New Treatment Ways: September 2011

Faux Pneumonia

If you work in a hospital you'll notice that pneumonia is the most common diagnosis. The reason is because it's the most reimbursable. Because of this, many times doctors write pneumonia as the diagnosis even though the patient doesn't have pneumonia. In these cases, what we have is faux pneumonia.

This is what happens when you have the government set the guidelines for reimbursement. Patients get diagnosed with faux diagnosis'.

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Is there a benefit from getting a bachelor's degree in RT?

Your Question: Do RTs who come from 2yr respiratory therapy programs share the same responsibilities as those from 4yr programs? Do new grads get treated differently from the seasoned veterans?

My humble answer: Pretty much. It's the same with nursing. The main advantage of earning a higher degree is opportunity. New grads are generally orientated as appropriate. RT school is so intense that most RTs come out of school fully prepared to function as an RT, and most are not treated differently than a veteran.

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Smoking rates decline -- slightly

Fewer people are smoking these days, and those who do are smoking less. This is according to a report released by the Centers for Disease Control and Prevention, the Associated Press notes.

In 2005 21 percent of adults acknowledged smoking. In 2011 19.3 percent of adults acknowledged smoking. This was a decline of 3 million smokers. While only a slight decline in the general scheme, this is a trend in the right direction.

This is significant to us RTs because smoking is the number one contributor to lung disease. Studies have shown that those who quit smoking allow their bodies to heal, and this reduces the risk of smoking related diseases.

If the current trend continues, 17 percent will be smoking by 2020. This will be far short of the government set goal of 12 percent. Likewise, credit for the decline is given to educational efforts to inform people of the dangers of smoking, and the advantages of quitting if you do smoke.

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Common Treatments For Melasma: Skin Whitening Techniques

Hyperpigmentation problems begin to affect us as we age. You may begin to notice that you no longer have an even skin tone, in fact, you may have started to spot larger stains that have begun to appear on your face, hands, chest and back.

This blotchy skin can make your skin look older and even affect your own self esteem. Hyperpigmentation problems are usually caused by hormonal issues (during and after pregnancy) and by over exposure to the sun. No matter what the cause may be, most women are eager to find a solution.

When hyperpigmentation spots appear on your face it is most commonly known as melasma. Darker skinned women are the most prone to suffer this type of skin problem, however, it is more noticeable in lighter skinned individuals.

The most common types of melasma treatments usually rely on skin whitening products and procedures. These procedures strive to reduce and control the amount of melanin in each cell. The most common whitening techniques include laser treatments, chemical peels and bleaching products.

The intensity of a chemical peel can be controlled to best suit your needs, making it a great option in the treatment of melasma. The depth of a peel will depend on the chemicals used by the specialist performing the procedure. If at any moment you experience any discomfort, they specialist may use cooling agents or topical anesthetics to treat the problem.

Laser treatment will work on melasma, but it can also lead to more hyperpigmentation and even hypopigmentation problems. The results can also be inconsistent. Laser treatment is recommended more for darker skinned individuals.

Bleaching creams will help lighten the skin and are best suited to treat larger areas of skin. Bleaching creams contain a variety of different active ingredients.

Hydroquinone is one of the most popular bleaching ingredients. This ingredient can lead to problems such as irritation or permanent discoloration. However, there seem to be safer alternatives.

Azelaic acid is one such alternative that is also used in acne medication. Kojic acid and glycolic acid have also been proven to be a good alternative to hydroquinone.

Once you've undergone any of these products you should take special heed to the following precaution. Since bleaching procedures correct skin tone by eliminating melanin, our skin's natural sun block, it is important to use a strong sunscreen product. If you're not sure which SPF to use, ask your doctor to recommend one for your particular case.

http://www.articlesnatch.com/Article/Common-Treatments-For-Melasma--Skin-Whitening-Techniques/1018072#ixzz1ZGKZQYvm
Under Creative Commons License: Attribution No Derivatives

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Everything you need to know about the Neopuff

Introduction to the NeoPuff:

The need to perform positive pressure ventilation (PPV) on neonates is rare. In fact, statistics show that about 90% of infants make the transition to extra-uterine life with no problem. The other 10% will need resuscitation, with 1% requiring an extensive work-up.

In the past PPV has been performed with an AMBU-bag, and rate and depth of breaths determined by a steady hand. New evidence shows that using AMBU-bags on neonates is too risky, and many hospitals, including ours, are making the transition to using a NeoPuff instead of AMBU-bag.

What can a NeoPuff be used for?

Blowby oxygen
PPV
CPAP

How to get NeoPuff ready for use? (Must be completed when birth expected)

Check manometer reads zero with no gas flow. (If not, call RT)
Make sure patient supply line is connected to outlet port
Make sure a T-piece is connected to the patient supply line
Turn on air & oxygen tanks (not needed if air & oxygen connected to wall source)
Connect test lung to T-piece
Turn flowmeter on NeoPuff to 8lpm (or 5-10lpm)
Check for desired oxygen (recommended setting is 40% FiO2)
Place finger over PEEP valve. Pressure manometer should read 20cwp.
While still occluding PEEP valve, turn PIP valve clockwise as far as it can go. It should not go higher than 40. If it does go to step 10. If not, go to step 11
Continue occluding PEEP valve. Remove cap from Maximum Pressure control knob. Turn knob until Maximum Pressure set at 40 (or as desired)*
Close cap that so Maximum Pressure knob is covered
Turn PIP** knob to set desired PIP (We like to use 20cwp)
Adjust PEEP cap to desired PEEP level. We like to use 5 CWP. The PEEP cap is located on the T-Piece
Turn off gas supply from flowmeter on NeoPuff
If used, make sure you turn off the air and oxygen tanks (otherwise you’ll have to replace them when they go empty)
Make sure neonatal resuscitation mask is in the basket
Remove test lung from patient circuit
If used, check oxygen and air tanks and replace as necessary
Failure to complete any of the above steps may cause unacceptable delays in resuscitating newborns.

*The factory setting of the Maximum Pressure Relief is 40 cwp. This is to prevent the PIP from being adjusted over 40 cwp. Likewise, resuscitation above 40 cwp cannot be achieved unless the Maximum Pressure Relief valve is adjusted. So long as no one does this, step 10 above can be skipped.

**PIP is Peak Inspiratory Pressure. This is the pressure given for each breath.

How to get NeoPuff ready when you need it NOW?

Turn on oxygen and air tanks (not necessary if O2 & air plugged into wall outlet)
Turn flowmeter on NeoPuff to 8lpm (or 5-10lpm)
Make sure PIP is set at 20
Make sure PEEP is set at 5
Make sure FiO2 is set to 40%
Fit neonatal resuscitation mask to the T-Piece
Now it is ready for the impending delivery. Hopefully you won’t need it.

Blowby oxygen: If the infant is breathing yet continues to be blue or otherwise requires oxygen, the NeoPuff can be used to blow oxygen past the patient’s face (an AMBU-bag cannot be used to give blowby oxygen)

Place mask close to baby’s mouth and/nose
Occlude PEEP valve with your finger and hold it there
Oxygen should now be blowing by the patient’s face
Adjust oxygen as required to maintain desired SpO2 (see below)

How to give PPV with NeoPuff?

If the infant is not breathing adequately, or the heart rate dips below 100, you should do the following:

Place mask over the baby’s mouth and/nose (or fit patient T-piece to ETT).
Resuscitate by placing and removing thumb over the PEEP cap to allow inspiration and expiration.
Give 40-60 breaths per minute (recommended by NRP)
Do this until HR > 100 and patient breathing adequately

How do you know PPV is working?

Heart rate increases
Improved Color
Spontaneous respirations
Increased muscle tone

If the NeoPuff appears to not be working:

Check equipment
Make sure have good seal
Make sure PIP is adequate
Check respirations
Reposition infant

How to give CPAP with NeoPuff?

If infant heart rate is above 100 and breathing remains labored, CPAP may be trialed:

Place mask over the baby’s mouth and/nose (or fit patient T-piece to ETT)
Resuscitate by placing and removing thumb over the PEEP cap to allow inspiration and expiration.
Place finger over PEEP valve and hold
This will allow patient to breath spontaneously while providing CPAP (PEEP)

Why use the NeoPuff to give PPV rather than an AMBU-bagBag?

Evidence shows the NeoPuff is the best way to ventilate neonates
Less pressure (prevents pneumo)
Consistent Pressure (prevents Hyaline Membrane Disease*)
Bags should be available for backup only
I-Time and Rate controlled by finger instead of whole hand
Less stress on caregiver (don’t have to worry about giving too much or too little pressure)

*Evidence shows that inconsistent pressures from AMBU-bags actually cause bruising in the neonate airway and can result in further complications for newborns making them extremely difficult to treat. The Neopuff gives constant, equal breaths that are much easier for the infant.

Fallacies about using Neo-Puff to give PPV:

Many medical care practitioners are afraid to use the Neo-Puff because they are used to “feeling” each breath go into the baby with their hands by squeezing the bag. When using the Neo-Puff you will not “feel” the breath go in.

However, every study so far completed comparing the Neo-Puff to PPV overwhelmingly supports using the Neo-Puff to the Ambu-Bag. The Neonatal Resuscitation program (NRP) highly recommends we get over our fear of the Neo-Puff and use them.

Oxygenating Neonates:

When using our AMBU-bags you have to give 100% oxygen. The NeoPuff allows you to adjust the FiO2 from 21% to 100%.

A growing number of literatures have proven you shouldn’t use 100% oxygen for newborn infants. New studies show that high levels of oxygen -- even for term babies -- can be detrimental to the short term and possibly even long term health of newborns.

Several studies have linked 100% oxygen (even for as little as ONE minute) to:

Leukemia
Cancer
Cellular death
Infection
Delayed development of oxygen sensing tissues
Oxygen radical disease of neonate

It is for this reason that 40% is the recommended starting point for FiO2. If needed, this can be titrated as appropriate for the patient, or as recommended by physician.

Pay attention to oxygen sats, don’t just leave baby at 100% SpO2. With Baby less than 30 weeks, Spo2 should be kept <90, the concern is early eye development. Plus scientists are not sure if primie organs should be rapidly exposed to too much oxygen too fast; when in utero they were developing in a SpO2 of 60% or less.

Butterworth is currently doing a study of using 21% on all newborns. It is now believed that it’s not oxygen that stimulates a baby to take its first breath, but heat, stimulation, and PPV. So some hospitals have gone to 21% FiO2 already.

Benefits of lowering oxygen Sats:

Increased neurological function
Decreased Retinopathy of Prematurity
Decreased Chronic lung disease
Increased weight gain
Decreased Infection
Decreased Ventilator days
Decreased Oxygen days
Decreased Length of stay
Decreased neonate mortality rate by 30-40%

However, if a baby is not responding to 40% FiO2 after 90 seconds, you should increase to 100%

The recommended goals of oxygenation:

Weeks Gestation	SpO2	Alarms High Low
<30	85%	93	80
30-34	88%	93	83
35-39	91%	96	86
40 or >	94%	99	89

Achieve Sat gradually (increasing PO2 too fast has potential to cause harm)
Decrease FiO2 as Sats rise > 95%
If HR not rising, check for correct ventilation
Increase to 100% FiO2 if no improvement after 90 seconds
Do not chase saturations, fluctuations in sats is normal (better to bounce low than to bounce high
SPO2 should not exceed 95% unless suspect Persistent Pulmonary Hypertension

Benefits of CPAP for neonates: (PEEP and CPAP is the same thing)

Always keeps little air in lungs to make next breath easier.
If HR >100 and breathing remains labored, then you can try CPAP.

Keeps small amount of air in lungs
Keeps alveoli open, and prevents alveoli from collapsing
Improves oxygenation
Makes next breath easier

Conclusion: So you can see the NeoPuff is proven to be a safe and effective method of providing blowby oxygen, PPV and CPAP for neonates. It’s also easy to set up, requires only one finger to use, and takes away the stress of squeezing the bag too hard. In this regard, a well educated caregiver will realize it’s actually easier to use than an AMBU-bag.

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Study: Doctors admit to ordering useless procedures

Breitbart.com reports today on an interesting study that reveals 42 percent of doctors say they over treat patients just to cover their butts in case of a lawsuit. As a person who works in a hospital this is not surprising news to me, and I bet many doctors are being dishonest -- that the percentage is much higher.

The study, published in the Journal of the American Medical Association, also showed that 52 percent of doctors said their patients received the right amount of care, and 45 percent reported that 1 of 10 patients didn't even need to be in the doctor's office.

Seventy six percent said they believed the main reason for useless medical procedures was the result of fear of a malpractice suit. For this reason they order a variety of tests and procedures that they don't think are needed, but order just so they look good in a court of law.

Breitbart notes that the United States has the highest per capita spending on healthcare of developed nations of about $5,475, and the second highest nation is Switzerland at $3,581.

When unnecessary procedures are ordered this increases the price of the product, according to economics 101. As the demand for a product or service increases (more patients getting x-rays for example) and the supply stays the same (same # of x-ray machines and x-ray technicians) the price has no where to go but up.

Other things that have been proven to drive up the cost of healthcare is free healthcare that results from medicare and Medicaid services. When something is available for free to the patient they don't hesitate to seek help even when they could have stayed home.

This study sheds more light on the need for healthcare reform that provides doctors with an incentive to order what is needed rather than what they think lawyers would like to have ordered or what needs to be ordered to meet reimbursement criteria.

What do you think?

9 breathing exercises for asthmatics

If you have asthma there are plenty of exercises you can do do strengthen your lungs and make your breathing easier in the short and long term.

This post was my asthma column from MyAsthmaCentral.com on March 14, 2011: "Breathing Exercises to Control Asthma."

I remember the first time a respiratory therapist talked to me about the importance of breathing exercises to control my breathing. I was 11, and the year was 1981. Several years later, 2006 to be exact, a study was completed to confirm that breathing exercises really do help us asthmatics.

In fact, the study was completed in Australia and first reported inThorax, and showed that asthmatics who used their rescue inhalers regularly for mild asthma, and who performed breathing exercises on a regular basis, reduced their need for rescue inhaler use by 86 percent. Also, inhaled corticosteroid use dropped by 50 percent.

Likewise, the study confirmed that it does not matter what breathing exercises you do, all that matters is you do one or the other. Other evidence already confirmed, as the RT back in 1981 already knew, that breathing exercises during asthma episodes can help make breathing better.

How does the way we breath affect our asthma?

Experts now believe that asthmatics tend to breath faster than people with normal lungs, and many also have a tendency to be mouth breathers. This exposes the lung to cooler and drier air which is an asthma trigger. This results in increased need for rescue medicine.

So it only makes sence that breathing exercises that encourage shallow breathing at a controlled rate may actually reduce asthma symptoms and the need for rescue and preventative medicine.

What are good breathing exercises for asthmatics?

1. Diaphragmatic breathing (belly breathing): (Click here for video) This is what I was taught back in 1981, and what I was encouraged to teach in RT school. It's a basic and simple breathing technique that maximizes air distribution in your lungs.

You can lie down or sit.
Concentrate on your breathing
Preferably you should breathe in slowly through your nose
When you inhale your abdomen should go out (not your chest)
Exhale slowly with your abdomen going inward
Ideally exhalation should be twice as long as inhalation

2. Reduced breathing exercises: (Click here for video)

Sit upright, relax, focus on posture feet on floor with legs uncrossed
Relax chest and belly muscles while breathing
Focus, close your eyes and look up
Breath through your nose gently (keep mouth closed)
Breath slowly and shallow
After exhaling slowly until you feel their is no air left in your lungs
Hold your breath as long as you can and then return to gentle breathing (do not hold breath so long that you feel urge to inhale through mouth)

3. Physical movement exercises: (Click here for video)

Focus on good posture (sitting in firm chair with feet on floor, legs uncrossed with your back straight)
Relax (Tense all muscles, and then relax, paying particular attention to muscles in shoulders and belly. This should release all tension) This makes breathing easier. This is rest position
Concentrate on breathing (close eyes)
Focus on breathing while relaxed in rest position
Focus on breathing with shoulder rotation
Focus on breathing with Forward curl
Focus on breathing with arm raises
Rest position with focus breathing can be done anywhere

4. Yoga: One study showed that regular yoga participation reduced asthma symptoms and rescue inhaler use by 43 percent. In doing yoga you hold poses and concentrate on your breathing. Click here to learn more and to see if Yoga classes are held in your area.

5. Buteyko: According to the Mayo clinic this is a a breathing technique that teaches asthmatics to "habitually breathe less." Click here for the Buteyko website.

6. Papworth method: Similar to diaphragmatic breathing and Buteyko method. You can read more about it here.

These breathing exercises are believed to be beneficial to patients with mild asthma that is caused by rapid breathing and mouth breathing, and may not necessarily benefit those with more severe asthma, or those asthma episodes caused by other asthma triggers, such as colds and allergies.

There are other methods of controlling your asthma:

7. Pursed lip breathing: This can be used when you are having an asthma attack. Since asthma causes air to become trapped in your lungs, this may help you get more air out and may make breathing easier. This is where you inhale slowly through your nose and then exhale through pursed lips, or exhale slowly as though you were going to whistle. You should exhale twice as long as you inhale. This should be done while using diaphragmatic breathing as described above.

8. Progressive Relaxation Technique: This is a technique I was taught while I was a patient at National Jewish in 1985, and it works great. In fact, I think this works so great that I might dedicate an entire post to it some day.

Lie down and close your eyes
Concentrate on breathing through your nose
Use Diaphragmatic breathing
Tighten muscles of right foot and hold for 20-30 seconds, relax, feel tension release
Do same for right upper leg, left foot, left upper leg, right hand and forearm, right shoulder, left hand and forearm, left shoulder, jaw area, mouth chin, and forehead.
Continue to concentrate on your breathing this entire time.
When done your body should feel "heavy and warm... weightless."
Stay in relaxed state for as long as you want or need

9. Other: Work with your doctor and use whatever method that works for you.

The recommendation of the researchers is that asthmatics incorporate breathing exercises to go along with asthma preventative medicine. The recommendation is first thing in morning, and last thing at night (the same as most asthma controller meds are taken).

Likewise breathing exercises should be incorporated into your asthma action plan. If you're feeling mild asthma symptoms slow down and concentrate on your breathing. Do this and you may find you won't need your rescue medicine.

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Michael Trout at the ATTACh Conference

I have just returned from a wonderful week immersed in learning about new treatment ideas and meeting marvelous people. I have a lot to share. This week I am going to focus on Michael Trout, who I had the honor of meeting at the ATTTACh conference (http://www.attach.org/). Michael is the author of the Multiple Transitions video that we include in our Risking Connection training. This video, which our participants always find so moving, can be purchased at the Infant Parent Institute store (http://infant-parent.com/). Many organizations have begun to use it to train new staff, and I highly recommend it.

Michael Trout is the Director of the Infant Parent Institute which engages in research, clinical practice and clinical training related to problems of attachment. He was the founding president of the International Association for Infant Mental Health; was on the charter Editorial Board of the Infant Mental Health Journal; served as regional vice-president for the United States for the World Association for Infant Mental Health; and currently serves on the board of directors (and as editor of the newsletter) for APPPAH — the Association for Pre- & Perinatal Psychology and Health. In 1984 he won the Selma Fraiberg Award for “ . . . significant contributions to the needs of infants and their families.” Mr. Trout has produced 14 clinical training videos that are used by universities and clinics around the world, including the six-hour video training series, The Awakening and Growth of the Human: Studies in Infant Mental Health. He has also written and produced four videos focusing on the unique perspective of babies on divorce, adoption, loss and domestic violence. The most important part of Mr. Trout’s work continues to be in his quiet private practice where he sees individuals and families of all ages on a daily basis.

I attended a work shop by Mr. Trout on the topic of the therapist as a secure base for their clients. He showed videos and led the audience in an experiential exercise to demonstrate attunement. Mr. Trout shared three actions that are essential for the therapist to create a secure base.

Wonder: The therapist must approach the patient with genuine curiosity and awe. He must remain interested in this person’s story, this person’s experience. This wonder can be side tracked by theories. If the therapist thinks he already has the situation figured out, his mind will only go down one path and he will close his eyes to contrary evidence. Hearing others describe the patient, or reading their record, can also interfere with wonder. Hurrying, or having a pre determined agenda, are also problems. When the therapist keeps his mind open in wonder and curiosity, he will deeply hear the patient, and that person will know they have truly been seen.

Following: The therapist must be in pursuit of the patient. The therapist does not come in with a pre-decided agenda. He follows where the client wants to go and what the client wants to talk about.

Holding: This takes many forms. Its opposite is dropping. It means creating a feeling for the client that the therapist has his back. You won’t starve, I won’t leave, we will work this out together. It may require active advocating for the client.

These are the elements of creating a secure bases for the client.

Mr. Trout ended his workshop with a meditation from a CD that can also be purchased at the Infant-Patent Institute store. I plan to add it to my training. It comes from this CD (I include the description from their web site).

The Hope-Filled Parent

What could meditation mean to a foster mother who has learned to arise at 5:15 each day, in order to have 10 minutes of quiet before she begins the careful morning ritual needed for awakening her deeply troubled child without a meltdown? What could meditation mean to an adoptive father sitting alone at midnight, pondering what was happening to the peace of his home, the safety of his other children, and the intimacy he used to share with his wife? Could meditation make a difference to those foster or adoptive families who are on the brink of placement disruption, who are about to conclude they can simply not make it through another day?

Use these meditations in any way that suits you. There is no right or wrong way. If you find one that particularly speaks to you, you may find yourself listening to it every day, at about the same time. Maybe you will invite your spouse to join you, on the screened-in porch. Maybe you will listen to the entire CD on certain nights of despair, or listen to a funny one in the kitchen, while whistling. But it is my hope that you will find something herein that restores hope, that challenges your feelings of impotence that reminds you why your efforts are far from being in vain.

Learning from our mistakes

I believe it's best that we learn for ourselves. I think that it's important for parents to teach as much as we can while our children are younger, yet there comes a time we must let them go and hope we taught well.

Even during the course of teaching, I believe it's important to let kids figure things out for themselves as opposed to correcting them every time they do something we think might not be right.

Some people tend to be more choleric and they tell kids how to do everything. They show kids how to fix everything. Every time their children attempt something that parent shows the right way.

There are forms of government that do this to. They have experts decide what is best force everyone and then force us to do it right. Yet my problem with this is: what if the experts are wrong? What if the parent or the politician is wrong?

If you're deciding what is right all the time, then you must darn well hope you are right. If you are wrong, chaos will ensue. The child (or you) will have a much tougher road than if you had been encouraged to tough it out on your own.

That's one reason why I think it's a good idea not to start kids out with an inheritance, or with a ton of money. We should provide them with a wealth of information and very little money. That way they are forced to live and learn.

I'll tell you from my own personal experience that I wouldn't be who I am today, I would not be here right now doing this, if my parents or my government had provided a blanket for me, or a bridge that I could re-cross for comfort.

And Lord knows I've failed along the way. I was fired more than once. I endured over 18 jobs before I became an RT, and I endured much suffering before I finally got married when I was 32. Yet thanks to that rocky road, I am what I am and I'm happy what I am.

Yet I believe that we don't know any more which way is the right way unless we have the directions sitting right in front of us.

Sure we might have the correct and best way to piece a model together, yet we do not have such blueprints for piecing our lives together. So I believe it's best for our children to be shown the best way, yet there comes a time we must allow them to attempt things on their own.

While they are younger we may need to stop them when they are set on a course for disaster, we might need to help them cross a bridge, yet once they are across the bridge it is best to take the bridge away and let the child learn how to survive. If the bridge is still there, they may be tempted to go back to it to be suckled by the parent.

If the bridge is still there, then that child may not take the risk that might make a difference to the world. Perhaps if Einstein or Thomas Edison had had such a bridge, they never would have taken the risks that make our world what it is. We might also place the founding fathers in this same boat, and any other discoverer or inventor or creator.

I believe it's important to guide my kids, yet then it's time to allow them to discover. It will start with something simple, like making scrambled eggs for breakfast. The choleric parent will never allow this, yet the parent like myself will allow that child to make breakfast even at the risk of getting eggs on the floor, and even at the risk of getting a child's hair in your poached egg.

If you do everything for your child, if you provide cover from all pain, or if you provide money for everything they want to do, then they will become lazy and dependent. If you let them go, you may have to watch them suffer, yet even if they fail they will learn a life's lesson. There's no lesson learned if you do it for them.

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What to do if your patient has a low sat

Dear RNs:

So your patient suddenly has low sats. Do the following before calling the doctor:

Check the connections
Check the flowmeter (is it on?)
Assess the patient
Call respiratory therapy.

Follow these three simple steps and your RT will love you.

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What are the most violated ethical standards in RT?

Your question: What are the most violated ethical standards in RT? The AARC statement has some dramatic case examples, but I would love to get a better picture of the day-to-day.

My humble answer: The two big ones that I'm concerned about most is delaying time and wasting time. I think much of what we do keeps people alive when we should let nature take it's course. Example: someone comes in full arrest, is blue and has taken a major anoxic hit, yet we spend hours -- maybe even days -- trying to save that patient. If he lives he's a ward of the state at the cost of millions of dollars. If he dies he still costs thousands in our efforts to save him. However, it's not my decision to make. If someone hasn't already declared what they want at the end of their lives, or if they don't have a responsible person making those decisions, it can get pretty tricky.

The other thing that concerns me as unethical are all therapies we do just to make sure the patient meets criteria for reimbursement, or just because the doctor wants the patient or patent's family to think we're doing something. I think this is a waste of my time and all of our money. For example: CMS won't reimburse for pneumonia patients unless the patient was sick enough to need oxygen, breathing treatments and something else I can't remember. So to cover our bases doctors simply order all of these procedures on every patient admitted with a certain DRG (diagnosis). I feel it's unethical to give breathing treatments to people who don't need them, yet I do so all the time because they are ordered.

I also find myself lying to patients and telling them what I'm doing will help them get better. I find this is unethical. Yet I find I have no choice in the matter. If a doctor tells a patient one thing, I feel it's my obligation to back up the doctor.

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What are the most violated ethical standards in RT?

Your question: What are the most violated ethical standards in RT? The AARC statement has some dramatic case examples, but I would love to get a better picture of the day-to-day.

My humble answer: The two big ones that I'm concerned about most is delaying time and wasting time. I think much of what we do keeps people alive when we should let nature take it's course. Example: someone comes in full arrest, is blue and has taken a major anoxic hit, yet we spend hours -- maybe even days -- trying to save that patient. If he lives he's a ward of the state at the cost of millions of dollars. If he dies he still costs thousands in our efforts to save him. However, it's not my decision to make. If someone hasn't already declared what they want at the end of their lives, or if they don't have a responsible person making those decisions, it can get pretty tricky.

The other thing that concerns me as unethical are all therapies we do just to make sure the patient meets criteria for reimbursement, or just because the doctor wants the patient or patent's family to think we're doing something. I think this is a waste of my time and all of our money. For example: CMS won't reimburse for pneumonia patients unless the patient was sick enough to need oxygen, breathing treatments and something else I can't remember. So to cover our bases doctors simply order all of these procedures on every patient admitted with a certain DRG (diagnosis). I feel it's unethical to give breathing treatments to people who don't need them, yet I do so all the time because they are ordered.

I also find myself lying to patients and telling them what I'm doing will help them get better. I find this is unethical. Yet I find I have no choice in the matter. If a doctor tells a patient one thing, I feel it's my obligation to back up the doctor.

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Ways to Prevent Melasma

The most common type of skin disorder called Melasma usually affects women, although men could be affected as well. It is characterized by the appearance of brown patches or dark spots around the face, often symmetrical and evenly distributed. Excessive sun exposure is the common predisposing factor since it stimulates the melanocytes on the skin resulting to skin pigmentation. Melasma is commonly seen on areas with tropical climates.
Melasma is often seen on the prominent areas of the face such as the cheekbones, forehead and upper lip but it can also appear on other areas like the lower cheeks, nose, chin and sides of the neck. Although Melasma is completely harmless and is not anyway related to any types of disease; its unsightly appearance is of great concern. Melasma prevention can be done starting by protecting your face against the harmful rays of the sun.
Prevention is always better than cure. Melasma cannot be exactly prevented from happening but there are ways of minimizing your chances of getting it. Since sun exposure has been seen to be a big contributing factor in the occurrence of Melasma, daily sunscreen use and sun avoidance is still seen to be the best prevention tips. Wearing a good sunscreen is your best defense against Melasma.
A good sunscreen is determined by its strength and measured by SPF (Sun Protection Factor). Keep in mind that within minutes of sun exposure the UV rays can rapidly stimulate melanocyte on the skin which is the primary culprit to the development of Melasma that is why wearing broad spectrum, high SPF sunscreen daily even when you are at home is highly recommended. Avoid the use of products that can make your skin sensitive to the sun, usually known as photosensitivity. Use of certain drugs can also result to side effects that might increase your skin's sensitivity, so you should be aware of these drugs and avoid using them.
Sometimes, the simplest preventive measure is often overlooked. The use of a hat, umbrella and other things that can help shield you against the sun is an easy and conventional way of Melasma prevention. Covering yourself up is a good way of minimizing the effects of UV rays to the skin. It will help you protect your skin to be in direct contact with the sun. The less contact you have with the UV rays, the most unlikely you'll get to have Melasma.
In case of hormone triggered Melasma, discontinue the use of birth control pills. Female hormones estrogen and progesterone have been associated to the occurrence of hyperpigmentation. Prevalence is seen on pregnant women, a type of Melasma that is usually termed as mask of pregnancy. Further prevention isn't really needed in this type of Melasma since it will fade away after the course of the pregnancy and is usually not permanent.
It is important to arm yourself with knowledge of melasma and how to treat the condition as well. http://www.melacor.net/ has some informative ways to treat it naturally, as well as an interactive forum.
You can certainly follow these simple ways of Melasma prevention but results cannot be guaranteed. On a brighter note, even if Melasma is less likely to be prevented, you can definitely do something to minimize it. Just remember to use sunscreen constantly and continuously. Indeed, sun protection is still the most effective way of Melasma prevention. Always protect yourself from excessive sun exposure since it is the main predisposing factor that causes over produced melanocytes on the skin to be stimulated resulting to skin hyperpigmentation.

COPD now affects more women than men

Since smoking became a popular trend during WWI and WWII more men smoked, more men developed COPD, and more men died of the disease than women. Yet that trend seems to have changed, as a new report by the Center for Disease Control (CDC) confirms.

U.S.News.com writes that the study followed COPD patients from 1998 through 2009, and found that COPD prevalence has relatively stayed the same, and the only trend that changed was that more women than men died of the disease. In fact, in 2007, as WebMD notes, "COPD killed nearly 60,000 men and nearly 65,000 women."

U.S.News notes the report concluded that "Just over 6 percent of women now have COPD, the study found, compared to just over 4 percent of men."

So why this shifting trend. U.S. News quotes Dr. Lara J. Akinbami, a medical officer in the Office of Analysis and Epidemiology at the CDC's National Center for Health Statistics with the explaination.

She said, " "The relative increase of COPD among women is largely due to more women taking up smoking in the 1970s and 1980s, Akinbami believes. These women are only now entering a time when the symptoms of COPD start to appear."

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COPD now affects more women than men

Since smoking became a popular trend during WWI and WWII more men smoked, more men developed COPD, and more men died of the disease than women. Yet that trend seems to have changed, as a new report by the Center for Disease Control (CDC) confirms.

U.S.News.com writes that the study followed COPD patients from 1998 through 2009, and found that COPD prevalence has relatively stayed the same, and the only trend that changed was that more women than men died of the disease. In fact, in 2007, as WebMD notes, "COPD killed nearly 60,000 men and nearly 65,000 women."

U.S.News notes the report concluded that "Just over 6 percent of women now have COPD, the study found, compared to just over 4 percent of men."

So why this shifting trend. U.S. News quotes Dr. Lara J. Akinbami, a medical officer in the Office of Analysis and Epidemiology at the CDC's National Center for Health Statistics with the explaination.

She said, " "The relative increase of COPD among women is largely due to more women taking up smoking in the 1970s and 1980s, Akinbami believes. These women are only now entering a time when the symptoms of COPD start to appear."

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Pleurisy and Pleural effusions

When fluid or air make it into the pleural cavity this can cause a restriction that makes it impossible for the lungs to completely expand. Pleurisy, pleural effusions, pneumothorax and hemothorax are three disease processes that involve the pleural cavity..

Pleural cavity: Surrounding the lungs is a small cavity filled with air. The outer layer is called the parietal pleura, and this is attached to the chest wall. This outer layer is attached to neurons and is highly sensitive to pain. The inner layer is called the visceral layer and it covers the lungs. The space within the visceral and parietal layers is called the pleural space.

The pleural space contains mostly air, although there is a small amount of pleural fluid. The fluid is used as a lubricant to allow the two layers of membranes to easily rub against each other to aid in inspiration. When the muscles of respiration contract, this pulls the pleural cavity outward creating a negative pressure that expands to the lungs. This allows for air to be drawn in. I discussed how we breathe in this post.

There are not connections between the pleural cavity of the right and left lung, and it is for this reason if you have air in the right lung (collapsed lung or pneumothorax) it will not effect the other lung.

Pleurisy: This is usually a complication of some other disease, and generally causes pain with inspiration. Likewise, it can precede a pleural effusion. According to Egan's Fundamentals of Respiratory Care, it's characterized by "fibrinous exudate on the pleural surface." It can also produce a rub on inspiration.

Rub: This is a grating sound on inspiration.

Pleural effusion: This is when fluid accumulates in the pleural cavity that surrounds the lungs. The only way fluid can increase in the pleural cavity is if more is produced than is reabsorbed by the body. The only way for this to happen is if there is an underlying disease process.

There are two types of pleural effusions. Yet first we must define oncotic pressure and hydrostatic pressure.

Oncotic pressure: This is pressure exerted by proteins in the pleural space (or blood) that pulls water into this area. This pressure must be balanced with hydrostatic pressure in order for the fluid in the pleural space to stay at a normal, healthy level.

Hydrostatic pressure: Also called fluid statics. It's a pressure that drives fluid out of the cavity.

Transudative causes: This is when either the oncotic or hydrostatic pressure increases and causes water to accumulate in the plueral spaces. This can be caused by:

Congested heart failure
Liver cirrhosis
Pneumothorax
Atelectasis
Pulmonary embolism

Exudative causes: This is when fluid builds up in the pleural space without the hydrostatic pressure or osmotic pressure changing. They differentiate from transudates in that there will be a higher protein buildup. This is usually due to inflammation, infiltrative diseases, or tumors: Other causes include:

Lung cancer
Mesothelioma
Lymphoma
Tuberculosis
Fungal or Viral infections
Systemic Lupas
Rheumatoid arthritis
Pulmonary embolism
Pancreatitis

Small effusions may go without notice, yet large effusions may effect a patient's ability to breath. Common signs and symptoms are:

Atelectisis due to lack of ability of lungs to expand
Dyspnea (feeling of air hunger)
Fever
Sweats
Increased sputum production
Lack of chest movement
Diminished or absent breath sounds over effusion
Vocal fremitis is absent
Percussion of chest wall is flat
Egophany may on effected side
Medistinal shift away from the fluid
Tracheal shift away from the fluid

Pneumothorax and hemothorax will be discussed next Wednesday.

References: Egans Fundamentals of Respiratory Care

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School kids need quick access to rescue medicine

Think about this. There are many asthmatic adults who are embarrassed or too modest to seek medical attention. Many are even so modest that they prefer to use their rescue medicine in private. So why would this be any different with children.

The truth is -- and this only makes sense -- that children are even more likely to not want to seek out help when they're having trouble breathing, let alone want to use their inhaler in front of someone. And it's for this reason alone that school policies that ban kids from carrying their own inhalers are ridiculous.

The main concern of schools is that kids will abuse the medicine. Yet the facts show that when an asthmatic kid needs his rescue medicine, he needs it prompt. If he hesitates to seek out help, and it then takes a while to gain access to the rescue inhaler, this can result in worsening asthma and even death.

The fact is that kids need rapid access to their inhalers. They shouldn't have to stress about how they are going to gain access to it, it should be right in their own little pockets. If they want to grab it and hide around a corner to use it, then they should be allowed to do that.

I know for a fact when I was a kid I hated the other kids to see me using my inhaler. I also hated them to see I was having trouble breathing. So when I needed it I hid around a corner and took my puffs. I was a shy kid, so seeking out adult help wasn't an option and probably never would have happened.

Many schools with "no medicine in kid pockets" policies are learning the hard way that these policies may not always be such a good thing. It's sometimes better to risk kids abusing their rescue medicine than it is for those kids to suffer or die.

Likewise, it should be noted here that using your rescue inhaler when you are short of breath is not abusing it. I think that some people assume -- especially those who don't have asthma -- that if a child uses his inhaler more than the doctor recommends that this constitutes abuse. Yet that's not true at all.

Surely overuse of an inhaler can be a sign of worsening asthma and prompt medical attention is necessary. Yet it can also be a sign of hardluck asthma, or asthma that is not well controlled with common asthma preventative medicines.

Perhaps with this wisdom in mind as many school policies -- like this one -- are being changed to the way it was when I was a kid where asthmatic kids can carry their inhalers and have quick access to them when they need them.

Sure kids should be educated. Parents should be educated. And even more important, teachers and any person who will be responsible for that child at school -- including janitors, cooks, and aides --- must be educated about asthma. They must know who has it, what signs to look for, what to do if the signs are observed, what that kid's asthma triggers are, etc., etc., etc.

To be honest, when I was a kid, if a school had such a policy, I would have ignored it. Not that I would be trying to be a rebel, but one size fits all school policies that don't consider the different personalities and needs of asthma students are bogus. Asthmatic kids need to carry their own inhalers. Period.

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School kids need quick access to rescue medicine

Think about this. There are many asthmatic adults who are embarrassed or too modest to seek medical attention. Many are even so modest that they prefer to use their rescue medicine in private. So why would this be any different with children.

The truth is -- and this only makes sense -- that children are even more likely to not want to seek out help when they're having trouble breathing, let alone want to use their inhaler in front of someone. And it's for this reason alone that school policies that ban kids from carrying their own inhalers are ridiculous.

The main concern of schools is that kids will abuse the medicine. Yet the facts show that when an asthmatic kid needs his rescue medicine, he needs it prompt. If he hesitates to seek out help, and it then takes a while to gain access to the rescue inhaler, this can result in worsening asthma and even death.

The fact is that kids need rapid access to their inhalers. They shouldn't have to stress about how they are going to gain access to it, it should be right in their own little pockets. If they want to grab it and hide around a corner to use it, then they should be allowed to do that.

I know for a fact when I was a kid I hated the other kids to see me using my inhaler. I also hated them to see I was having trouble breathing. So when I needed it I hid around a corner and took my puffs. I was a shy kid, so seeking out adult help wasn't an option and probably never would have happened.

Many schools with "no medicine in kid pockets" policies are learning the hard way that these policies may not always be such a good thing. It's sometimes better to risk kids abusing their rescue medicine than it is for those kids to suffer or die.

Likewise, it should be noted here that using your rescue inhaler when you are short of breath is not abusing it. I think that some people assume -- especially those who don't have asthma -- that if a child uses his inhaler more than the doctor recommends that this constitutes abuse. Yet that's not true at all.

Surely overuse of an inhaler can be a sign of worsening asthma and prompt medical attention is necessary. Yet it can also be a sign of hardluck asthma, or asthma that is not well controlled with common asthma preventative medicines.

Perhaps with this wisdom in mind as many school policies -- like this one -- are being changed to the way it was when I was a kid where asthmatic kids can carry their inhalers and have quick access to them when they need them.

Sure kids should be educated. Parents should be educated. And even more important, teachers and any person who will be responsible for that child at school -- including janitors, cooks, and aides --- must be educated about asthma. They must know who has it, what signs to look for, what to do if the signs are observed, what that kid's asthma triggers are, etc., etc., etc.

To be honest, when I was a kid, if a school had such a policy, I would have ignored it. Not that I would be trying to be a rebel, but one size fits all school policies that don't consider the different personalities and needs of asthma students are bogus. Asthmatic kids need to carry their own inhalers. Period.

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