s the color of momentum.

And yeah, it shows up on the other side too. In The Lord of the Rings, Tolkien uses pale, sickly greens for things that aren’t right—Gollum, decay, corruption. Same color family, different tone. Healthy green versus something off.

That’s kind of the point.

Color isn’t just color. Context matters.

In the hospital, green isn’t eerie or sickly. It’s clean. It’s certain. It’s oxygen. It’s the thing keeping the brain firing and the heart beating.

So no, green wasn’t chosen because of the Northern Lights.

But it fits anyway.

And maybe that’s why it works so well.

Because whether it came from a committee or a codebook, it ended up matching something deeper—something we already understood without thinking about it.

Green means life.

And in a hospital, that’s exactly what you want it to mean.

2026-04-25T17:39:00.001-04:00

I had an appointment with my ENT today.

I usually see the PA now instead of Dr. Hengy. Nothing against him—good doctor, smart guy—but his office is in Manistee. That’s a 40-minute drive. The PA is in Ludington, just a few blocks from my house. Easy choice.

I’ve been on allergy shots since 2021. If you’ve ever done them, you know the routine. You start twice a week, then once a week, then every other week. That part is easy to remember.

Then it gets weird.

Every three weeks. Once a month.

That’s where I fell off.

I hadn’t been in since December. I didn’t even realize it had been that long, but she told me—almost five months.

And I’ll be honest, I was expecting a lecture.

Didn’t happen.

She was actually kind of excited.

She said, “You’ve gone almost five months without shots, and you’re not having symptoms?”

I said, “Yeah, I feel fine.”

She said, “It’s allergy season… let’s test it.”

I liked that.

No guilt. No pressure. Just, “let’s see what happens.”

So we decided to stop the shots—for now—and see how I do.

I asked her how long I could go without having to start all over, and she said quite a while. That made the decision easier.

I also brought up Singulair. I told her if I had stayed on shots, I was thinking about coming off it. But honestly, I don’t have side effects from it. It’s cheap. It works. So for now, I’m staying on it.

Then I did something I don’t usually do with doctors.

I was honest.

I told her I’ve actually been doing fine in the spring even before the shots—as long as I’m on Singulair. And I admitted that part of the reason I went along with allergy shots in the first place was because Dr. Hengy was the first doctor in a long time who actually wanted to try something different.

That’s hard to say to a doctor.

But I said it.

And she handled it perfectly. Didn’t get defensive. Didn’t push back. Just took it in and moved on.

That felt good.

We set up a six-month follow-up. I told her straight up, “If I don’t schedule it now, I won’t come back.” She laughed and agreed. At that appointment, we’ll decide what to do next.

She also said if I start having symptoms at all, just call and we’ll restart the shots.

Simple.

Now, here’s the honest part.

I can’t say I’ve noticed a huge difference with the allergy shots.

But I also haven’t really tested it.

Flipping through old baseball cards has always been a trigger for me—tight chest, symptoms. I haven’t tried that lately. But I have been going through old photos, and that hasn’t bothered me at all.

So maybe they helped.

Or maybe the Singulair is doing most of the work.

Hard to say.

And yeah, part of me thinks, “well… it didn’t hurt.”

I hate that phrase. I hear it all the time at work with albuterol. But in this case, it kind of applies.

Either way, I walked out of that appointment feeling good.

No pressure. No lectures. A plan that made sense.

We’ll see what happens.

This Works—So Why Are They Trying to Take It Away?

2026-04-24T12:23:00.002-04:00

In my first post, I shared how I got started with a GLP-1 after insurance denied coverage. In the second, I explained what compounding pharmacies are and why they’re cheaper.

This post is about something different.

Why all of this is under pressure right now. Why does it feel like it’s being taken away?

You can feel it.

The more people start finding out about compounded GLP-1s, the more pushback there is.

Pharmaceutical companies don’t like when people go outside the system and spend their money somewhere else. And regulators? They step in when something grows this fast, asking questions about safety, sourcing, and whether the rules are being followed.

And here’s the part that matters to me:

They aren’t getting $1,700 from me.
They aren’t getting $300.
They aren’t even getting $200.

I can’t afford that. Most people can’t.

If compounding pharmacies didn’t exist—if they didn’t make these medications available—then I wouldn’t be taking them at all.

Not unless prices came back down to reality.

And here’s the part that really gets me—they want to take this option away and push everyone back through the same system. You have to schedule a doctor’s visit—there’s time and money. Then wait for approval. Then deal with insurance. Then go to the pharmacy. Pay again. Drive there. Wait in line. All of it adds up—time, stress, gas, money. And after all that? You still have to take their dose, their schedule, their one-size-fits-all approach. You have no control. Compare that to having something show up at your door, being able to manage your own dosing, and actually making it work for your life. That difference matters.

And honestly, it doesn’t take a genius to see why this is happening.

On one side, you’ve got companies like Eli Lilly and Company. They built these drugs. They spent years and billions getting them approved by the U.S. Food and Drug Administration.

But here’s the reality for people like me:

You’re told, “This medication could help you.”
And then right after that—“You can’t have it.”

Insurance denies it.
The price is $1,500… $1,700 a month.

So what are we supposed to do?

Just sit there and stay unhealthy?

No.

We find another way.

And when we do—when we finally find something that works and we can actually afford—it changes everything.

And that’s when the pressure starts.

Because now it’s not just about the medication anymore.

It starts to feel like control.

Like they don’t want us to have control over what we put in our bodies.
Like they don’t want us to be able to afford it unless we go through their system, on their terms, at their price.

And yeah—maybe that’s not how they’d say it.

But that’s how it feels on this side of it.

So now you’ve got the U.S. Food and Drug Administration stepping in more.
You’ve got pharmaceutical companies protecting their patents and their market.

Pressure from both sides.

And right in the middle?

Us.

People who are just trying to get healthier without going broke doing it.

And this is the part that frustrates me the most:

The system works great… if you can afford it.

If you can’t?

You’re out.

So when something like compounding gives people a way in—a way to actually take the medication, to control dosing, to make it work financially—you’re going to see people take it.

Of course they are.

This isn’t about trying to game anything.

It’s about not being locked out.

Is compounding perfect? No.

There are trade-offs. People need to understand that.

But the bigger issue is this:

People are being priced out of something that could help them.

And until that changes, this isn’t going away.

Because this isn’t just about a drug.

It’s about whether regular people actually get a say in their own health.

Let Me Get the Medicine I Already Know I Need

2026-04-23T12:44:00.004-04:00

I like doctors. I like pharmacists. I like insurance companies. I like the U.S. Food and Drug Administration. They all serve a purpose.

But there are certain medicines that shouldn’t require going through all of them every single time.

And I’m not talking about new diagnoses or complicated cases. I’m talking about people with established conditions who already know what works for them. I still see my doctor twice a year. I’m not trying to avoid care—I just don’t need to keep jumping through the same hoops over and over.

For instance, I need Trelegy Ellipta. One puff a day. I’ll likely need it for the rest of my life unless something better comes along. It’s already been determined that I need it to breathe. So why do I have to keep going through a doctor, a pharmacy, and an insurance company just to get it? It should just be automatically available to me.

Same with my blood pressure medication, like lisinopril. Doctors are helpful in figuring out what I need. But once that’s established, why do I have to keep jumping through hoops? I’m not saying it should be free—but it should be accessible and reasonably priced.

There’s a difference between maintenance meds, rescue meds, and acute treatments—and right now, the system treats them all the same.

Maintenance meds should be automatic once they’re established.

Rescue meds—like Albuterol—should be easy to access. It’s proven to be safe for shortness of breath. Why do I need a prescription for that? It should be on the shelf—over the counter—like Tylenol or Ibuprofen.

And yes, people worry about overuse. But the real issue isn’t the albuterol—it’s the uncontrolled asthma behind it. That’s where doctors come in. It’s called education and follow-up, not restriction.

Hell, epinephrine inhalers are generally considered more risky than albuterol, and they’re already available over the counter. If the goal is safety, then give people better options, not fewer. I’d bet the use of epinephrine inhalers would drop off pretty fast if albuterol were just as easy to get.

Then there are acute treatments like corticosteroids, such as prednisone. I understand these need more oversight. But if I’m having an asthma flare and I’ve been down that road before, there should be a faster, easier way to access them than paying $40 just to be told what I already know I need.

Right now, they tell me I need a refill. My doctor has me come into the office twice a year. I pay $40 for that visit. Then I pay whatever price the pharmaceutical company and insurance decide. And after insurance, I’m sure the system is making a lot more than that $40.

So let me just get the medicine I need.

Of course, I’m not saying you shouldn’t see your doctor regularly. They’re needed to monitor your health and adjust medications when necessary. But once it’s established that I benefit from a certain dose, why do I have to call for a refill every six months? Why not just auto-renew it unless something changes?

It would save patients a lot of stress—and a lot of money.

And honestly, it would make the system work the way it was supposed to in the first place.

Compounding Pharmacies — What They Are and Why GLP-1s Cost Less

2026-04-22T12:05:00.002-04:00

In my last post, I shared how I got started with a GLP-1. My doctor wanted me on Wegovy for prediabetes and weight loss, insurance denied it, and I wasn’t about to pay $1,700 a month out of pocket. That led me down the road of finding alternatives, which is how I ended up using a compounded version of tirzepatide.

Since then, I’ve had a lot of people ask the same question: what exactly is a compounding pharmacy, and how are they able to sell this stuff so much cheaper?

A compounding pharmacy is a licensed pharmacy that custom-makes medications for individual patients. Instead of a one-size-fits-all pen, they can adjust the dose, formulation, or delivery based on what a provider prescribes. This isn’t new—it’s actually how medicine used to be practiced before mass-produced drugs became the norm.

Back in the 1800s, you’d go to a doctor with a symptom, get a prescription, and then the pharmacist—sometimes the same person—would mix the medication right there. There was no one-size-fits-all dose. The dose was tailored to you.

In the case of GLP-1s like tirzepatide, that often means getting a vial instead of a preloaded pen, and drawing up your own dose with an insulin syringe.

That’s where the cost difference comes in. The brand-name versions—like Zepbound or Mounjaro made by Eli Lilly and Company—are patented, heavily marketed, and come with all the research, development, and delivery systems built in. You’re paying for all of that. Compounded versions don’t carry those same costs, so they’re often a fraction of the price.

In my case, I’m paying about $300 for a 50 mg vial. It comes with bacteriostatic water, syringes, and instructions. At lower doses, that can last more than a month. And instead of being locked into a preset weekly pen, I can adjust my dosing. If I’m doing well on a lower dose, I stay there. If I need to move up, I can. That flexibility has been one of the biggest benefits.

That flexibility also helps with side effects. If higher doses are causing symptoms like nausea, one option is to split the weekly dose—taking half at the beginning of the week and the other half a few days later. This avoids a large single dose, which can make it easier on your system. It also keeps the medication more steady in your body, so you don’t feel it wearing off toward the end of the week.

Another thing worth understanding is what this medication actually is. Tirzepatide is a peptide—a short chain of amino acids. The easiest way to think of peptides is like keys fitting into locks. Your body has receptors, and when the right peptide binds to the right receptor, it triggers a specific effect. In this case, tirzepatide targets GLP-1 and GIP receptors, helping regulate blood sugar, slow digestion, and reduce appetite. That’s why people lose weight on it, and often with relatively targeted effects.

Now, here’s where things get a little gray, and it’s important to be honest about it.

Some of these online sources don’t operate exactly like a traditional pharmacy. You’ll sometimes see language like “for research use only.” That’s there for legal and regulatory reasons. At the same time, it’s not hard to see why people are going this route. When something costs $1,700 through the traditional system and a few hundred dollars through an alternative channel, people are going to look for options.

But that also means there are trade-offs.

These products are not the same as FDA-approved, brand-name medications. They don’t go through the same level of oversight, and quality can vary depending on where you get them. You’re also taking on more responsibility—mixing the medication, measuring doses, and giving the injection correctly. That’s not nothing.

For some people, that level of involvement works. For others, it’s not a good fit.

I also had a friend who had been taking this for years before I ever started. That made it easier for me to consider. When she first told me about it, my thinking was pretty simple: You’ve been on it for years and you’re still here—it must be safe. It worked for you, so maybe it could work for me too.What I will say is this: people aren’t doing this because they want to play pharmacist. They’re doing it because they’re priced out of the system.

If insurance covered these medications, or if pricing made sense, most people would go through their doctor, pick it up at the pharmacy, and never think twice about it. Instead, people are left figuring it out on their own.

For me, and for a few friends, it’s worked. One of them is down 50 pounds and feels great. I’m losing weight, my appetite is under control, and I feel like I finally found something that works.

That’s why I wrote this follow-up—to explain what’s actually going on behind the scenes, what a compounding pharmacy is, and why more and more people are going this route.

It’s not perfect. But for a lot of people right now, it’s the only realistic option.

When Insurance Said No, I Found Another Way: How I Now Afford the Weight Loss Drug of My Choice

2026-04-16T14:36:00.003-04:00

My doctor wanted me on a GLP-1—both to get my blood sugar down (I was prediabetic) and to help me lose weight. He prescribed Wegovy. My insurance denied it.

So I couldn’t get it. And paying out of pocket would have been around $1,700 a month.

A few months later, I learned about Trump Rx. I told my doctor I could get it for about $200 a month, and that got me started. But then during that first month I realized the catch—after a couple months, the price jumps to around $450. GoodRx and the deals on the pharma sites all work the same way.

That’s what got me looking for alternatives.

What I found is there are online options offering compounded versions of these medications. Instead of the expensive auto-injector pens, you get a vial, mix it with bacteriostatic water, and use a simple insulin syringe. Much cheaper.

A friend introduced me to the company and their website. I won’t share the name here, but if you want more information, you can email me using the link to the right.

Because I’m the one paying for it—and making the decision—I skipped Wegovy and went straight to tirzepatide—the medication behind Zepbound—for a fraction of the cost (not the brand name). I chose it because it targets two pathways—GLP-1 and GIP—and has been shown to help people lose more weight than semaglutide.

The cost is about $300 for a 50 mg vial. It comes with bacteriostatic solution, mixing syringes, and insulin syringes, along with instructions so you can prepare and use it properly.One vial can last more than a month, especially at lower doses, and you can control your dosing instead of being locked into a preset pen.

It’s nice. No doctor. No insurance. Simple. Easy. Inexpensive.

A couple things to be clear about:

This is compounded, not brand-name
It’s not exactly the same as what you get from the pharmacy
You’re trading cost for convenience and tighter controls
You need to know how to mix the medication, measure the dose, and give the injection properly
You also need to understand dosing—what to take and when (or if) to increase

But because you’re essentially your own caregiver, you have some flexibility. For example, if the plan says to move up to a higher dose but I’m still losing weight on the current dose, I just stay where I am.

That’s the freedom of it.

But here’s the bigger issue:

People aren’t going this route because they want to. They’re doing it because they’re getting priced out.

If insurance covered these medications—or if pricing made sense—most people would just go through their doctor and pharmacy and be done with it.

Instead, people are left figuring it out on their own.

For my friends, this has worked great. One of them has lost 50 pounds and said, “I love this.” That’s how I was introduced to it—and so far, I’m losing and loving it too.

When BiPAP Works… and the Blood Gas Looks “Worse”

2026-04-08T06:51:00.005-04:00

Here’s a scenario many respiratory therapists and clinicians have seen.

A chronic CO₂ retainer wears their BiPAP all night.
Morning labs come back.

And suddenly…

The pH is alkalemic.
The bicarbonate is higher.
The base excess is elevated.

At first glance, it looks confusing.
Shouldn’t the gas look better?

Actually — this is often a sign that BiPAP worked.

The Setup: Chronic CO₂ Retention

Many patients with:

COPD
Obesity hypoventilation syndrome
Chronic respiratory failure

Live with chronically elevated CO₂.

For example:

CO₂ in the 60–70 range
pH near normal
Elevated bicarbonate

How does the body tolerate this?

The kidneys compensate.

They retain bicarbonate to buffer the respiratory acidosis.
This is slow compensation — it takes days.

So over time, these patients develop:

High CO₂
High bicarbonate
Near-normal pH

This becomes their baseline.

Then Comes a Good Night on BiPAP

The patient wears BiPAP consistently overnight.

Ventilation improves.
CO₂ is blown off more effectively.
Gas exchange improves.

But here’s the key:

The kidneys cannot adjust quickly.

Respiratory changes happen in minutes to hours.
Renal compensation takes 24–72 hours.

So what happens?

CO₂ improves overnight
Bicarbonate remains elevated
pH rises

Result:

Metabolic alkalosis with alkalemic pH

It Looks Like This

Chronic respiratory acidosis (CO₂ ~63–65)
Renal compensation (chronically elevated bicarbonate)
Improved ventilation overnight with BiPAP
Kidneys can’t adjust quickly → bicarbonate stays high
Result → metabolic alkalosis / alkalemic pH

Why This Is Actually a Good Sign

When you see this pattern, it often means:

The patient wore their BiPAP
Ventilation improved
The body is adjusting

In other words:

The therapy worked.

It may look worse on paper — but clinically, it's often reassuring.

A Common Clinical Pearl

Chronic CO₂ retainers often develop post-hypercapnic metabolic alkalosis when ventilation improves.

This happens:

After BiPAP
After intubation
After improved ventilation
After resolving respiratory failure

It’s not unusual.
And usually, it resolves gradually.

Why It Still Matters

Significant metabolic alkalosis can:

Reduce respiratory drive
Promote CO₂ retention later
Make weaning more difficult

So it's worth:

Monitoring
Checking electrolytes
Watching trends

But in most cases, it’s expected physiology — not a problem.

The Bottom Line

Sometimes when BiPAP works…
the blood gas looks “worse.”

But when you understand the physiology, it makes perfect sense.

And often, it’s actually a quiet sign of improvement.

The Stages of Respiratory Therapy Apathy

2025-12-17T13:01:00.002-05:00

Stage 1: Innocence

You don’t know any better, so everything feels important.
A call comes from the ER and you drop whatever you’re doing — including your food — and rush down. STAT means stat. You walk fast. Sometimes you run. You feel needed.

Stage 2: Questioning

You start to notice things.
Why was this called stat? The patient looks fine. Why am I giving a breathing treatment to someone with a head cold? Is this pneumonia, or is she just wet?

You still do the work, but the questions start piling up.

Stage 3: Total Realization

At some point it hits you: a lot of what we do doesn’t change outcomes. Sometimes it just fills time. Sometimes it delays something else.

This lady doesn’t need it.

You do the treatment anyway — frustrated. An annoying patient really annoys you now. What burns you out isn’t just the work, it’s doing work that isn’t needed, over and over, until it piles up.

This is the stage where you try to educate. You explain to nurses. You explain to doctors. You go out of your way to say why it isn’t necessary.

And in the end, you do it anyway.

You realize you just wasted valuable time and training. You’ve been busy all day, finally sit down, and another treatment pops up. You feel it physically. Acceptance doesn’t arrive calmly — it arrives irritated.

Stage 4: Acceptance

You stop fighting reality. You understand the job for what it is. You may look at other careers. You may even daydream about leaving.

Then you realize leaving would mean more school, less money, or starting over.

So you stay.

You do what you’re told. You get it done. The anger fades, but it doesn’t completely disappear.

Stage 5: Selective Engagement

At this stage, you simply go into action.

You don’t blow up. You don’t complain — at least not much. You don’t argue anymore. You don’t try to change the course of treatment. You just do it, get it done, and go back to the RT cave.

You chill.

This is where experience finally turns into control. You don’t rush for everything anymore — you triage with your brain. You know when something actually matters and when it doesn’t. You still show up when it counts. You still advocate when it matters.

But you stop letting every unnecessary call hijack your nervous system.

You don’t care less.
You care more precisely.

And maybe that’s the part no one tells you:
apathy isn’t the end stage.

Clarity is.

Do Mucus-Clearing Treatments Really Work? A Look at the Evidence (and the Myths)

2025-11-15T05:09:00.002-05:00

I’ve been a respiratory therapist for 28 years and 4 days. Hard to believe it’s been that long. I remember learning about hypertonic saline in RT school back in ’96. By the time I hit the floors in ’97, it was already out of style — “proven useless.”

Now?

It’s back with a vengeance. I see it ordered almost every day for… whatever disease of the week.

Same with CPT.

We used to pound on the chests of every post-op patient as if soreness alone was a mucus diagnosis. Eventually studies caught up and said, “yeah… this doesn’t actually do anything.” Plus, hitting fragile 85-year-old ribs? Maybe not our best era.

Mucomyst has always been the strange child. Ordered for people who “can’t bring up secretions,” or because a doctor thinks “it’ll help.” And of course the whole room ends up smelling like rotten eggs. The only people who don’t mind are the ones so old they don’t care about anything anymore — including their own room smelling like poop, as their comode sits filled in the corner.

And after this many years in the job, you learn the difference between:

something that actually works
and
something that looks like work.

Hypertonic saline. Pulmozyme. Mucomyst. The Vest. Acapella. CPT.

We’ve all done them. We’ve all questioned them.

Some days you walk into a patient’s room and they have everything ordered. If I actually did all of it by the book, I’d be in the room for two straight hours. No thanks. Nobody’s got that kind of time.

And eventually the question creeps in:

Does any of this actually help the patient?

Or are we just doing it because we've always done it?

So I dug through the research — real numbers, solid studies, repeatable results. Because one study is not science, guys. Science is when multiple studies show the same thing again and again — and even then, people still argue about it. That’s real science. And honestly, the reason we debate it is because only God knows the full truth — we’re just here trying to figure out our tiny piece of it.

Here’s what actually holds up.

CYSTIC FIBROSIS

The only place where mucus therapy truly delivers — even if the gains are smaller than you think.

Hypertonic Saline (3–7%)

FEV₁ improves ~3%
Exacerbations drop ~50%
Good, repeatable evidence
Helps clear mucus and improves sleep

Pulmozyme (Dornase Alfa)

FEV₁ improves 5–12%
Fewer infections
Slows long-term decline

The Vest

Works about the same as solid manual CPT
FEV₁ improves 1–3%
Reliable long-term airway clearance

Now here’s the part no one says out loud:

"If Pulmozyme improves FEV₁ 5–12%, that means, in 88–95% of patients, of lung function does not change.

CF is the condition where these therapies shine — and even there, the gains are modest.

Still worth it. Still life-extending. Just not magic.

BRONCHIECTASIS (Non-CF)

Helpful, but not groundbreaking.

OPEP Devices (Acapella, Aerobika, PEP)

Patients feel less congested
Increased sputum production
FEV₁ improves 1–3% (which also means it does absolutely nothing in the other 97–99% of cases).
Some studies show 10–20% fewer exacerbations (So in 80-90% of cases it has no effect)

The Vest

Helps move mucus
Patients feel better
Minimal FEV₁ impact

Bottom line:
Therapies help people feel better and cough more effectively —
but they barely move the pulmonary function numbers.

THE VEST (General Use)

It looks dramatic. It sounds dramatic.
It helps the right patients — but it’s ordered for the wrong ones just as often.

Good for:

CF
Bronchiectasis
Chronic heavy secretions

Not good for:

Most COPD patients
Pneumonia
Mild secretions
People who just “have rhonchi”

The Vest does not:

Improve oxygenation
Shorten hospital stays

A lot of doctors order it because it feels like “doing something.”
The evidence does not back that up for most inpatients.

COPD

The land where tradition rules over data.

Most COPD orders look like this:

Mucomyst
Acapella
Light CPT
Maybe the Vest (usually pointless)

Mucomyst (NAC Neb)

We all know it thins mucus.
But when you actually look at outcomes?

No meaningful FEV₁ change
No better oxygenation
No reduction in hospitalizations
Bronchospasm 10–20%
Studies are old and weak

Translation:
Mucomyst for COPD is 90% tradition, 10% actual effect.

And the smell?
Rotten eggs. Every time.

Acapella / Aerobika

This actually does something.

Helps mobilize mucus
Patients feel better after using it
FEV₁ changes 0–2%
Some studies: 10–30% fewer COPD readmissions

Not a miracle — but useful.

The Vest (in COPD)

The research says:

Helps the small handful of COPD patients with lots of mucus
Does little to nothing for the majority
No significant FEV₁ improvement
No consistent length-of-stay improvement

80–90% of COPD patients get almost no benefit.

Yet it still gets ordered on autopilot.

PNEUMONIA

If we’re doing airway clearance here, we’re doing it for comfort — not cure.

Research shows:

Chest PT does not cure pneumonia faster
Vest does not improve oxygenation
OPEP does not reduce mortality
ACT does not reduce complications
Does not shorten length of stay

The only tiny benefit?
A couple small studies suggest fever may break 12 hours sooner.

That’s it.

NEUROMUSCULAR & SPINAL CORD INJURY

Finally — a therapy that actually does exactly what it should.

CoughAssist / MIE

Increases cough flow 50–150%
Prevents mucus plugging
Cuts pneumonia risk
Reduces intubations
Reduces hospitalizations

These patients don’t have a mucus problem —
they have a weak cough problem.

This device is a game-changer.

THE BOTTOM LINE

After almost three decades doing this job, this is the simplest way I can put it:

Some therapies help a lot.
Some help a little.
Some don’t help much at all.

But tradition sticks around forever.

And some days, when you’re dragging a Vest into the room of a COPD patient who hasn’t coughed anything up since 2003, you can feel the gap between what we know and what we’re ordered to do.

Here’s the honest breakdown:

STRONG EVIDENCE

Pulmozyme (CF)
Hypertonic saline (CF)
CoughAssist (NMD, spinal injury)

MODERATE EVIDENCE

Acapella / Aerobika
OPEP for bronchiectasis
The Vest for CF & bronchiectasis

WEAK EVIDENCE

Mucomyst for COPD
The Vest for COPD
Chest PT for pneumonia
OPEP for pneumonia

ALMOST NO EVIDENCE

“We have to order something.”

I’m not trying to stir drama. I love respiratory care.
But I also like knowing the difference between what works and what’s just habit.

And honestly?

If a therapy only helps 10% of patients,
that means 90% of the time we’re basically doing busywork.
That’s not bad RT care — it’s just the reality of old habits in medicine.

And that’s why asking questions matters.

Giving Health Care Power Back to the People -- Fixing Obamacare

2025-11-13T09:24:00.000-05:00

Why the ACA can stay — but the money should follow the consumer

The Affordable Care Act (Obamacare) has been around for over a decade now, and it’s not going anywhere. It’s helped millions of Americans gain access to health insurance who otherwise might not have had it. That’s a good thing — nobody should go without coverage in a country like ours.

But there’s something that’s never sat right about how the system works.

Right now, the government sends premium tax credits — money meant to help lower- and middle-income families afford insurance — directly to insurance companies. That means the government pays the companies first, and consumers just pick from what’s left on the shelf.

It’s a system that guarantees access — but not competition. And without competition, prices rarely go down.

What if the money followed the person?

Imagine a system where the same ACA tax credits go directly to you — not the insurance companies. You could still use those credits to buy insurance, but you’d decide where to spend them.

You’d be free to shop around, compare plans, and reward the companies that offer the best coverage for the best price.

In other words, you’d be the customer — not the middleman.

Insurance companies would have to compete for your business. They’d have to innovate, streamline, and actually lower premiums to attract you.

Competition is what drives every healthy market — and health care should be no different.

Keeping what works — fixing what doesn’t

We don’t have to scrap Obamacare to make this happen. The structure already exists:

The tax credits are already there.
The income limits and protections are already in place.
People already use the Marketplace to compare plans.

The only change would be who gets the money first.

Right now, insurers get guaranteed payments — no matter how good or bad their service is. If consumers got the credit directly, those same companies would suddenly have a reason to earn it.

You could still choose from any approved plan. The government could still make sure everyone has access. The difference is that the power shifts from Washington and big insurers — to you.

Why this matters

Since the ACA passed, insurance companies have grown richer, not leaner. Health care costs haven’t gone down. Premiums keep climbing. And for many families, “affordable” coverage still means sky-high deductibles.

If the goal is affordable care, then we need real competition — not government-protected monopolies.

By giving consumers control of the credits, we’d see:

More innovation among insurance companies.
Transparent pricing and simpler plans.
A stronger link between value and cost.

It’s the same logic that makes every other market work — when people control the money, businesses listen.

A simple, fair middle ground

We can keep the ACA, keep protections for people with preexisting conditions, and keep access open — all while making the system work for consumers, not just insurance companies.

Let the government fund health care, but let people choose where their dollars go.

If that sounds like common sense — it’s because it is.

Myth Buster: Don’t Panic Over One Frickin’ Study

2025-11-04T17:30:00.003-05:00

Melatonin made headlines again this week—this time for supposedly increasing the risk of heart failure by 90 percent.

Cue the panic, the clickbait, and the sudden flood of patients ready to toss every bottle of sleep aid into the trash.

Let’s slow down.

Science Doesn’t Work on Panic

Real science isn’t built on a single data dump. It’s built on reproducibility—different teams, different patients, same results.
One study—no matter how big—only raises a question. It doesn’t answer it.

The research making the rounds came from an observational look at 130,000 people with insomnia.
The folks taking melatonin long-term seemed more likely to develop heart failure.
Interesting? Yes.
Proof? Nope.

They weren’t randomized.
They already had insomnia (a known heart-risk condition).
We don’t know their doses, their over-the-counter brands, or how accurate their medical coding was.

In other words, this study says, “Hey, we noticed something weird. Somebody should check this out.”
That’s how science starts—not how it ends.

How This Should Actually Change Behavior

If you pop melatonin occasionally to reset after night shifts or travel, this isn’t your cue to panic.
If you’ve been taking 10 mg every night for years, maybe talk with your doc about whether you still need it.
Use data as information, not as doom.

The smarter takeaway is balance:

Don’t treat any supplement like candy.
Don’t assume “natural” equals “harmless.”
And don’t change meds or supplements because of a single headline.

What To Do Instead

Talk to your provider before stopping or starting anything.
Stay curious, not fearful. Ask why the data might look that way.
Watch for follow-ups. If three or four future studies confirm the same link, then we have something real to chew on.

Until then, melatonin is still what it always was: a hormone your body already makes, sometimes helpful, sometimes over-used, rarely catastrophic.

Bottom Line

Don’t stop taking melatonin—or any medication—because of one frickin’ study.
Science isn’t a headline. It’s a process.

Breathe. Sleep. Question everything—but don’t overreact.book

I write this and I don't even take Melatonin. Still, I'm smart enough to know that one study is not science. People tried to pull that tone on us during Covid, where one study showed masked present COVID, whan all it showed was that it reduced your risk for COVID a few percentage points. Be careful what you read.