COPD patients may feel dyspnea in flight

If you have COPD you may have noticed that your breathing is a bit more difficult when you are flying. And this poses an additional challenge for you that people with "normal" lungs don't have to worry about.

In fact, a new study by Norwegian scientists revealed that COPD patients flying were over six times more likely to experience hypoxia (low oxygen in the blood) and feel dyspnea (feeling of shortness of breath) while flying.

One of the main reasons is because those with COPD already carry less oxygen in their arteries, which are the vessels in the body that carry freshly oxygenated blood to tissues. When the lung are chronically obstructed, less oxygen is able to get to the lungs, and this results in less blood to the arteries.

While under the pressure of the cabin of an airplane, the amount of oxygen in the air is already less than on the ground. For example, the fraction of oxygen inspired (FiO2) at ocean level is 21%. Yet the higher you go the lower the percentage of oxygen that's available to breath.

For example, at the top of a mountain, or in the cabin of an airplane, the FiO2 may be as low as 19%. This might cause dyspnea in a person with normal lungs. Yet in a person with COPD, who already has less oxygen in the lungs and arteries, this will almost certainly cause a feeling of shortness of breath.

Consider the following facts according to Egan's Fundamentals of Respiratory Care:

The air we inhale consists of 21% oxygen. In the medical arena we refer to this 21 percent as the fractional concentration of oxygen, otherwise known as the fraction of inspired oxygen (FiO2).

Thus, to compute the partial pressure of oxygen (PO2) you multiply the FiO2 by the total pressure of the atmosphere. A normal atmospheric pressure is 760 mm Hg at sea level.

Or, the formula would look like this:

• PO2 = 0.21 * 760 = 160 mm Hg

So the normal PO2 of oxygen we inhale is 160 mm Hg
Now, according to Egans, "At a typical cruising altitude of 30,000 feet, the barometric pressure outside the airplane cabin is about 226 mm Hg. Thus, the partial pressure of the inspired oxygen (PO2) would be calculated as such:

• PO2 = 0.21 * 226 = 47 mm Hg

"Thus, should the cabin depressurize, travelers inside would be exposed to this low PO2, most people would become unconscious within seconds, and will eventually die of lack of oxygen (anoxia)."
To fix this problem, the passengers would wear oxygen masks that supply 70% oxygen. This new formula would be calculated as such:

• PO2 = 0.75 * 226 = 158 mm Hg

This would supply enough oxygen to sustain life.
Still, as you go higher, the PO2 will decrease the higher you go because the barometric pressure changes. So COPD patients who already have a low PO2 inside their arteries are going to feel the effect of a lower atmoshperic PO2 as compared to someone with normal lungs and a normal PO2.
Consider that oxygen travels the path of least resistance. By this, the normal PO2 in the atmoshpere is 160, the normal PO2 in the arteries is 104, and the normal PO2 in the veins is 40. So oxygen travels easily from the air, to the lungs and arteries, and then from the tissues to the veins.
However, with COPD the PO2 in your arteries might be 60 instead of 104. So if the PO2 in the atmosphere is low, the PO2 in your arteries will be even lower. Hence, you may feel dyspneic before other passengers would.
It should be said here that the percent of oxygen in the air inhaled (whether it be 21% or 75%) does not determine how the oxygen works in the body. How the oxygen works is determined by the partial pressure of oxygen inhaled (PO2).
So, the lower the PO2 inspired the more dyspnea a person will feel. This is why mountain climbers and pilots sometimes carry extra oxygen with them. By increasing the FiO2, we can increase the PO2.
The barometric pressure
So if you are flying, and you have COPD, you may want to discuss the the airline the possibility that you might require oxygen in flight. If you already have oxygen at home, then you definitely want to either take it with you, or work with the airline to make sure oxygen is available to you in flight.

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COPD patients may feel dyspnea in flight

If you have COPD you may have noticed that your breathing is a bit more difficult when you are flying. And this poses an additional challenge for you that people with "normal" lungs don't have to worry about.

In fact, a new study by Norwegian scientists revealed that COPD patients flying were over six times more likely to experience hypoxia (low oxygen in the blood) and feel dyspnea (feeling of shortness of breath) while flying.

One of the main reasons is because those with COPD already carry less oxygen in their arteries, which are the vessels in the body that carry freshly oxygenated blood to tissues. When the lung are chronically obstructed, less oxygen is able to get to the lungs, and this results in less blood to the arteries.

While under the pressure of the cabin of an airplane, the amount of oxygen in the air is already less than on the ground. For example, the fraction of oxygen inspired (FiO2) at ocean level is 21%. Yet the higher you go the lower the percentage of oxygen that's available to breath.

For example, at the top of a mountain, or in the cabin of an airplane, the FiO2 may be as low as 19%. This might cause dyspnea in a person with normal lungs. Yet in a person with COPD, who already has less oxygen in the lungs and arteries, this will almost certainly cause a feeling of shortness of breath.

Consider the following facts according to Egan's Fundamentals of Respiratory Care:

The air we inhale consists of 21% oxygen. In the medical arena we refer to this 21 percent as the fractional concentration of oxygen, otherwise known as the fraction of inspired oxygen (FiO2).

Thus, to compute the partial pressure of oxygen (PO2) you multiply the FiO2 by the total pressure of the atmosphere. A normal atmospheric pressure is 760 mm Hg at sea level.

Or, the formula would look like this:

• PO2 = 0.21 * 760 = 160 mm Hg

So the normal PO2 of oxygen we inhale is 160 mm Hg
Now, according to Egans, "At a typical cruising altitude of 30,000 feet, the barometric pressure outside the airplane cabin is about 226 mm Hg. Thus, the partial pressure of the inspired oxygen (PO2) would be calculated as such:

• PO2 = 0.21 * 226 = 47 mm Hg

"Thus, should the cabin depressurize, travelers inside would be exposed to this low PO2, most people would become unconscious within seconds, and will eventually die of lack of oxygen (anoxia)."
To fix this problem, the passengers would wear oxygen masks that supply 70% oxygen. This new formula would be calculated as such:

• PO2 = 0.75 * 226 = 158 mm Hg

This would supply enough oxygen to sustain life.
Still, as you go higher, the PO2 will decrease the higher you go because the barometric pressure changes. So COPD patients who already have a low PO2 inside their arteries are going to feel the effect of a lower atmoshperic PO2 as compared to someone with normal lungs and a normal PO2.
Consider that oxygen travels the path of least resistance. By this, the normal PO2 in the atmoshpere is 160, the normal PO2 in the arteries is 104, and the normal PO2 in the veins is 40. So oxygen travels easily from the air, to the lungs and arteries, and then from the tissues to the veins.
However, with COPD the PO2 in your arteries might be 60 instead of 104. So if the PO2 in the atmosphere is low, the PO2 in your arteries will be even lower. Hence, you may feel dyspneic before other passengers would.
It should be said here that the percent of oxygen in the air inhaled (whether it be 21% or 75%) does not determine how the oxygen works in the body. How the oxygen works is determined by the partial pressure of oxygen inhaled (PO2).
So, the lower the PO2 inspired the more dyspnea a person will feel. This is why mountain climbers and pilots sometimes carry extra oxygen with them. By increasing the FiO2, we can increase the PO2.
The barometric pressure
So if you are flying, and you have COPD, you may want to discuss the the airline the possibility that you might require oxygen in flight. If you already have oxygen at home, then you definitely want to either take it with you, or work with the airline to make sure oxygen is available to you in flight.

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Breathing treatments make no money for hospital

When it comes to your RT department boss being happy by the breathing treatment count, he is not happy because a breathing treatment means higher profits for the RT department and the hospital. That's not the case at all.

The truth is, he's happy because of the procedure count. Procedure count is important because the more procedures a department does, the more money is allocated to your department. Likewise, the procedure count has to be high enough to justify the allocation of a staff position.

That's right. In order for you to keep your job you have to do so much work. So the next time you or your co-worker complain about needless work, just think of it from this perspective. I like protocols, yet if we discontinue all needless procedures, we RTs will be our of work.

And trust me, I too am one to complain about needless work. For one thing it makes me feel like an assembly line worker: it diminishes self esteem, dignity and mercy. However, a job is a job. It pays the bills.

As far as reimbursement is concerned for a specific patient, it is a fact that it doesn't matter if you give 1 treatment or 100 to a patient on Medicare or Medicaid, because the Centers for Medicaid and Medicare Services (CMS) reimburses a flat fee for each diagnosis related group (DRG).

This is what happens when we allow the government to make the rules. This is what happens when the government is flipping the bill. So while your department charge for a breathing treatment might be $100, the only person paying that $100 is the person who has no health insurance.

Actually, the best health care reform would be to make it so that people without health insurance paid the same as those who do. This might help lower the cost of medicine as far as the customer is concerned, and it might just allow people visiting hospitals a better opportunity to pay the bill. It might prevent some health related bankruptcies.

On a related issue, Anthony L. DeWitt (AARC Times, December 2010), Whisteblowing 101, wrote that a hospital can bill for the 10 treatments that were ordered while the patient was admitted, and this will not be considered as fraud even if the treatments were not given.

The same principle applies: CMS reimburses a flat fee for a specific DRG (diagnosis). DeWitt writes that:

"In essence, the hospital is banking on being able to treat the patient efficiently and get them out of the hospital quickly. So whether the patient gets one treatment or 10 treatments, the cost to Medicare is the same because it's calculated on the basis of the diagnosis. Internally, the hospital can bill for 40 treatments never done, and it won't have any effect on the final bill to Medicare."

Poppycock? Why sure it is. Yet such is how it is when the government is in charge of flipping the bill. However, as goofy as this sounds, useless and un-indicated breathing treatments that burn you and me out might be what's keeping us on the job.


Something to think about anyway.


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Breathing treatments make no money for hospital

When it comes to your RT department boss being happy by the breathing treatment count, he is not happy because a breathing treatment means higher profits for the RT department and the hospital. That's not the case at all.

The truth is, he's happy because of the procedure count. Procedure count is important because the more procedures a department does, the more money is allocated to your department. Likewise, the procedure count has to be high enough to justify the allocation of a staff position.

That's right. In order for you to keep your job you have to do so much work. So the next time you or your co-worker complain about needless work, just think of it from this perspective. I like protocols, yet if we discontinue all needless procedures, we RTs will be our of work.

And trust me, I too am one to complain about needless work. For one thing it makes me feel like an assembly line worker: it diminishes self esteem, dignity and mercy. However, a job is a job. It pays the bills.

As far as reimbursement is concerned for a specific patient, it is a fact that it doesn't matter if you give 1 treatment or 100 to a patient on Medicare or Medicaid, because the Centers for Medicaid and Medicare Services (CMS) reimburses a flat fee for each diagnosis related group (DRG).

This is what happens when we allow the government to make the rules. This is what happens when the government is flipping the bill. So while your department charge for a breathing treatment might be $100, the only person paying that $100 is the person who has no health insurance.

Actually, the best health care reform would be to make it so that people without health insurance paid the same as those who do. This might help lower the cost of medicine as far as the customer is concerned, and it might just allow people visiting hospitals a better opportunity to pay the bill. It might prevent some health related bankruptcies.

On a related issue, Anthony L. DeWitt (AARC Times, December 2010), Whisteblowing 101, wrote that a hospital can bill for the 10 treatments that were ordered while the patient was admitted, and this will not be considered as fraud even if the treatments were not given.

The same principle applies: CMS reimburses a flat fee for a specific DRG (diagnosis). DeWitt writes that:

"In essence, the hospital is banking on being able to treat the patient efficiently and get them out of the hospital quickly. So whether the patient gets one treatment or 10 treatments, the cost to Medicare is the same because it's calculated on the basis of the diagnosis. Internally, the hospital can bill for 40 treatments never done, and it won't have any effect on the final bill to Medicare."

Poppycock? Why sure it is. Yet such is how it is when the government is in charge of flipping the bill. However, as goofy as this sounds, useless and un-indicated breathing treatments that burn you and me out might be what's keeping us on the job.


Something to think about anyway.


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Is itchy lungs normal with asthma?

The following is a q and a session from Myasthma central.com I though my fellow asthmatics might be interested in:

Your question: I have an itchy sensation in my upper back and chest. It feels like my lungs are itching yet I can't scratch it. Does this have something to do with asthma. I used to get this sensation a lot as a kid, yet accassionally as an adult. I just got over a week long dose of antibiotics for an infection that I think is resolved by now. What do you think?

My humble answer: I'd like to reiterate this could be normal with asthma. It could be that the infection in your lungs is breaking up and the secretions in there are irritating your airways, causing them to itch. I had this feeling many times too, although mostly as a kid. I think it's more common in kids because their airways are smaller (this is also why asthma tends to be worse in kids too).

It usually resolves with time, or sometimes with the use of your rescue medicine. However, if it doesn't, it might possibly be an early warning sign of an asthma attack, perhaps caused by a new onset of infection. So if it doesn't dissipate you may need to put your asthma action plan into action.

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Is itchy lungs normal with asthma?

The following is a q and a session from Myasthma central.com I though my fellow asthmatics might be interested in:

Your question: I have an itchy sensation in my upper back and chest. It feels like my lungs are itching yet I can't scratch it. Does this have something to do with asthma. I used to get this sensation a lot as a kid, yet accassionally as an adult. I just got over a week long dose of antibiotics for an infection that I think is resolved by now. What do you think?

My humble answer: I'd like to reiterate this could be normal with asthma. It could be that the infection in your lungs is breaking up and the secretions in there are irritating your airways, causing them to itch. I had this feeling many times too, although mostly as a kid. I think it's more common in kids because their airways are smaller (this is also why asthma tends to be worse in kids too).

It usually resolves with time, or sometimes with the use of your rescue medicine. However, if it doesn't, it might possibly be an early warning sign of an asthma attack, perhaps caused by a new onset of infection. So if it doesn't dissipate you may need to put your asthma action plan into action.

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Don't forget you have asthma

You outgrew your asthma, and now it seems as though it has gone away. In the past I wrote about asthma forgetfulness and recovered asthmatics. In a more recent post from AsthmaCentral.com I provide some reasons you MUST never forget you have asthma.

9 Reasons You Must Never Forget You Have Asthma

In the first season of "The Biggest Loser" one of the final contestants lost a ton of weight, and he proclaimed in his ebulient New York accent something like, "The best part of losing all this weight is: my asthma is gone. Gone! GONE!!!"

This happens to a lot of people. The reason is because asthma is a strange disease, in that it can be bothersome one minute, and then it can go into remission for days, weeks, months and even years. In essence, it can appear to be gone. Gone! GONE!!!

Yet it's not. And because it's not you must continue to know you still have asthma, and you should continue to work with your doctor. That's right: it's a myth that asthma goes away with age.

In some cases your asthma may get so much better your doctor may actually allow you to quit taking your asthma medicines. To learn when you can quit taking your asthma medicine check out this post.

The following are some reasons your asthma might seem to be gone, and why you must never forget you have it:

9. You are on the best asthma medicine: Some people have good control of their asthma because of the newer asthma medicines used to treat it. Thus, if you stop taking your asthma controller medicines your asthma may come back.

8. You never had asthma to begin with: Well, it probably doesn't happen to much any more, yet there are some diseases that can mimic asthma symptoms. To learn how doctors determine if it's asthma, click here.

7. You lost weight: Recent science has have proven that obesity not only can make asthma worse, it can also make asthma medicines less effective. So it only makes sense that shedding those extra pounds will make your asthma seem to go away. If you forget you have asthma, you may forget the importance of keeping off the pounds.

6. You are in better shape: Study after study has confirmed that exercise not only helps you maintain or lose weight, it also helps to make your heart and lungs stronger and work better. Good asthma control and exercise may go hand in hand.

5. As an adult you have more control: When I was a kid we had a dog, and getting rid of it was not an option because my brothers would have thrown a fit. We also had a Michigan basement (half of it was sand), and Lord knows there were many asthma triggers down there such as molds and fungus. In this way, I had no control of my surroundings, and this made my asthma worse. As an adult I have complete control, and have made sure to limit asthma triggers in my home. Thus, if you forget you have asthma, you may actually move into a home filled with asthma triggers.

4. You moved away from your asthma triggers: My asthma was bad when I was a kid, yet when I went off to college it seemed to disappeare. Chances are, in the confines of my dorm room, there were fewer molds and other asthma triggers. The result was fewer asthma triggers and fewer asthma symptoms.

3. You don't roll around in the dirt anymore: Well, it's true. When we're kids, we tend to play outside with our friends, and we're more likely to be exposed to our asthma triggers, like dusts, molds, etc. As we grow up we move away from the ground, per se. We don't roll around in the wood chips and dust under swing sets and porches.

2. Your Lungs become less sensitive as you age: So you're now able to sit in the hay shed without your asthma acting up. Chances are it's because as you grew older your airways became less sentitive to your old asthma triggers.

1. Your lungs get bigger as you age: William E. Berger in Asthma for Dummies, writes, "As children grow, their lungs and airways become larger. If the amount of airway obstruction stays the same, the blockage may proportionally constitute a smaller part of the total airway diameter, thus resulting in fewer symptoms as an adult.

It is very important that if your asthma is in remission (if you want to use that word), that you never forget that you still do have asthma. The reason is simple: if you forget you have asthma, your symptoms may come back.

So be smart, stay wise to asthma facts by continuing to hang out with us on this site, and you'll continue to maintain good control of your asthma. With time, your asthma may also appear to be gone! Gone! GONE!!!

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Here are my last wishes

Based on my own experiences with end of life care, I have discussed the following with my wife, who would be in charge of making decisions for me should I become incapable of such. I think it's important that every human adult have a similar discussion with someone to assure you don't end up a vegetable in the care of the government.

At this point in my life when I am relatively healthy, I do not want to be a DNR. If I stopped breathing, or if my heart were to stop, I'd like medical workers to do whatever they had to do to try to save my life. I call for this mainly because I value life and love life.

However, if I arrive in the hospital after CPR has been done on me for a half hour and my face is STILL blue by this time, just let me go. If you think I'm gonna not be me when I wake up, just do the humane thing and let me go.

I do not mind if I have to be on a ventilator for a few days in order to give medical professionals the opportunity to rest my body and treat the underlying cause of my problem. Yet if whatever caused me to be on a vent is terminal, then after a few days just pull the plug. Considering I have asthma, I do not want to suffocate.

Oh, and that's the next area of discussion. I do not want to suffocate at the end of my life. If I appear to you as a fish out of water, then give me all the oxygen I want and sedate me to the point I'm comfortable. Don't let me drown. Don't let me suffer in pain.

Also, if I so happen to by a CO2 retainer, and I need oxygen, make the doctor give me oxygen. Don't let the doctor deprive me of the main source needed to maintain life. Don't make him let me suffocate because of the hypoxic drive hoax.

If I have a chronic disease and am chronically addicted to pain killers or alcohol or other drugs as a result, don't allow a doctor to set me in a hospital bed and allow me to go through detox. Have him solve my underlying problem and then he can deal with the addiction. So make him give me some kind of sedative.

Now, if I have a CO2 greater than 80 (like say 190), again, don't let my doctor withhold sedatives because he's afraid my breathing will slow down and my CO2 will rise. Don't make me suffer this way.

This is especially true if I'm awake and fighting the RT and the RN and the DRs efforts to treat me. Say, for example, the doctor order is for me to be on BiPAP, and I keep refusing to keep the BiPAP mask on (which I can see myself doing), don't allow the nurse to hold my hands down while the RT forcibly puts the mask back on my face.

Please, if this is the case, just let me have my way.

Look, I don't mind if I need to be on a ventilator to get over the hump, and I don't think I even would mind being ventilator dependent so long as my brain is fully in tact. Yet I do not want either of the above if my brain is not intact.

In summary, if I'm blue oxygenate me. If I'm still blue, ventilate me. If I'm still blue, just let me go. And don't be blue yourself, because I'll be in a happier place. My time has come. And by me writing you this letter you should be at peace knowing I lived a good life and you prevented me from unduly suffering at the hands of medical professionals who have to do everything for fear of getting sued -- unless you step in.

Oh, and one more thing. Be good to the people caring for me, even if they aren't friendly. Don't be sue happy just because you're angry I died (because I don't want you to be angry. I want you to be happy for me). However, in the rare chance of medical neglect, feel free to do what you need to do.

Likewise, since I will no longer be using my body, don't let my body rot for no good reason if it can be of use to help someone else live a better life in the one they currently have. Don't be afraid to donate certain parts of my body to the Gift of Life.

I know it sounds kind of disgusting, yet I believe God's underlying mission for each of us in this life is to make life better for our fellow men and women. I know I've done my part on this earth by improving the lives of many in my own way (hence my blog family and my own family). So don't be afraid to let me make one final gift to a fellow human being.

There, I think I covered all the bases. Life is good. But life without a brain is not good. I'd much rather move on to be with the Lord than to be a vegetable in this one. Capish.

Now, I don't plan on dying any time soon. Yet I write this post because I've seen some horrible things in the hospital setting. Sure I've seen many miracles and have seen more good things than I'll ever see horrible things. Yet the end of life should be peaceful, and that's how I want mine to be.

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Here are my last wishes

Based on my own experiences with end of life care, I have discussed the following with my wife, who would be in charge of making decisions for me should I become incapable of such. I think it's important that every human adult have a similar discussion with someone to assure you don't end up a vegetable in the care of the government.

At this point in my life when I am relatively healthy, I do not want to be a DNR. If I stopped breathing, or if my heart were to stop, I'd like medical workers to do whatever they had to do to try to save my life. I call for this mainly because I value life and love life.

However, if I arrive in the hospital after CPR has been done on me for a half hour and my face is STILL blue by this time, just let me go. If you think I'm gonna not be me when I wake up, just do the humane thing and let me go.

I do not mind if I have to be on a ventilator for a few days in order to give medical professionals the opportunity to rest my body and treat the underlying cause of my problem. Yet if whatever caused me to be on a vent is terminal, then after a few days just pull the plug. Considering I have asthma, I do not want to suffocate.

Oh, and that's the next area of discussion. I do not want to suffocate at the end of my life. If I appear to you as a fish out of water, then give me all the oxygen I want and sedate me to the point I'm comfortable. Don't let me drown. Don't let me suffer in pain.

Also, if I so happen to by a CO2 retainer, and I need oxygen, make the doctor give me oxygen. Don't let the doctor deprive me of the main source needed to maintain life. Don't make him let me suffocate because of the hypoxic drive hoax.

If I have a chronic disease and am chronically addicted to pain killers or alcohol or other drugs as a result, don't allow a doctor to set me in a hospital bed and allow me to go through detox. Have him solve my underlying problem and then he can deal with the addiction. So make him give me some kind of sedative.

Now, if I have a CO2 greater than 80 (like say 190), again, don't let my doctor withhold sedatives because he's afraid my breathing will slow down and my CO2 will rise. Don't make me suffer this way.

This is especially true if I'm awake and fighting the RT and the RN and the DRs efforts to treat me. Say, for example, the doctor order is for me to be on BiPAP, and I keep refusing to keep the BiPAP mask on (which I can see myself doing), don't allow the nurse to hold my hands down while the RT forcibly puts the mask back on my face.

Please, if this is the case, just let me have my way.

Look, I don't mind if I need to be on a ventilator to get over the hump, and I don't think I even would mind being ventilator dependent so long as my brain is fully in tact. Yet I do not want either of the above if my brain is not intact.

In summary, if I'm blue oxygenate me. If I'm still blue, ventilate me. If I'm still blue, just let me go. And don't be blue yourself, because I'll be in a happier place. My time has come. And by me writing you this letter you should be at peace knowing I lived a good life and you prevented me from unduly suffering at the hands of medical professionals who have to do everything for fear of getting sued -- unless you step in.

Oh, and one more thing. Be good to the people caring for me, even if they aren't friendly. Don't be sue happy just because you're angry I died (because I don't want you to be angry. I want you to be happy for me). However, in the rare chance of medical neglect, feel free to do what you need to do.

Likewise, since I will no longer be using my body, don't let my body rot for no good reason if it can be of use to help someone else live a better life in the one they currently have. Don't be afraid to donate certain parts of my body to the Gift of Life.

I know it sounds kind of disgusting, yet I believe God's underlying mission for each of us in this life is to make life better for our fellow men and women. I know I've done my part on this earth by improving the lives of many in my own way (hence my blog family and my own family). So don't be afraid to let me make one final gift to a fellow human being.

There, I think I covered all the bases. Life is good. But life without a brain is not good. I'd much rather move on to be with the Lord than to be a vegetable in this one. Capish.

Now, I don't plan on dying any time soon. Yet I write this post because I've seen some horrible things in the hospital setting. Sure I've seen many miracles and have seen more good things than I'll ever see horrible things. Yet the end of life should be peaceful, and that's how I want mine to be.

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The Primacy of Safety

Feeling safe is necessary for relationships, for fun, for relaxation, for sleep, for concentration, for verbal learning, in fact for daily living. I have quoted before the experiment in which baby rats in a cage were playing, and the experimenters introduced three cat hairs for ten minutes. All play stopped. When the cat hairs were removed, it was weeks before the play started again and it never resumed its previous levels.

The kids we work with feel so unsafe. They are constantly on the lookout for the danger that has permeated every part of their lives. A central fact of their existence is that any small indication of danger sends them into full life-or-death alert mode. And the world is full of indications of danger.

So how do we recognize this, make sense of it and work with it? How do we help our kids to feel safer?

Allison talks often about feeling unsafe. And, in fact the other girls do pick on her and at times assault her. Allison comes out of her room and stands in the lounge swearing at the girls, calling them names and insulting their families. She is smart and knows exactly what to say to each individual girl to totally infuriate her, and she constantly does so.

Malcolm runs away two or three times a week. Anything at all that upsets him can trigger him to run away. Often it doesn’t seem that anything has upset him, and the run aways seem planned. He often persuades other boys to go with him. When he runs he puts himself in very unsafe situations. He also does self destructive things, including jumping into the street and using his belt to threaten to hang himself in the middle of a town park.

Both Allison and Malcolm have had very unsafe lives, and now seem to be deliberately courting danger with every ability that they have. How do we understand this?

Maybe it feels safer for Allison to bring the danger and abuse on herself; at least she has some control. It may feel to her like she has the upper hand over others for once, even when it results in her being hurt. Maybe when the unit is calm and quiet Allison feels foreboding, like something terrible is about to happen. So she precipitates it and no longer has to wait for it.

Maybe Malcolm is so used to a life of danger that it feels familiar to him. Maybe the danger of relationships, letting people down, failing, being disappointing others, is so acute that the danger on the streets pales in comparison. Maybe (using a reenactment approach) he relishes leading others into danger instead of being led.

We can look at the patterns, explore with the kids how they feel and what they think just before they do something, and gradually come to an understanding of the adaptive function of these behaviors for these particular kids.

So what can we do to help these children and all the others in our care?

First, of course, we should try to achieve as much actual safety as we possibly can. With staff supervision, schedules, routines, checks, the physical environment, and planning we should create as safe a world as we can.

Then let’s talk about safety in our community. In unit groups let’s discuss what kind of community we want to live in. It is important to acknowledge that everyone there has experienced an unsafe childhood, and has not been protected as they should have been. We can use a psycho-ed approach to teach the youth about how early exposure to danger changes the bio-chemistry of the brain and body, and hence every youth there reacts easily to any sign of danger. We can teach them to observe this in themselves and others, and hopefully over time to feel some compassion for themselves and each other. And we can collaboratively develop some plans for our community by which we will increase everyone’s safety.

And let’s actively address the issue of safety with each individual child. This could include (depending on what fits with the individual) looking at and mourning the ways the child was not kept safe when she was young. We could talk about what makes him feel safe and unsafe. How do you make others feel safe or unsafe? We could be clear that we are trying to be different than adults in their past: we are trying to keep them safe. We can use multi media: drawing, collages, music, movies, all exploring safety and lack of safety. We must surround this investigation with as many experiences as possible in which the youth is engaged in positive, active, physical fun interactions with caring adults. All members of the team should know that the treatment theme is safety, and inquire and comment regularly on their own feelings of safety in a given situation.

Our days in residential are precarious. We are always trying to keep groups of deeply suffering children safe. The more we are aware of this, articulate it, and address it collaboratively with our kids, the better chance we have at succeeding.

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Rules

---

To: Bosses

From: Workers

Regarding: Rules

Message: Some rules are good. They keep people in line and create unity. Yet when there are too many rules, or when rules are created every time something undesirable occurs, rules cease to have an added benefit. In fact, rules are good up to a certain point of which you reach a point of diminishing returns.

What you have to remember about rules is that each one takes away a freedom; each decreases choice; each decreases individual thought; each decreases individual creativity; they decrease the incentive to think. And this is not good for a hospital, where critical thinking is essential.

Besides, it gets to the point that if you add so many rules it's hard to follow them all, and your staff will get sloppy with some of the laws. This will result in unhappiness on both your part and theirs, and ultimately low morale.

Keep in mind that people are smart and poeple make mistakes. We don't need rules to manage every aspect of our lives. While you might get upset over a crumb on the ground, to others this may not matter so much. So you don't need to make a rule that you can't eat in the break room

If you have a problem with one particular worker, talk to that person. Don't punish the entire department with new rules. And, likewise, if you create a new rule, take away an old rule that's no longer needed anymore. That would make more sense.

Sincerelly,

Staff

---

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Rules

---

To: Bosses

From: Workers

Regarding: Rules

Message: Some rules are good. They keep people in line and create unity. Yet when there are too many rules, or when rules are created every time something undesirable occurs, rules cease to have an added benefit. In fact, rules are good up to a certain point of which you reach a point of diminishing returns.

What you have to remember about rules is that each one takes away a freedom; each decreases choice; each decreases individual thought; each decreases individual creativity; they decrease the incentive to think. And this is not good for a hospital, where critical thinking is essential.

Besides, it gets to the point that if you add so many rules it's hard to follow them all, and your staff will get sloppy with some of the laws. This will result in unhappiness on both your part and theirs, and ultimately low morale.

Keep in mind that people are smart and poeple make mistakes. We don't need rules to manage every aspect of our lives. While you might get upset over a crumb on the ground, to others this may not matter so much. So you don't need to make a rule that you can't eat in the break room

If you have a problem with one particular worker, talk to that person. Don't punish the entire department with new rules. And, likewise, if you create a new rule, take away an old rule that's no longer needed anymore. That would make more sense.

Sincerelly,

Staff

---

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Order sets are stupid, IMO

Based on my experience as a departmental representative at various administrative committees, I am privy to some wisdom not available to the general public. For instance, many hospitals have order sets that are hidden under the guise as protocols.

No, they are not protocols. Protocols increase personal accountability and responsibility. Protocols increase personal thought and intellectuality. Protocols preach individuality.

Yet order sets, while started with the intention of doing what is best by best practice medicine, generally make it so each patient is treated the same. Order sets take away personal accountability, individual thought, personal accountability and responsibility.

Protocols improve morale, and order set decrease morale. Order sets decrease morale because all we do is a bunch of procedures not because they are needed, or even because a doctor wanted them, but just because. Order sets are cook book medicine.

Order sets (which, again, go under the guise as protocols and guidelines) not only result in decreased morale, they increase the cost of medicine because, ahem, someone has to pay for all of this impractical medicine.

CMS only pays a flat fee (because of DRGs), and those obtaining CMS services get free healthcare (well, free to them anyway. We have to pay for their free). Therefore, the one's who will pay are those of us who pay premiums for health insurance.

We will pay more. This goes along with the premium hikes we will now have to pay because Obama care provisions to force insurance companies to pay for dependents until they are 25, and previous medical conditions (liabilities).

Consider the following:

1. Of the 20 EKGs I did today, only 15 were needed. All were ordered not by a doctor but by an order set.

2. Of the five ABGs I did today, none were needed. All were ordered not by a doctor but by an order set.

3. Of the 30 breathing treatments I did today 28 were not needed. All 28 were ordered not by a doctor but by an order set.

4. Of the six stress tests completed in my department today, none were needed. All were ordered as a result of an order set.

Order sets wouldn't be so bad in and of themselves, but most of the items on them are pre-checked, at least at my institution. To not order something, the doctor has to scratch out the item and sign. And then risk a lecture by the Quality Review lady. So it's easier for them not to bother.

If order sets were as they were initially intended, a list of all possible procedures the doctor might want to order, then order sets wouldn't be so bad. And balanced by good protocols to eliminate ordered procedures that aren't needed, order sets would also be good.  Yet that's not how it is when you resign yours institution to cook book medicine.

Thus, most items on order sets are ordered whether needed or not. Common sense is not the result of an order set. Common sense and individual thought are down the drain.

The following are unintended consequences of order sets:

• Lots of not needed procedures
• Wasted money
• Increased workload for RTs
• Increased burnout
• Loss of confidence due to loss of ability to decide what patients need
• Loss of morale due to inability to use common sense
• Poor attitude at bedside because after the umpteenth not needed EKG or treatment you get irritated by it all. It becomes a job rather than a profession, like working an assembly line at a factory
• Poor patient care due to low morale and in a hurry to get all the procedures done
• Feeling of irritation by RTs because we're doing a bunch of BS
• Increased apathy
• RTs develop RATS, which isn't good for the institution (and I'm not talking about the creepy little critters either.)

In the ideal world order sets are counterbalanced by protocols.  But in the real world idealism in merely a pipe dream. 

Yes, there are some advantages to order sets. Yet the disadvantages are way more than the advantages. There's an old saying: Something is worth the investment only when the advantages out weight the disadvantages.

And in this case, the few recommending these order sets (mainly people sitting at a desk in Lansing or Washington) have a clue of the negative consequences. Or do they? Perhaps the intent is to collapse the health care system. Perhaps that's the intent. If it's not, I have a hard time justifying it.

Thoughts?

read more...

Order sets are stupid, IMO

Based on my experience as a departmental representative at various administrative committees, I am privy to some wisdom not available to the general public. For instance, many hospitals have order sets that are hidden under the guise as protocols.

No, they are not protocols. Protocols increase personal accountability and responsibility. Protocols increase personal thought and intellectuality. Protocols preach individuality.

Yet order sets, while started with the intention of doing what is best by best practice medicine, generally make it so each patient is treated the same. Order sets take away personal accountability, individual thought, personal accountability and responsibility.

Protocols improve morale, and order set decrease morale. Order sets decrease morale because all we do is a bunch of procedures not because they are needed, or even because a doctor wanted them, but just because. Order sets are cook book medicine.

Order sets (which, again, go under the guise as protocols and guidelines) not only result in decreased morale, they increase the cost of medicine because, ahem, someone has to pay for all of this impractical medicine.

CMS only pays a flat fee (because of DRGs), and those obtaining CMS services get free healthcare (well, free to them anyway. We have to pay for their free). Therefore, the one's who will pay are those of us who pay premiums for health insurance.

We will pay more. This goes along with the premium hikes we will now have to pay because Obama care provisions to force insurance companies to pay for dependents until they are 25, and previous medical conditions (liabilities).

Consider the following:

1. Of the 20 EKGs I did today, only 15 were needed. All were ordered not by a doctor but by an order set.

2. Of the five ABGs I did today, none were needed. All were ordered not by a doctor but by an order set.

3. Of the 30 breathing treatments I did today 28 were not needed. All 28 were ordered not by a doctor but by an order set.

4. Of the six stress tests completed in my department today, none were needed. All were ordered as a result of an order set.

Order sets wouldn't be so bad in and of themselves, but most of the items on them are pre-checked, at least at my institution. To not order something, the doctor has to scratch out the item and sign. And then risk a lecture by the Quality Review lady. So it's easier for them not to bother.

If order sets were as they were initially intended, a list of all possible procedures the doctor might want to order, then order sets wouldn't be so bad. And balanced by good protocols to eliminate ordered procedures that aren't needed, order sets would also be good.  Yet that's not how it is when you resign yours institution to cook book medicine.

Thus, most items on order sets are ordered whether needed or not. Common sense is not the result of an order set. Common sense and individual thought are down the drain.

The following are unintended consequences of order sets:

• Lots of not needed procedures
• Wasted money
• Increased workload for RTs
• Increased burnout
• Loss of confidence due to loss of ability to decide what patients need
• Loss of morale due to inability to use common sense
• Poor attitude at bedside because after the umpteenth not needed EKG or treatment you get irritated by it all. It becomes a job rather than a profession, like working an assembly line at a factory
• Poor patient care due to low morale and in a hurry to get all the procedures done
• Feeling of irritation by RTs because we're doing a bunch of BS
• Increased apathy
• RTs develop RATS, which isn't good for the institution (and I'm not talking about the creepy little critters either.)

In the ideal world order sets are counterbalanced by protocols.  But in the real world idealism in merely a pipe dream. 

Yes, there are some advantages to order sets. Yet the disadvantages are way more than the advantages. There's an old saying: Something is worth the investment only when the advantages out weight the disadvantages.

And in this case, the few recommending these order sets (mainly people sitting at a desk in Lansing or Washington) have a clue of the negative consequences. Or do they? Perhaps the intent is to collapse the health care system. Perhaps that's the intent. If it's not, I have a hard time justifying it.

Thoughts?

read more...

Difficulty breathing through races? Why?

Every day at COPDConnection.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Your Question: my step son runs cross country but has a difficult time breathing through out his races we have tried zyrtec,claritin,cetirizine I know there is something that has to work but what.

Your Question:I can empathize with your stepson, because I've also been having a tough time with fall allergies, as I wrote about in my most recent post here. I find that even while new allergy medicines help, those pesky allergens still manage to find a way to cause problems.

The best thing to do is to discuss your concerns about your step son with his doctor (or have him do it if he's old enough). There are still other medicinal options available to you, as you can see in this post. Another option to discuss with your doctor is allergy testing and allergy shots, if you haven't done so already.

Obviously I can't diagnose your stepson, yet what you describe here makes me wonder if perhaps your step son might have exercise induced asthma or asthma in general. If this is the case, asthma preventative medicines might help.

At least these are some options to consider. Either way, you should definitely have a discussoin with his doctor, because there are options.

If you have any further questions email me, or Visit COPDConnection.com Q&A section.

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Difficulty breathing through races? Why?

Every day at COPDConnection.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Your Question: my step son runs cross country but has a difficult time breathing through out his races we have tried zyrtec,claritin,cetirizine I know there is something that has to work but what.

Your Question:I can empathize with your stepson, because I've also been having a tough time with fall allergies, as I wrote about in my most recent post here. I find that even while new allergy medicines help, those pesky allergens still manage to find a way to cause problems.

The best thing to do is to discuss your concerns about your step son with his doctor (or have him do it if he's old enough). There are still other medicinal options available to you, as you can see in this post. Another option to discuss with your doctor is allergy testing and allergy shots, if you haven't done so already.

Obviously I can't diagnose your stepson, yet what you describe here makes me wonder if perhaps your step son might have exercise induced asthma or asthma in general. If this is the case, asthma preventative medicines might help.

At least these are some options to consider. Either way, you should definitely have a discussoin with his doctor, because there are options.

If you have any further questions email me, or Visit COPDConnection.com Q&A section.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Breathing exercises for asthma

The following was a question and answer session from myasthmacentral.com I thought you'd be interested in.

Your Question: Have you ever heard of breathing exercises to control your asthma?
 My humble response:

Oh, yeah, I have a lot of experience with this. The ideal breathing method you should focus on is diaphragmatic breathing (you can google it). When you start to feel short of breath it's a good idea to stop what you're doing and concentrate on your breathing. Sometimes this is all that's needed to calm your asthma and/ or whatever anxiety comes with it. Another breathing technique that is more tailored to COPD patients is pursed lip breathing (you can google that too). This asthma and COPD result in air getting trapped in your lungs, this helps you to get the extra air out.

When I was a kid my thearpist had me doing some unique things, like blowing up balloons and stuff like that to strenthen my lungs. So there's actually a variety of breathing exercises good for asthmatics other than what I've mentnioned here. Relaxation exercises also work. I've hear dome say Yoga works too, however that's not up my ally.

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Breathing exercises for asthma

The following was a question and answer session from myasthmacentral.com I thought you'd be interested in.

Your Question: Have you ever heard of breathing exercises to control your asthma?
 My humble response:

Oh, yeah, I have a lot of experience with this. The ideal breathing method you should focus on is diaphragmatic breathing (you can google it). When you start to feel short of breath it's a good idea to stop what you're doing and concentrate on your breathing. Sometimes this is all that's needed to calm your asthma and/ or whatever anxiety comes with it. Another breathing technique that is more tailored to COPD patients is pursed lip breathing (you can google that too). This asthma and COPD result in air getting trapped in your lungs, this helps you to get the extra air out.

When I was a kid my thearpist had me doing some unique things, like blowing up balloons and stuff like that to strenthen my lungs. So there's actually a variety of breathing exercises good for asthmatics other than what I've mentnioned here. Relaxation exercises also work. I've hear dome say Yoga works too, however that's not up my ally.

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Alfie's Attack

A good book about asthma is essential when you want to communicate about this disease with your children. Such was the topic of a recent Sharepost from MyAsthmaCentral.com

Start the Asthma Talk with "Alfie's Attack!"

Getting children to understand about asthma is a tricky task. This is where a good children's book comes in handy. "Alfie's Attack! The Story of a Fish with Asthma," by David Bohline, should be a good tool to start the asthma talk with your child.

As a former child asthmatic myself, I remember thinking that when I couldn't breathe I felt like a fish out of water. Bohline uses this metaphor by writing about a fish called Alfie who has asthma.

Alfie comes upon a shark who also has asthma, and it is up to Alfie to save the day. The story emphasizes the need to know about your disease and to have a rescue inhaler available at all times. It also shows the importance of relaxing in order to control an asthma attack.

The story lacks in that it doesn't go into preventative medicine, avoiding asthma triggers, asthma signs and symptoms, and asthma action plans. Yet this book, in my opinion, is not so much about covering all the asthma topics as it is about simply a tool for starting a greater conversation with your child about asthma.

My asthmatic daughter loves it when I sit down with her before bed with a good book. When I pulled out the story about Alfie, she was excited and started reading right away. She read some, I read some, and when we finished we had a brief conversation about asthma.

It's kind of neat, actually, how that happens. We didn't go into much detail, as my daughter is only seven. Your conversation can be short and sweet as ours was, or you can go into greater detail. It depends on your child's personality.

When my daughter's asthma is acting up it's hard for me to tell, so I think it's important for her to learn how to communicate to me. So that's the angle I took in our pithy discussion. Yet her active mind soon drifted off, and I tucked her in for the night.

The book also comes with some neat Alfie stickers kids can put on their inhalers. Since my daughter doesn't like inhalers, she put them on her nebulizer.

This book also has some notes to parents at the back where they can learn about asthma basics. So not only is this book a conversation starter, but a start of the process of moms and dads improving upon their own asthma wisdom.

Considering I never felt my parents really understood my disease, to me it's important for any such conversation starter to also educate the parent, or at least start the learning process for both child and parent.

There were a few changes I'd make if I were writing this book. For example, Alfie obviously has control of his asthma. He's asthma wise.

Therefore, I think it would be neat if, along with the rescue inhaler later in the story, Bohline mentioned how Alfie uses preventative medicines every day to keep his asthma under control, and how he works hard to avoid his asthma triggers.

Regardless, it was a good read for us.

Alfie's Attack is a good children's book, and used in conjunction with other books such as Breathless Bethany Buttercup, and tools like the asthma wizard and Dusty the Asthma Goldfish, you should have many options available to start the parent-child asthma conversation.

Disclaimer: This book was provided by Vitality Books for review. I was under no obligation to offer a favorable review.

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Passionate Resignation versus passionate faith and hope

Most of us feel passionate resignation during the dog days of winter with no sunlight, short days, too cold to go outside. We tend to feel gloomy and often that reflects on our behavior toward ourselves and others.

Depressions are higher during winter months, episodes of cabin fever are high. Yet this is because many of us feel passionate resignation toward winter. Yet what we should feel is passionate hope and passionate faith, because we all know brighter days are coming. We all know the sun will rise again, spring will come, the days will get longer and warmer.

Yet it's hard to find passionate faith and hope during the winter. Yet those who do are happier and this resonates in their demeanor and how they treat others. A positive demeanor resonates a positive demeanor. When a baby smiles, for example, one has to work hard not to smile back.

Many people have passionate resignation about death. They see death as the end of their life and therefore the end of days are hard and often depressing and gloomy. And this resonates through us, and those around the dying with passionate resignation also feel gloomy.

Yet we should feel passionate faith and hope about death. We should know that with death is not everlasting nothingness, but everlasting life and life with peace and with Jesus. Studies show that people who believe in Jesus are happier and are happier patients (I wrote about this here). Those who are passionately faithful and hopeful about death resonate faith and hope and therefore happiness in others.

I had an experience with passionate resignation at work recently. I was at a meeting and I was feeling hopeless and lost because a doctor was refusing to allow RTs and RNs to use their individual thoughts and experience to the benefit of the patient

She said, "I don't want nurses deciding on their own what to do for the patient, when what they decide is against hospital policy." She was talking about order sets that mandate certain things be done to patients with a certain diagnosis.

I hate order sets because they decrease individualism. I think nurses and RTs should be allowed to make individual decisions based on the patient and given the circumstances. I wasfrustrated. I believe protocols are better because they encourage positive outcome based medicine to improve patient outcomes and improve RN and RT morale.

I wanted to quit dealing with the administration. I wanted to quit the committee. I actually wanted to walk out of the meeting, because if a doctor is going to have that attitude then what's the point of me even being there. Doctors thinking like that make us RTs feel passionate resignation. She actually believes people are stupid, and only an expert (her) should be able to make decisions. Everyone else is stupid.

Then I decided that passionate resignation only resulted in apathy, decreased confidence (I couldn't look at her let alone talk or negotiate with her), and no chance of progress. I decided it's better to have passionate faith and hope even though passionate faith and hope are hard to obtain. I took the harder path, the noble path, and the better path. This resonates hope and faith in others.

This is the only way to better patient care. We must have faith and hope. We must have confidence? We must have optimism? Lest we will fail and they will win.

I think one of the philosophic recommendations someone once told me about was to think positive thoughts about people before you approach them. you should do this especially with people of whom you do not agree with or care for. The idea here is if you think positively -- have hope and faith -- your good feelings resonate and you will be well thought of and liked and respected.

Plus by thinking good thoughts about the person (however hard that may be sometimes) you are less likely to allow them to drag you into their pessimistic and gloomy world, and the less likely you are to say something you might regret, something that might slow or stop progress.

Once people learn to respect you they will develop a feeling of passionate hope and passionate faith. We must all have passionate hope and faith. We must not take the easy path of passionate resignation. We must have faith and hope and know that death does not mean we are taken away from God and his people. We must know that with death comes eternal life.

We must not meet our fate with resignation. We must know the facts, and know what we believe in, and me must keep moving in a direction of hope and faith.

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What Administration Can Do to Support Trauma Informed Care

The actions of the agency administration will determine the success of a transformation to trauma informed care. The administration must truly understand and support this approach, or it will not have a chance. Staff are keenly attuned to what is actually expected and rewarded within an agency. Mere lip service will not convince them to make this difficult change.

How can administrators demonstrate their support? First, they can arrange financing for training for all staff on trauma, how it affects people, and how they can heal through attuned relationships. Key members of the administration should attend at least a portion of trauma training themselves (vs. sending designees in their places). The agency must make provisions for the staff to attend the training and be released from their regular duties.

Expectations are conveyed in many ways throughout an agency. Does the administration value control and lack of disruption more than anything else? Can the administration tolerate certain level of organizational chaos in making the transition, including such things as staff confusion, conflict within treatment team, resistance to change, and increased property destruction? Trauma informed practice encourages staff to be flexible and to offer choices to the clients, even when the result is that the client is not immediately brought under control. Can the administrators support this?

In one residential agency trauma informed care champions had been working with the staff to be more flexible. They were teaching staff to ask upset clients what is wrong and to listen and to validate their feelings before discussing consequences or solutions. Maggie, a sixteen year old, had just learned that her mother had relapsed. She was screaming in the main hall on the afternoon of the Board Meeting. The CEO was wondering what Board members would think if they walked in the door and heard a girl yelling about killing herself and running away, and heard staff empathizing with how bad she was feeling. So he went out and said he knew she was upset but could staff please get her to go back to the unit or at least into one of the meeting rooms?

What messages are sent in this two minute interaction? That not upsetting the Board is more important than what is happening to Maggie; that in fact what Maggie is feeling and saying is unacceptable and shameful and should be hidden; and that the job of staff is to get Maggie to quiet down and stop bothering people. Those two minutes can undermine months of training.

Administration should look for every opportunity to praise staff members for their patience and kindness. They should express their sadness about what the children are going through, and acknowledge how real and important the stressors on these children are. A response of compassion to both the child’s and the staff’s experience in an incident will have a very powerful effect in reinforcing the staff’s flexibility with the child.

This example also points out that it is important to share the principles of trauma informed care with the Board of Directors. They need to know why the agency is making this change, and how it will affect agency functioning. Both possible positive and possible negative ramifications must be shared with the Board. If possible, Board members can be invited to attended some portion of the trauma training, or even participate in the over site committee.

Staff members want to do a good job. They want to be seen as competent and successful. If administration makes them feel bad about the children’s emotional outbursts, they will try to stop these outbursts. It administration helps them feel proud of their kindness and flexibility with the children, these behaviors will increase.

Fundraising is a key function of the CEO of any agency. Implementing trauma informed care can help with fund raising. The agency can become a leader in a cutting age treatment modality. Developing sophisticated treatment skills will help the agency survive current economic stressors. Emphasizing the trauma histories of the clients served helps donors understand why they need assistance. Also, using research such as the ACES study will demonstrate the economic benefit of helping people heal from trauma.

Administrative leaders can further set the tone for trauma informed care by celebrating both staff and client achievements. Their concern, kindness and compassion towards issues affecting both staff and clients model the response needed from staff. Their heartfelt joy when a client wins and award or a staff member gets their professional license reminds everyone of the purpose of this difficult work.

A transformation to trauma informed care is not possible without this strong administrative support.

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It’s All for You, Mallory

Picture Mallory sitting in the Main Lounge. She is a large sixteen year old girl in tight garish clothes. Next to her is an over turned couch. She is surrounded by glass from the window she just broke. Her legs are swathed in gauze bandages covering the cuts she just inflicted on them, and there is blood on the carpet. The wail of the fire alarm she pulled is giving voice to her pain. Her face is frozen.

Everything we are doing is for you, Mallory. For you, who was abused by a relative repeatedly over five years. Your mother struggled with her own abuse history and depression, and has made several suicide attempts. She is not able to endure your pain, but she cares about you. She has advocated for you as you have travelled between treatment programs and hospitals.

Because of the transformation we have made at our treatment center, someone is holding your hand. No one is talking to you about consequences. There is compassion and caring in the eyes of the staff who look at you.

When you have left for the hospital, the staff discussion will center on your pain, not that you were difficult or annoying. Your team knows that you read an article in the paper today about your molester. They understand how this would be unbearable. They are shaken and disturbed, and they are feeling with you, not feeling angry at you.

Because of the changes we have made, everyone appreciates how hard this incident was on Mallory’s team, and immediately people rush to comfort her therapist, the people who saw her cut, all those who helped. We are aware of how this difficult work takes its toll on us all as we stay present with Mallory’s sadness.

We know we have work left to do when the policemen says sarcastically to Mallory “well, I guess someone’s angry” and the EMT threatens to drag her to the ambulance. And we are working on it through a grant to train the police force and have regular fun activities shared by the police and the kids. This has made great improvements in our cooperation as agencies- but today wasn’t our best day. Still more to do.

Nothing that happened to you was your fault, Mallory. You are not being manipulative and just wanting attention. You are unbearably unhappy, and you have every right to be. We are honored to be by your side, even when it doesn’t go well, even when you are not cute, even when we are exhausted and far from perfect, even when the system lets all of us down.

When Mallory is in the ambulance ready to go to the ER she asks her special staff member Rebecca if she can have a hug. Mallory is covered in blood and Rebecca hesitates. “Here, I’ll put on my coat” Mallory says. They hug.

We are trying to change the world for you, Mallory.

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Beauty Shopping: Genifique by Lancome

I finally splurged on my spring skin care kick. This year it is concentrated treatment from Lancome Genifique, the Youth Activator. This is an expensive product so I actually tested it 3 times before I finally decided to part with some $$$. I loved the effect from the samples so let's see how impressed I will be with the results from a full size product.For my incredible generosity I received a

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Becoming Naked

Today I would like to ask for a consultation on a certain behavior- namely, taking off all one’s clothes.

Davonte is 12 years old, and is small for his age. He has a history of extreme abuse, and has lived in 19 places. He exhibits many problem behaviors, such as aggression and threatening. However, one of the most common is taking off all his clothes and coming out of his room. He often makes statements about how great his body is and how he will someday be on magazine covers. Sometimes he will respond to and matter of fact directive to get dressed, other times that will lead to a full fledged meltdown.

What is the adaptive function of this behavior? What does it communicate and/or accomplish? What needs does it meet?

We see this behavior quite regularly, in boys and girls, in younger children and in adolescents. Often children take off all their clothes within a crisis, but other do so in every day times and when it is unexpected.

Obviously this same behavior means different things to different youth, but what are some of the possibilities, just to start us thinking?

Some possibilities that occur to me are:

1. To shock and get a reaction

2. To keep people away

3. To test whether someone is going to molest them or use them sexually

4. To determine whether people will accept their real, true self

5. To replicate what they saw in their family

6. Because a child is uneasy about his or her body, they want to see if people are revolted

There must be many other thoughts.

I am sure that Davonte does not disrobe because he is happy about his body and wants to show off how wonderful it is. Instead I feel certain his behavior comes from a place of fear and shame, in which he fears that there is something inadequate, awful and disgusting about his body.

Have you had experience with this behavior in your settings? How have you come to understand it? How have you and your team responded?

Please click on comment and share your experiences so we can all learn from each other.

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