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What is short of breath?

I ask people all day long "Are you short of breath?"  Yet every once in a while someone asks, "What's that?"

Most of your chronic lungers know what it is.  Yet we RTs give breathing treatments to people all day long that you know are not short of breath, and never have been.  They have no lung disease and never have.  These are your folks who might ask:  What is shortness of breath?

Shortness of breath (SOB):  It's a subjective measure.  It's how your breathing feels to you.  Do you feel winded?  Do you feel you can't get air in?  Do you feel dypneic.

Dyspneic:  A feeling that you can't catch your breath.  It's the medical description of shortness of breath.  Prior to modern times dyspnea was defined as breathing with a conscious effort. 

I've been an asthmatic and RT for so long I guess I just assume people know what it is.  Yet, understandably so, some people have no reason to know the definition.

Short of breath should have been described on day #1 of this blog.  Yet here I am well into year #4 of doing this, and here is your definition.

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What if... A Post-Penn State Fantasy About the Prevention of Child Sexual Abuse

Here is the second article written by Dr. Steve Brown


by Steve Brown, Traumatic Stress Institute

Roxanne is a fictitious 27-year-old mother of six-year-old Sarah. A single mom since Sarah’s birth, Roxanne has finally found the “love of her life”-– 35-year-old Justin. He’s got a steady job, only drinks on weekends, and seems to just adore Sarah. He loves playing with her and even has been willing to babysit whenever Roxanne needs a girls’ night out. Quite frankly, Justin almost seems too good to be true.

Six months ago, Roxanne and Justin were ready to take their relationship to the next level so they moved in together. Justin pays most of the rent and gas so things are looking up financially for Roxanne. They have even talked about marriage, prompting lots of chatter between Roxanne and her girlfriends about when Justin was going to “pop the question.”

Sarah was SO happy when Justin moved in. She’s never really known her father and always felt jealous seeing her best friend playing with her dad in their front yard. She secretly hoped her mom and Justin would get married.

Three weeks ago, Roxanne grew concerned when Sarah started to wet her bed, something she had not done for years. Sarah also seemed especially clingy at bedtime, not wanting to say goodnight or to go into her bedroom alone. Roxanne needed to lay down with her at night in order to get her to go to sleep.

Once, when Roxanne went to lay down with Sarah, Sarah’s bed smelled like cigarette smoke. She didn’t smoke, only Justin did. In the morning she asked Justin if he had been in Sarah’s room and he shook his head, looking at her as if she was crazy. Another night, Justin came home late and Roxanne happened to wake up and hear the door to Sarah’s room creak. She thought it was strange because Sarah almost never gets up to go to the bathroom in the middle of the night. A third time, Roxanne found Justin’s shoes underneath Sarah’s bed -- “That’s strange," Roxanne thought, “well, maybe Sarah was just playing her make-believe games and used Justin’s shoes.”

In a post-Penn State sex scandal world, maybe, just maybe, the following would transpire.

Like millions of other Americans, Roxanne has been riveted by the news about the alleged sex abuse by Jerry Sandusky at Penn State. On CNN’s Late Night with Anderson Cooper, she sees an expert talk about how most people think of sex abusers as creepy perverts, lurking around playgrounds, but in fact over 70 percent of sexual abusers are known, and often loved, by the children they abuse. They point out that true prevention of sex abuse will only happen when mothers, grandmothers, neighbors are alert to the possible signs of troubling behavior by their boyfriends, uncles, the next door neighbors. They need to pay attention to their gut feelings when they think something isn’t right about the sexual behavior of the person they know. It’s hard to face the possibility that someone you’ve trusted may be hurting a child, even harder to speak up.

Suddenly, Roxanne flashed to the smell of cigarette smoke in Sarah’s bed – “why on earth would Justin be in Sarah’s bedroom without me knowing about it. There must be an explanation. Maybe he was just tucking her in that night and I didn’t know about it. Maybe I’ll ask Sarah.”

When Roxanne asks Sarah, Sarah looks away and doesn’t say anything. When Roxanne asks her again, “Has Justin ever come into your room at night?” she quietly says, “no.”

“This isn’t possible,” Roxanne thinks, “Justin is SO good with Sarah. He adores her and she seems to like spending time with him. There’s no way. Finally, I’ve found the man of my dreams. Everything is working out. I might even get married. I love Justin. But, I can’t stop thinking about this.”

The next night Anderson Cooper reports:

“One of the most disturbing parts of the Penn State sex abuse scandal is how many people likely either had direct information or suspected Mr. Sandusky of abuse and failed to come forward and speak up on behalf of the victims. They were passive bystanders, not active ones. Think how many victims could have been spared if JUST one of those adults had come forward and had the courage to not let it rest.”

Roxanne suddenly feels like she’s been kicked in the stomach. “How many times now have I had this yucky feeling about Justin. I keep wanting to put it out of my mind. WHY does it keep nagging at me? All those people at Penn State, they looked the other way. Am I looking the other way? It CAN’T be possible, but maybe…I have to talk with someone.”

The next day Roxanne has lunch with her girlfriend. “Can I talk to you about something? This is going to sound so strange, but I just can’t get it out of my head…” and she goes on to tell her friend about what she has observed ending with “I’m sure it’s nothing, right?” Her friend looks stunned, “I CAN’T believe you’re saying this. Justin has always struck me as a little creepy. I never told you this, but I saw him sort of hitting on a 13 year-old girl. I didn’t think anything of it, but it was WEIRD. Once, when I was at your house, I heard him tell Sarah that her butt was cute in her tight jeans. I didn’t think it was anything so I didn’t tell you. But, it did seem really inappropriate. ”

Two days later, Justin came home again in the middle of the night. Roxanne stayed awake this time. Again, that creak of Sarah’s door. When Roxanne burst into the room, she saw Justin lying next to Sarah on her bed. He immediately stood up and yelled, “What the hell are you doing here? I was just tucking Sarah in.” Justin had clearly been drinking. Roxanne threatened to call the police unless Justin left immediately.

When she talked to Sarah about what had happened, Sarah said that Justin had been coming into her room numerous days in the past month. He always woke her up, lay down next to her, and talked about how she was so special. He always had alcohol on his breathe. He’d kiss her face and rub her back. When Roxanne asked if he had touched her on her private parts, she said “no”, but she hated when he came in. She couldn’t fall asleep at night thinking it might happen again. Roxanne said, “Sweetie, I’m so sorry this happened. He will never do that again to you. I promise. I swear.”

As Roxanne sat awake in bed that night, she could barely contain her rage. "But, at least I caught it before anything really bad happened. It could have been like those boys at Penn State. Thank God I trusted my gut. Thank God I talked with someone. Thank God I spoke up!!!”

Now THEN we’d be making progress on preventing sexual abuse of children.
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Things only an RT would say

I just finished giving the lady's mom a breathing treatment when she said, smiling, "So you just gave that so my mom meets criteria, right?"

I said, "You have GOT to be a respiratory therapist."

"I am," she confirmed.

Some things only an RT would say, and that's one of them. Here are some other things only an RT would say:
  1. I have the ABGies
  2. That breathing treatment's not needed
  3. Now that the patient has allbetterol in his system he's good to go
  4. The hypoxic drive theory is a hoax
  5. Xopenex is the same as Albuterol
  6. Bronchodilator abuse
  7. All that wheezes is not asthma
  8. All shortness (dyspnea) of breath is not asthma
  9. The only reason the treatment helped that patient with dyspnea was the oxygen boost
  10. I only work so I can have days off
  11. I'm not smart enough to be an RT (or maybe I'm smart enough not to be an RN)
  12. I love being an RT
  13. I hate being an RT
  14. That patient does not need suctioning
  15. Suctioning an awake and alert patient is unethical
  16. Most of what we do is a waste of time or delays time
  17. You don't intubate a number
  18. Q4ever treatments
  19. Doctors don't wean on weekends or after office hours
  20. Oxygen does not treat anemia
  21. Breathing treatments do not cure rickets
  22. Ventolin is like scrubbin bubble therapy.  Doctors think it gets deep into the lung and scrubs them clear of all lung ailments.
  23. Doctors think Ventolin prevents everything from asthma to rickets, from atelectasis to pneumonia
  24. Ventolin does not even get deep enough in the lungs to treat pneumonia
  25. There's no smooth muscle and no beta receptors in the alveoli
  26. Are you short of breath?
  27. Let me listen to your lungsounds
  28. Let me get you a stool, a fan and a table to lean on
  29. I walked 20 miles at work today
  30. You want a what...!!!
  31. The patient had no history of short of breath, has no lung disease, doesn't smoke, has clear lungsounds, a normal x-ray, and yet I had to give a treatment anyway
  32. I can't find (feel) a pulse
  33. Take in a deep breath... and blow, blow, blow, blow.....
  34. This EKG will be quick and easy.... unless you're a hairy man, then it'll be painful
  35. If you need me I'll be in the waiting room watching TV
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dnr vs full code

I often get asked what the difference is between full code and DNR.  So I'm going to take a moment to define these two terms.

Full Code:  You do everything possible and necessary to save the life of the person.  This means if the patient stops breathing you'll intubate and put the patient on a ventilator, and if his heart stops you'll do chest compressions with ventilations.  You will also provide medications necessary to try to save that person.  Any patient who does not have a DNR order is considered full code.  If you don't know if the patient is a DNR, then you consider the person a full code.

DNR:  This stands for do not resuscitate.  This means if the patient's heart and breathing stops you do not perform any heroic efforts.  You do not intubate or ventilate.  However, you will still care for the patient and do whatever is necessary to help the patient get better.  The only things you don't do is heroic activity.

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Happy Thanksgiving

Surely I get to work on Thanksgiving, and I'm thankful for that.  I'm thankful for all the great people I work with, and for all the great food.  I'm thankful for the wonderful conversations I had today with all my wonderful patients.  I'm thankful that my kids all called to talk, even my one year old (although all I heard out of him were the beeps of the buttons).  I'm thankful for the profession of respiratory therapy that allows for me to work in a clean environment, and provides me the opportunity to blog when my work is done.  I'm thankful for bosses who are cool about it.  I'm thankful for where I am in life.  I'm thankful for all the great folks who tune into my blog, whether it be by chance, an occasional peak, or on a regular basis.  I'm thankful for a good life.  I'm thankful for the Internet, Google, and Blogger for making all this possible.  I'm thankful for God and this life and everything that's lead to me being able to sit here typing at this computer console at this moment.  Thank you readers.  Happy Thanksgiving!
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Should hyperventilating patients breathe into a bag?

I remember it used to be advised that when a person is hyperventilating that they breathe into a paper bag.  Yet according to new medical practice guidelines this is not only no longer recommended, it is considered malpractice to recommend it to a patient.

Dr. Jeff Clawson, in his article, "Stand By The Protocol:  Some advice should stay in the bag," The Journal of Emergency Dispatch ( Sept./ Oct., 2011, pag7), explains that if you have otherwise not assessed the patient, you have no idea why the patient is hyperventilating. 

Dr. Clawson opened up this topic to discussion, to which one responder explained hyperventilating can be a symptom of a variety of underlying problems, such as:
  • Asthma attack 
  • Pulmonary emboli
  • Heart attack
The responder explained that breathing into a paper bag when you have an underlying pulmonary problem can cause hypoxia and can make the patient's condition worse, and even cause death. 

The concept behind breathing into a paper bag is the belief that if a person is hyperventilating he is blowing off too much carbon dioxide (CO2).  If a person is breathing into a bag he will be rebreathing CO2 and thus bringing his CO2 level back to normal.  It's believed this might help stop the hyperventilating.

Another responder noted the following fact:  "I would also add that true hyperventilation, left untreated in the pre-arrival environment, is benign." 

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You do not have to intubate if you have a good airway

Other than certain ethical issues, the things that irritates this RT more than anything are when certain medical workers become rapt on the idea they have to intubate right away during a respiratory or cardiopulmonary arrest.  The patient turns blue and they think intubate.  The neonate needs CPR and they think intubate.

An intubated patient is easier to ventilate that's no doubt, yet more often than not the process wastes valuable time better spent giving breaths, giving chest compressions, and giving medicines.  In most instances, I think intubation can wait until you have the situation under control.

In fact, we'll just jump to the case here and come out with RT Cave Rule #52:
RT Cave Rule #52:  So long as you have a good airway and ventilations are effective, intubation can wait until the patient is stabilized.
Under stress of a code intubation is often the first thing to come to mind.  It shouldn't be. The first thing to come to your mind should be "are we ventilating?"  If yes, leave well enough alone and move on to the next question:  "are we circulating blood?"  If the answer to both these are yes, then you can intubate.

Now obviously there are exceptions to this rule, such as obstructed airway.  Yet this would still fall under rule #52 which states, "so long as you have a good airway."  If you don't have a good airway, then you can rush to intubate.  In that case, you have to intubate.

Some people might contend another exception is overdose and high risk for aspiration.  Yet I would never recommend intubating such a patient.  Why you ask?  Because sticking a hard, metal object through someone's gag reflex is the perfect way to get someone to vomit.

But you don't have to intubate a neonate you just started doing chest compressions on.   I sat and watched a doctor doing this, and also watched as the pulse oximeter went from 90 to 80 to 70 to 60.  I verbalized these falling heart rates and the doctor said, "Don't worry about it."

Sorry, but I was right and that doctor was wrong.  He spent way too much time trying to intubate, and his attempt, even while he had noble intentions, was inappropriate.

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More Asthma Terms

The following post was published at MyAsthmaCentral April 11, 2011 by Rick Frea:  "Asthma Terms You Should Know:  Part 2."

One of the first priorities of anyone new to this asthma thing is to improve our asthma wisdom. We need to know as much about this disease as possible. By this we improve our ability to get it under control, and keep it that way.

That in mind, I've created an asthma lexicon of terms every asthmatic should know. Consider this part 2 of my post of a few years ago aptly titled "An Asthma Lexicon: Important Terms You Should Know."

So here's today's terms:

AcuteIt's happening right now.

ChronicIt's going on all the time. Permanant.

Allergy(Synonym: atopy) It's estimated 75 percent of asthmatics also have this. It's an abnormal reaction to an allergen. A normal reaction would be no reaction at all. The first time your body comes into contact with the allergen (dust mites for example) your body develops a defense against it. When the allergen is reintroduced your body attacks it the same as it would an enemy bacteria or virus. The reaction includes inflammation of the respiratory tract, eyes or skin. This often results in nasal congestion, itchy eyes, runny nose, wheezing (asthma), and skin rash.

Allergen: Anything that induces an allergic reaction. Common ones include dust mites, cockroach urine, molds, fungus, and animal dander. For a more detailed list of allergens and asthma triggers, check out this link.

Hypersensitivity: Extremely sensitive, as in sensitive to an allergen. The air passages (bronchioles) of asthmatic lungs are often hypersensitive to various asthma triggers, and they may become acutely inflamed (swollen) as a result of such contact. See allergy.  This increased sensitivity may also be due to chronic inflammation of the air passages (which can be improved with corticosteroids).

InflammationSwelling and redness caused by some irritation. In asthma there is some chronic swelling of the air passages, and when exposed to asthma triggers this inflammation may become worse, or acute. Acute asthma is your asthma attack.

Rhinitis: (Synonym: hay fever) Inflammation (swelling) of the mucus membrane inside the nasal passage.

Sinusitis(Synonym: sinus infection) Inflammation of the sinus passages

Beta Agonist: (Synonym: bronchodilator, rescue medicine) This is a medicine that has an affinity to beta receptors that line the respiratory tract, particularly the bronchioles. Once attached to the beta receptors a reaction occurs that relaxes the bronchiole muscles and opens up the air passages. This makes breathing easier. Examples include Ventolin and Xopenex.

Long Acting Beta Agonist (LABA): These work the same as Beta Agonists only the medicine can last up to 12 hours. Common examples are Serevent (a component in Advair) and Formoterol (a component in Symbicort).

Corticosteroids: (Synonym: steroids, glucocorticosteroid) A medicine often used to reduce inflammation in the air passages. Common examples include Flovent (a component in Advair) and Budesonide (a component in Symbicort).

Metered Dose Inhaler (DPI): (Synonym: puffer, inhaler, breather, rescue inhaler, atomizer) An easy to use and convenient to carry device used to aerosolize asthma medicine such as beta agonists and inhaled corticosteroids. It consists of the medicine mixed with a propellant held under pressure inside a metal cannister and a plastic sleeve with a little mouthpiece. When you press the canister medicine is sprayed and can be inhaled. For more information click here.

Dry Powdered Inhaler (DPI): The medicine is in powder form and usually comes in a device such as a discus or other device. The medicine is usually held inside a capsule that is crushed when you twist the device. The powder is inhaled when the patient places his mouth over the mouthpiece and inhales. For more information click here.

Nebulizer: (Synonym: Updraft therapy, Aerosol, Magic Mist, breathing machine, breathing treatment, peace pipe) This is a small cup that you put liquid medicine into, and once hooked up to an air source (like an air compressor) and pressurized air causes the liquid to become aerosolized and reduced to a fine mist that can be inhaled. Such treatments usually last five to 10 minutes. This is ideal for anyone who has trouble using an MDI. For more information click here.

If you come across an asthma term you want defined, leave a note in the comments below, or ask a question in our Q&A section.


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Preventing and Reporting Child Abuse: The Questions Raised by the Penn State Scandal

This excellent article was written by my colleague Steve Brown, PsyD.

Last week, a Pennsylvania Grand Jury indicted former Penn State defensive coordinator Jerry Sandusky for sexually abusing eight boys over the course of a 15-year period. The indictment also charged two top university officials with perjury and failure to report what they knew about the allegations. The indictment has kicked off a firestorm of media attention both in the sports world and the US at large. On November 9th, the Penn State Board of Trustees fired legendary football coach Joe Paterno and Penn State President Graham Spanier. Allegedly, a graduate assistant told Paterno that he observed Sandusky abusing one of the boys. Paterno reported this to Athletic Director Tim Curley although did not follow up later on the matter or alert legal authorities himself. The indictment stated that President Spanier was made aware of the incident reported to Paterno as well.

In any particular abuse situation there is an abuser, a victim, and (almost always) bystanders. This is true in bullying, street violence, as well as child sexual abuse. One of the most important questions that the Penn State situation, and cases like it, raise is -- what is it about the nature of intimate sexual violence that stops so many bystanders from taking action when they either have direct information that abuse has occurred or, more commonly, just an inkling that something might not be right.

It is true that men like Mr. Sandusky can often be well-regarded, upstanding citizens, involved in the community, even loved as a role-model by many. However, it is ALSO true, as has come out in the press, that numerous people had direct knowledge of, and even directly witnessed, Mr. Sandusky sexually abusing boys. Despite this knowledge, they were passive bystanders, not active ones. If any one of these adults took appropriate action to report this to the proper legal authorities, maybe the abuse would have ended with one or two boys rather than eight. Maybe the victims would have been given help and protection.

While some adults in this situation had direct knowledge of the abuse, I'm guessing there are likely many others who had troubling gut feelings about Mr. Sandusky --family, neighbors, players, coaches, etc. Many such people are now wracking their brains about what signs they might have missed, why didn’t they trust their gut, and, most importantly, what prevented them from coming forward. These are good and important questions. Even Joe Paterno, whose Penn State football team proudly extolled a reputation for being “squeaky clean” and whose motto was “success with honor,” could not see clear to act on his moral responsibility to protect current and future victims. It is especially disturbing that those with direct knowledge could not muster the resolve to actively speak out.

However, for all of us, there is this critical question -- WHAT prevents us from speaking out, not ignoring what we see, paying attention to these gut feelings, checking them out, talking with a friend or colleague about them, and ultimately taking action to alert the proper authorities?

I think there are complicated answers to this question.

Much of it relates to our societal denial about the reality of child sexual abuse. We SO want sex abuse to be about the creepy pervert, the stranger who abducts and molests our kids. Let’s just put them all on sex offender registries, attach GPS devices to their ankles and we’ll be okay. We DON’T want to admit that 90 percent of sex abuse is committed by people known by the victim and the family – our brothers, uncles, fathers, stepdads, and…yes…coaches.

If we do speak up, we are intruding on the privacy of the hallowed family --whether it be a family unit or the Penn State family. Sometimes, we don't know what signs to pay attention to in these men. Even if we do, we don't want to get involved: “I told my supervisor. If they don’t act, it must not be that big a deal. Anyway, if anything happens, it’s on them, not me.”

We especially don't want to get involved when there are powerful people and institutions involved. When those institutions have “squeaky clean” images to uphold, we don’t want to be responsible for tarnishing that image. If we do raise our concerns, we risk social rejection. We also need to have some comfort with our feelings related to the shrouded area of sexuality and the language of sex to get involved and speak up. If we speak up (as an adult bystander or a victim), it is HIGHLY likely that things will get worse in the short term although hopefully better in the long term.

Many people, playing Monday morning quarterback, are outraged about the fact that bystanders didn't speak up (and we should be outraged by this case), but this does NOT recognize the reality of the barriers listed above. Until we grapple as a society with these many barriers, we will make limited progress on prevention.

Child sexual abuse prevention, led by organizations such as Stop It Now!, seeks to answer exactly these questions – how do we help adult bystanders recognize the signs of sexual abuse, talk with others about what they are seeing, and find the courage and words to speak up. Unlike Penn State, most often it is a wife speaking up about (or to) her husband whom she sees repeatedly coming out of their daughters’ bedroom in the middle of the night; a neighbor speaking up about (or to) a beloved neighbor who frequently has boys coming in and out of his house; an adult niece speaking up about (or to) a great uncle who always wants to play video games in the basement alone with a 10 year-old relative.

This is not an easy subject to raise when the abuser is the primary earner for the family; when he is well-loved, even by the son or daughter he is abusing; when he is the founder of organizations for vulnerable kids which do a lot of good; when speaking up means a crisis will ensue.

To prevent sexual abuse, we must ALL struggle with these questions. Perhaps the Penn State situation will move us a little closer to speaking up as ACTIVE bystanders, not passive ones, looking out for the well-being of our children and those who cannot speak for themselves
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Faux (pseudo) pneumonia

With pneumonia as the most reimbursable diagnosis, that makes pneumonia that most common fake diagnosis written on charts.  I call it faux (pseudo) pneumonia.  You can call it fake pneumonia.  I like faux for fun.

You know the patient doesn't have real pneumonia because no x-ray is done, and if one is done it's normal. The patient's lungsounds are normal or not consistent with pneumonia.  White blood cells are within normal range, and do not indicate an infection. 

So the patient is sick enough to be admitted, yet doesn't meet criteria.  Therefore the diagnosis of faux pneumonia is made. 

A good example of this is an Alzheimer's patient was recently released from the hospital and sent to a nursing home. The home refused to admit the patient because he was combative.  Not knowing what else to do with the patient, we readmitted him to the hospital with faux pneumonia.

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How to deal with hotheads at work

For the first time in a while I arrived at work feeling completely refreshed.  The patient load was way down and the milieu of the RT Cave was relaxed.  All was going well until my boss handed me a sheet of paper with a few errors I made the last day I worked.

No big deal, I thought.  With lots of time before my first treatments were due, I wandered to the lab to result an ABG I did two days earlier.  The process was a little more complicated than I expected on the new system, yet after clicking a few icons the job was done.

The lab boss was sitting there so I thought I'd go out of my way to tell him the job was done.  I confidently said, "Hey, Mike, I fixed the ABG that was non-resulted."

"So how did that error get made?" he said. 

"It was just me being incompetent," I said in my normal fun tone.  As he spoke this I started wishing I hadn't said anything.  I could see horns growing on either side of his head -- red horns.  His hand moved quickly from the keyboard to the pitchfork -- also red.  Steam started billowing from the tops of the horns.

"You know that's a serious issue that needs to be dealt with," he whined.  "You really are incompetent if you're making errors like that.  That's two days a doctor didn't have those results.  That's unacceptable!  What are you going to do to make sure something like this doesn't happen again."

One mistake doesn't constitute a crisis!  I wanted to say.  Yet common sense took over my thoughts and what came out of my mouth instead was:  "You have a good day too."  I turned and walked away."

The truth was the doctor was handed the results by me, yet I didn't want to humor him with that information.  The fact the ABG wasn't resulted only meant it wasn't in the computer. 

This brings us to RT Cave rule #49:
RT Cave Rule #49:  One mistake does not constitute a crisis.  One mistake is a normal human error, and several mistakes may be considered a crisis that needs to be dealt with.
I knew from personal experience that dealing with a hot head during a hot situation never works.  A better solution is what I did next.  I went upstairs and went straight to my bosses office, handed him the receipt of the correction and said, "I told Mike I fixed this and he was sort of a hot-headed jerk about it."

I had to do that because that prevents Mike from going to my boss and getting the upper hand.  It was my way of staying on offense and staving off a worse situation.

Then I told my co-workers.  Then during lunch I was sitting at the table munching away on a carrot when Mike came into the cafeteria.  "Hey, there he is!  There's the hot-headed head of lab.  There's the guy who called me incompetent.  Should I wave!"

A good laugh ensued.  Yet more important, I had gained the sympathy of my fellow co-workers.  If Mike did anything to further this incident, I had the support and sympathy of my boss and co-workers.

I suppose the moral here is that hotheads never win.  So We'll make that RT Cave Rule #49:
RT Cave Rule #50:  Hotheads never win.  Getting hot says more about your incompetence in dealing with stressful situations and resolves nothing.  It merely results in you looking like the bumbling moron you are.
Likewise this also brings us to RT cave Rule #51:
RT Cave Rule #51:  When dealing with a hothead, it's best to shut your mouth and walk away.
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The Natural Progression of COPD

I saw this curve at my pulmonologist's office about 16 years ago yet I couldn't remember what it was called until I found it while surfing the Internet.  It's called the Fletcher and Peto Curve.

I think this curve is neat because it shows that we will all develop COPD if we live long enough, yet usually never enough damage will occur so it will present with symptoms.

Yet you can see that the longer you smoke the faster your lung function declines.  Essentially, this curve shows that smoking essentially speeds up the aging process.

The American Thoracic Society published a good article on the curve called "Natural Histories of Chronic Obstructive Pulmonary Disease" in 2008.  The article was written by Stephen I. Rennard and Jorgen Vestbo, who explained that the curve was the result of a 1976 study by Fletcher and Peto who studied the lung functions by measuring the FEV1 of a variety of participants, some who smoked and others who did not.

The result was this chart that shows the natural progression of COPD.  The writers propose that this curve comes with limitations as it only measures FEV1, yet even so, it still provides us with a vivid picture of just how effective cigarette smoke is at reducing lung function. 

It would be neat to see a similar curve showing the progression of lung function for those who inhale second hand smoke. 


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WHO spins facts about 2nd hand smoke

My uncle, who so happened to be a chain smoker, educated me one day about the fallacy that 2nd hand smoke caused cancer. He was a chain smoker, and he already had a lung removed, yet he still felt the facts were so that it was worthy to note the "bullshit that THEY teach kids these days."

At the time I just blew my uncle off as a smoker who didn't want to admit the truth. Yet being the person I am (and perhaps partly through his example), I decided a better response to his little speech was to do my own research.

In doing so I came upon this study that was independently funded by the World Health Organization (WHO). The study was a review of many other studies on the subject, and the goal was to prove that 2nd hand smoking causes cancer.

Ironically, the study proved the opposite: that 2nd hand smoke does not cause cancer. Yet since the study didn't show what they wanted, they didn't release it. They didn't do this because one of the goals of the progressive WHO is to create an ideal world. And in an ideal world people don't smoke because smoking kills.

Now it is still true that 2nd hand smoke is unhealthy, and most studies about it show this. Yet it is just about a proven fact now that 2nd hand smoke does not cause lung cancer. The WHO was hoping this study would help justify their attempts to get rid of smoking worldwide through higher taxes and laws banning it in public places.

The ultimate goal of the WHO is to ban smoking altogether, yet because of the U.S. Constitution, this is nearly impossible to do because people have a Constitutional right to be stupid so long as they don't infringe on the rights of others. Ideally, the Constitution protects us from each other, and not necessarily from ourselves. So if we want to smoke, so be it.

Of course another reason progressives want to get rid of smoking altogether is because another goal is universal healthcare. They don't want to pay for the health consequences of personal choices that are bad, like smoking.

This is yet another reason I'm opposed to universal healthcare, and even Obama care, because if someone is paying your bills, they have a right to tell you what to do. In other words, you are a slave to the person you are in debt to.

Thus, every time a new law is made, you lose another freedom. Every time we receive another government entitlement, we lose another freedom. So if we continue to allow our government to create more government programs, we will eventually be slaves to the state. The same thing happened in ancient Rome, and destroyed that republic.

The WHO once again has ignored the above mentioned study as it released a new study that shows that 2nd hand smoke kills up to 600,000 people each year, and this accounts for 1% of all deaths each year. You can read the report here.

The report notes that, "Researchers estimated that annually second-hand smoke causes about 379,000 deaths from heart disease, 165,000 deaths from lower respiratory disease, 36,900 deaths from asthma and 21,400 deaths from lung cancer."

In lei of the previous study by the NWO that showed 2nd hand smoke does not cause lung cancer, can we now assume the NWO is conveniently ignoring this study. Their ultimate goal is to get rid of smoking, regardless of facts.

This almost makes one wonder about the true intentions of progressives. Are they after what's best for the people, or the government? I almost think they want to get rid of smoking so the government doesn't have to pay for diseases caused by smoking.

So they raise taxes. They also create more rules or laws that ban smoking in public places. All of this with the intent of forcing people to quit, as opposed to people quitting by individual choice. Progressives don't believe in individual choice, the believe in the state making choices for the people.

Of course, as I've written before, too many rules (laws) and too high of taxes result only in people finding ways to get around the taxes or rules. It creates a world of cheaters and liars, because the natural tendency of human beings is to make their own decisions. People don't like people telling them what to do.

A great example of this is in New York where taxes are high on cigarettes and public smoking is not legal, a black market for cigarettes has been created, as you can read here.

I have no vested interest in people smoking. Well, I say that knowing that my career as an RT is mainly funded by patients who smoke. Yet I don't want people to smoke. It bothers my asthma when people smoke around me. It threatens the health of my kids.

So I don't want people to smoke. I want people to quit. I want my dad to quit, yet he has made the personal choice to smoke. And, yes, he does get cigarettes illegally over the Internet because he can get the cheaper that way.

Second hand smoke is bad as you can see by any link that lists the hazards of second hand smoke, such as this and even the WHO itself as you can see here.

You should educate your patients about the dangers of 2nd hand smoke. If someone says they quit smoking, make sure they know to not let others smoke around them. Yet also don't get all your wisdom from one place, and decide for yourself what is fact and what is not a fact.

Because Lord knows it's hard to get all the facts even from sources we otherwise think are trustworthy. Now I'm certain the American Cancer Society and other such resources are trying to provide honest facts. Yet they, like you and me, get their wisdom from sources they hope are being honest with us.

This is a perfect example of why I created this blog. You and I are interested in facts and then we make an educated decision, rather than just believing everything we read. While we might not have much of a choice what we do as RTs, we can be smart.
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What is Cancer Remission?


All of us know about cancer, and many of us have frequently heard terms such as cancer remission. What is cancer remission exactly? Literal meaning of remission is reduction. However, when doctors use this term in reference with cancer, they mean the level of the cancer cure achieved through a certain therapy or treatment.
There are two types of cancer remissions: complete remission and partial remission. As the name suggests, complete remission is the complete absence of cancer signs and symptoms, while a partial remission is disappearance of a few signs and symptoms of cancer.
However, even when we refer to the complete remission of cancer, it may not necessarily indicate complete cure of the cancer and partial cancer remission suggests the presence of cancerous cells, however, in a decreased amount than earlier.
Remission and Cure
No cure is possible without remission. Remission and cure are interrelated terms as doctors usually avoid using the term cure for they use remission as the term to signify the period, wherein the patient responds to the cancer treatment.
To decide whether the cancer has been cured, a person needs to wait for a stipulated time to determine the type of response to the treatment. Hence, a remission that has almost cleared all symptoms of cancer may be termed as a cure.
While, remission is the period, when the patient responds well and positively to the cancer therapy, he/she may still die following a different illness. To decide the exact type of remission achieved with the cancer treatment, there are various examinations to be conducted within a stipulated period of time and decide what cancer remission is, has it significantly reduced the cancer symptoms and cells or has it just decreased the cancerous cells to a certain level.

Visit  http://www.cancer8.com/, for more types of lawyer
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Facts about 2nd hand smoke

Here are some facts about 2nd hand smoke. This list may be different from other lists because I'm basing my list on facts obtained from studies and not my own personal opinion and vested interest.

Note, however, that I want people to quit smoking, and I want people who do not smoke to be protected from 2nd hand smoke. However I do not believe there should be any attempt by any government to force people to quit smoking other than through education.

It is my belief that most people are smart, and provided with facts they will make the best decision for themselves. I do not believe facts come from organizations and companies that in some way profit from smoking. I also do not believe the facts come from organizations like the World Health Organization (WHO) either.

In a way this is frustrating, because ideally we should be able to get all our facts from such organizations as the WHO, our government, or at least from the Media. Yes it's true, even the media can't fully be trusted.

So this is why we must keep our minds and ears open and get our news from a variety of sources. While I do not pretend to know all the truths, I do like to lay out all the facts so we can all make an educated decision. This, after all, is the goal of the RT Cave.

We do, however, agree that 2nd hand smoke is bad, even though all the information we receive might be twisted in one way or another. That in mind, here are some facts about 2nd hand smoke.
  1. 2nd hand smoke may not cause lung cancer, as you can see by this WHO study. Despite this, the WHO notes that 2nd hand smoke kills as many as 600,000 people each year, as you can read here. We're neutral here, so you decide.
  2. There are over 4,000 chemicals in cigarette smoke, and over 250 of them are known to cause damage to the human body such as aging the body, thinning the skin and arteries, destroying cilia in the lungs, etc. This effect is just as damaging to those who breath second hand smoke as those who inhale the smoke directly.
  3. It causes 600,000 premature deaths each year
  4. It causes hardening of arteries and heart disease (about 46,000 deaths annually)
  5. It increases your risk for stroke and brain aneurysms (thinning arteries)
  6. It increases your risk for getting chronic obstructive lung disease, especially if you have asthma
  7. It increases your risk for getting pneumonia
  8. It shortens your lifespan (yes, even if you inhale someone else's smoke)
  9. Separate areas in a building to not decrease your risk for second hand smoke related exposure. This is why smoking sections have no effect.
  10. Ventilation systems do not decrease your risk of inhaling 2nd hand smoke. Smoke can get from a smoking area to a non smoking area even if there's a door between rooms.
  11. 40% of children are exposed to smoke at home.
  12. 31% of smoking related deaths occur in children
  13. 2nd hand smoke greatly increases the risk of sudden infant death syndrome
  14. 2nd hand smoke increases risk your child will develop asthma
  15. Kids exposed to 2nd hand smoke are 1.5 to 2 times more likely to smoke themselves
  16. Results in increased sick days and lost wages
  17. Increases economic costs to society by forcing all of us to pay for the care of smoking related diseases and smoking cessation programs
  18. Decreases lifespans (each cigarette takes 7 minutes off your life)
  19. The World Health Organization notes that, "More than 94% of people are unprotected by smoke-free laws. However, in 2008 the number of people protected from second-hand smoke by such laws increased by 74% to 362 million from 208 million in 2007. Of the 100 most populous cities, 22 are smoke-free. (Note here, however, that a government has the job of protecting us from each other, but not from ourselves)
  20. Other breathing problems in non-smokers, including coughing, mucus, chest discomfort, and reduced lung function
  21. 50,000 to 300,000 lung infections (such as pneumonia and bronchitis) in children younger than 18 months of age, which result in 7,500 to 15,000 hospitalizations annually
  22. Increases in the number and severity of asthma attacks in about 200,000 to 1 million children who have asthma
  23. More than 750,000 middle ear infections in children
  24. Pregnant women exposed to secondhand smoke are also at increased risk of having low birth- weight babies.
  25. It may be linked to breast cancer
  26. Causes premature death and disease in children and in adults who do not smoke.
  27. Smoking by parents causes breathing (respiratory) symptoms and slows lung growth in their children.
  28. Secondhand smoke immediately affects the heart and blood circulation in a harmful way. Over a longer time it also causes heart disease and lung cancer.
  29. The scientific evidence shows that there is no safe level of exposure to secondhand smoke.
  30. Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces (a cause of occupational asthma) despite a great deal of progress in tobacco control.
  31. The only way to fully protect non-smokers from exposure to secondhand smoke indoors is to prevent all smoking in that indoor space or building. Separating smokers from non-smokers, cleaning the air, and ventilating buildings cannot keep non-smokers from being exposed to secondhand smoke.
  32. Driving in a car with the cigarette dangling out the window does not mean other people in the car will not be exposed to 2nd hand smoke
The following are facts about 2nd hand smoke some may not want you to know:
  1. 2nd hand smoke may not cause lung cancer, as you can see by this WHO study. Despite this, the WHO notes that 2nd hand smoke kills as many as 600,000 people each year, as you can read here. We're neutral here, so you decide
  2. The WHO also learned that parents smoked had had a 22% better chance of NOT contracting lung cancer than did adult children who came from homes where both parents did not smoke. WHO tried to hide this fact
  3. The WHO has a vested interest in getting people to quit smoking because they believe governments should have universal health care, and smoking would therefore increase economic costs to various governments.
  4. Despite what the WHO mentioned above, some studies show that technology such as air filtration systems in bars to filter as much as 100% of 2nd hand smoke from the atmosphere of the building. So ventilation systems can be effective.
  5. The number of deaths caused by 2nd hand smoke is often exaggerated. The study showing 2nd hand smoke does not cause lung cancer, and the fact 2nd hand smoke is still attributed to 2nd hand smoke, is a perfect example. The WHO and the Environmental Protection Agency have invested interests in exaggerating these numbers.
  6. Most people do not approve of smoking bans in public places. For example, in New York 85% said such laws went too far (however, personally, I believe such laws are necessary and Constitutional. The Constitution gives lawmakers the right to protect us from each other. However, I think such laws should give businesses the right to be smoke free or not smoke free and the people can choose whether or not to go to the businesses that allow smokers inside. Let the market decide and not some lawmaker in Washington).
  7. There are no studies that show people miss more work due to 2nd hand smoke. There are many reasons people miss work, and none could be ruled out. It could be second hand smoke, but there's no real evidence to show this.
  8. There is no real proof smoking increases medical costs. There is no proof these people would have had medical problems regardless whether they smoked or not. There is proof that people who smoke and have increased health problems have bad genes, so perhaps these people would have had bad health regardless that they smoked (or inhaled 2nd hand smoke).
  9. Even scientific studies are interpreted by people who have biases. Questions can be asked to generate a certain response. Studies can be interpreted with bias. In this way, sometimes statistics can be skewered.
  10. It is a fact that some studies show 2nd hand smoke causes certain diseases, and similar studies that show the opposite. As we can see by the WHO, the ones that are inconvenient to the biases of the organization are ignored and those that prove the bias are reported.
  11. The smoking industry lied about the dangers of 2nd hand smoke until recent years. This is why some smokers have succeeded in suing these companies.
  12. The U.S. government knew prior to WWI that smoking was dangerous to people's health, yet still gave out free cigarettes to soldiers in WWI and WWII. The U.S. government succeeded in getting America addicted to cigarettes knowing it was bad in order to help the smoking industry in order to boost the economy. This is a fact. Look it up for yourself.
  13. In 1929 a study was published in Germany linking cigarette smoke with lung cancer (see here).
  14. Automated cigarette machines were invented in the late 19th century which made it easy to make cigarettes. The industry soon took off, and it boomed with the help of the U.S. government
The above facts were obtained from common wisdom, the World Health Organization, the American Cancer Society, Citizens Freedom Alliance, Inc,
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Why do humidity and cold air trigger asthma?

Both humidity and cold air are common asthma triggers.  The question is why?  This was a topic I delved into in a recent post at MyAsthmaCentarl.com

Here's Why Humidity and Cold Air Trigger Asthma @ MyAsthmaCentral.com

Every asthmatic, and every asthmatic mom and dad, should be aware that both humidity and cold air are two very common asthma triggers. So why is this? What can you do about it?

It's been common wisdom for years that humidity and cold air helps with croup, or swelling of the voice box and trachea.   Put a croupy kid in the hot and steamy bathroom and the swelling gets better.

Another method that often works for croup is taking the child outside in the cold winter air.  This is why many times when a parent decides to take the child to the hospital, the child is fine by the time they arrive in the emergency room.

This is true for croup, so many doctors of old believed it must also be true for asthma. Yet it was a fallacy, and now -- thankfully -- most doctors are aware of this fallacy. In fact, now doctors are aware that both cold air and humidity can actually trigger an asthma attack.

When I was little boy way back in the 1970s my pediatrician recommended my parents have me sit in the hot steamy bathroom when I was having trouble breathing. It was also recommended I have a humidifier in my room.

Both of these made my asthma worse, not better. Yet I was a kid, so how was I to tell my parents that?  My doctor and parents thought they were doing something good, yet their wisdom was flawed.

I wrote a post before how low and high humidity can trigger asthma. Studies show that a humidity of 50 percent or greater may lead to a greater incidence of asthma trouble.

Two common theories for this are:
  1. Humid air is heavier and harder to breathe
  2. Humid air harbors fungus, molds and dust mites that trigger asthma
Humid air is most often a problem in the summer months, especially in August and September.

(On a side note here, when I was a kid there was also a fear that air conditioners were bad for asthma.  That was a fallacy that lead to many uncomfortable August car rides).

As I wrote before, I also remember having asthma trouble when my brothers and I would go sledding. I'd usually have to quit early and arduously walk home with my asthma symptoms raging.

Now we have research that shows air that is too dry can also trigger asthma. Air tends to be drier in the winter months. The reason for this is that the colder the air the less water it can hold.

When you inhale cold air that is dry this can dry the mucus membranes lining your lungs that are your bodies natural defense mechanisms against viruses and bacteria. So this can lead to increased infections too. And Lord knows viral infections are the most common asthma trigger.

Dry mucus membranes can also aggravate allergy symptoms. And considering 75 percent of asthmatics have allergies, this likewise is important.

Now that you understand that dry air can trigger asthma, consider the following:

1. Exercise can trigger asthma: As I write in more detail hererapidly breathing in air dries inspired air, which ultimately dries the airway, which then releases histamine that can increase inflammation of the air passages in your lungs. This then leads to bronchospasm. The fact runners tend to breathe through their mouths only exacerbates this problem because the nose is a better humidifier than the mouth.

2. Mouth breathing can trigger asthma: Your nose humidifies inspired air, so if you breathe through your mouth this air is not getting humidified enough. This is especially important during the winter months when the air is drier. Studies have linked nasal congestion with severe asthma, and I think this is one of the main reasons -- those with sinus trouble breathe through their mouths.

3. Cold air triggers asthma: Again, this is true because the colder the air the less humid the air is. This is why asthmatics, especially those with exercise induced asthma, have trouble exercising outside when the air is cold. Rapid breathing of cold, dry air triggers asthma as noted above.

To prevent asthma the The Center for Disease Control and Prevention recommends humidity be set between 35 percent and 50 percent. Humidifiers can be used in the winter months, and air conditioners and dehumidifiers in the summer months.

However, with good asthma control most asthmatics should still be able to exercise. Likewise, as I write here, many Olympians with asthma are still able to perform during the Winter Olympics.

It's good wisdom to know that cold air, dry air, and humid air can trigger asthma. It's also important to know that by working with your doctor to control your asthma you should still be able to continue doing the things you love most.
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Types of Treatment and Cure of Tonsil Cancer


Types of cure and treatment of tonsil cancer are vast and reliable enough to treat the disease in an efficient manner. Treatment pattern is recommended by the cancer specialists or physicians according to the location and seriousness of tumors and mental as well as physical sustainability of the patient.


Details about Types of Treatment and Cure of Tonsil Cancer

Tonsil cancer is not a very common type of disorder. It may originate in pharyngeal, palatine or lingual tonsils but develops mostly in the palatine areas. Squamous cell carcinoma is the most general cancer of the tonsil and may occur at any age. Tonsils play a vital role in developing and enhancing immune system of children though they are not that effective in adults. Hence, removal of tonsils in adult age by surgical methods is quite common and harmless to the body.

Regular medication and proper dental care is extremely important to prevent or control abnormal cell-growth in the tonsils and avoid severe ulcers, injuries or infections. Tonsils are quite vulnerable to infections and severe health issues may arise if the infections are not treated in time. Tonsil cancer comes under head and neck cancer and develops near the oral cavity. Hence, it may cause severe impact on the overall physical abilities of the person.

Surgical methods are also commonly adopted to cure tonsil cancer and their nature may vary according to stage of the disease. Surgery can be local or wide resection depending on the spread of tumors. In local resection, only a small part of tonsil tissues are removed as the infected cells are limited to only a certain area. Wide resection is practiced if the polyps are spread to a considerably large area but haven’t started to metastasize. Surgery can be carried out by normal methods or by usage of laser. Laser surgeries are quite popular as they treat tumors with minimum injuries and maximum efficiency. Health recovery is also fast in laser surgeries.

Chemotherapy is one of the main types of treatment and cure of tonsil cancer and is recommended if the tumors have begun to metastasize and are difficult to control. Tumors are killed or controlled by using certain chemicals and drugs and the treatment may have to be continued for a considerably long duration. It has severe side-effects and is recommended only in advanced stages.

Radiotherapy is a kind of radiation treatment undergone to kill tumors and avoid their re-growth. It is generally advised if all other treatment options prove hopeless as it carries a high number of side-effects and may also cause severe damage to the tonsil areas.

Immunotherapy is an innovative technique to boost a person’s immune system to fight cancerous growth as soon as it starts to develop and avoid it from advancing into a severe stage. It is generally undergone by prescribing normal medicines and certain dietary patterns.

Targeted therapies are the new types of treatment and cure of tonsil cancer and target mainly the affected area without causing any direct or indirect harm to the adjacent areas.

Types of treatment and cure of tonsil cancer should be studied and understood carefully before undergoing one. All types are not equally suitable to all victims and output of the treatment also depends on the medical history of the person. Proper diet and strong immune system is very necessary to prevent or fight abnormal growth in the tonsil areas.             


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Connecting Theory to Action

This is a long post that summarizes the way that the Restorative Approach provides a bridge between theory and action in treatment programs.

The Restorative Approach translates what modern science has learned about trauma and how it affects the brain into specific strategies for daily interactions with the children. The following points summarize the connections between theory and daily actions.

The Restorative Approach recognizes that a traumatized child’s brain is different, in that the prefrontal cortex is less developed. Because of that trauma-related difference, the child is easily overwhelmed by emotions. In treatment programs using the Restorative Approach, staff members understand that they will have to act as the child’s prefrontal cortex for awhile, teaching problem-solving rather than punishing a child for seeming to ‘choose’ to act out emotionally when the child is doing the best he can. The staff members’ brain building tasks include helping the child with selective attention, working memory, self-observation, and response inhibition. Further, the staff respond to the child’s emotional dysregulation with calming techniques rather than with thinking interventions.

A traumatized child typically has a strong, even over-developed, response to any situation perceived as dangerous. Using the Restorative Approach, staff members aim to soothe the child whose emotions are blowing up, to reassure him or her rather than get into a power struggle. The last thing a staff member trying to help an emotionally dysregulated child would do is back him or her into a corner. Instead, staff use soothing techniques when the child is upset. They teach uses of emotions and how emotions contain information, and actively teach self soothing. The staff provide and identify safety. One part of this is to talk before doing something, and to provide predictability. The program uses crisis kits and crisis prevention plans. Staff are aware that child will notice everything that they do, how they treat each other, their tone of voice, and their expressions.

Because of their focus on danger, the child may miss a large part of what goes on around them. Staff will have to coax child to have fun and point out joys in life.

Traumatic events that are experienced prior to the acquisition of language may return to the child as flashbacks, as though he were reliving, not remembering, the experience. At times the child may dissociate to manage the pain of his experience. Staff can teach grounding techniques that return the child to the present.

The physical underdevelopment of the child’s brain results in him having more difficulty accessing his verbal memory. Therefore, staff do not rely on verbal planning alone, and whenever possible use multi-model interventions such as charts, pictures, art, dance and music.

The child whose life has been unpredictable has confused, few or no regular bodily rhythms. Staff help develop bodily rhythms by maintaining predictable structures and offering rhythmic activities such as yoga and dance. The child also has an under-developed ability to sort out social cues, so staff are clear in communication and use simple language. They teach social interpretation through movies, books, etc.

Lake of early reliable care combined with trauma and attachment disruptions result in a child whose connection with his own body has not been reliably established. Therefore, he may have difficulty regulating their body functions. Staff can help through offering repetitive, rhythmic, rewarding activities to rebuild the lower brain, the part that controls the body. The child may have difficulty sleeping, so staff will not punish bed time problems, but instead look for ways to help child relax such as night light, reading, or music. Staff will therefore handle hygiene issues with sensitivity and understanding of complexity (symptoms are adaptations), not with consequences, and will find opportunities to teach healthy sexuality.

Because the child has had less attuned interactions, his brain is less integrated and he has more trouble with generalization from one situation to another. Staff therefore make connections explicit and specifically make comparisons between various aspects of life, distinguishing past from present. They give the child opportunities to practice new skills in many arenas and settings.

Children who grow up with neglect and trauma are not taught how to recognize or name emotions, so it is up to treaters to teach them the names of emotions and model healthy emotion. This includes the recognition of bodily sensations of emotions. The child may experience his emotions as moving from extremely aroused to extremely shut down quickly with no apparent rational. Staff can help child develop awareness of his own emotions and their stages, and develop tactics for each stage.

The hallmark of trauma is the victim’s lack of control. He cannot influence what is happening to him, and he is used to fulfill someone else’s needs. He is not treated like a person. After repeated exposure this powerlessness generalizes to all situations. The child learns that no effective action is possible in their life. Therefore it is important that treatment systems do not replicate this experience, and that they allow many opportunities for active participation in decisions involving the youth. They can also respond to problems by guiding the youth to fix damage they have created and repair relationships they have hurt. Because of this previous lack of control, the child may value control above all else. The program can give child control whenever possible, collaborate with him, and focus on him learning to control himself as opposed to staff controlling his behavior. Because control is so important, and lack of control is associated with victimization, the child may cover up vulnerable feelings such as fear and sadness. Staff can create safety to allow the child to share vulnerable feelings, and model having vulnerable feelings in a healthy way.

The child believes that everything that has happened to him is his own fault. To heal he must develop a sense of safety in which he can share what he finds shameful and receive compassion. Staff can also point out his strengths and achievements.

The child’s experiences have taught him not to trust adults. Programs can provide a different experience by being trustworthy, and by emphasizing trustworthy relationships. They can point out how present relationships are different from past relationships. The child expects the worst in relationships, and so may push people away. Staff understand the adaptive aspect of the child pushing the adult away, stay committed, and don’t pull back. They verbalize and validate the child’s fears.

The relationships in the child’s life have often violated his boundaries, involving him in adult problems and activities, requiring him to perform tasks beyond his abilities, causing him to be the caretaker of adults. Therefore the child is uncertain about boundaries and tests them. Staff can maintain firm yet flexible safe boundaries, be aware of the complexity of boundaries in child’s life, discuss boundary issues openly with each other and with children, and also seek supervision around these issues to identify their own reactions so that they don’t interfere with the work.

The child has not been taught how to handle problems in relationships. When he has had relationship difficulties, the other person has often just disappeared. He may have seen adults handle problems with drinking, drug use or violence. Staff has the opportunity to provide relationships that stick with the child. They can model relationship skills, speak from their hearts and share their own modulated emotional reactions. They can always address the relationship aspects of events, provide paths to work through relationship difficulties, and actively teach social skills. Since he does not trust others, the child may have trouble asking directly for what he wants. Staff can encourage direct communication and practice and model skills of making requests. They can say yes when possible.

Similarly, the child has not learned how to handle something going wrong without making it worse. Staff can teach distraction and calming techniques, help the child develop a list of tactics to improve situation, offer child alternatives, not consequences, when he is becoming agitated. and develop with the child a list of many positive coping tactics for handling pain.

Because of both his past and present situations, the child often feels hopeless. Staff can help through pointing out skills and gains. Also, they can teach and support the child in advocating for himself.

Working with children who have survived trauma, neglect and attachment disruptions caused strong reactions in all treaters. The trauma informed program is aware of vicarious traumatization, and imbeds in daily operations opportunities to discuss the effects of the work, care for one’s self and other team members, and encourages practices which promote vicarious transformation.
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Rise above evil to find good, and death to find life

Things often look bleak as we look at the world.  Yet we are reminded on Easter that life begins with one person.  You must start change if ever you want to change things.  You cannot simply let doom and gloom in the world take you down with it.  Life does not end with death.  If it did, the world would have ended long ago.

Jesus reminded us of this, as things looked bleak in his day, and he volunteered to die and he rose again.  Death may be what we see, yet we must rise above it all.  Rise above the evil.  Rise above the doom and gloom. 

Jesus did not promise that he would prevent evil and sickness.  He did not promise that times would not some day be bad again.  He never said the world would be free from war and evil people.  The reason he doesn't promise this is because what he did give us is free choice.  We have a right to make decisions, and then we also have a right to face the consequences of our decisions -- good or bad. 

When bad things happen it's of our own free doing, or someone else's. This can never be prevented, yet we can rise above it to stop these people.  We must look at the evil, we must look at what is bad, and find what is good in it.  This, in essence, was the miracle that Jesus provided.  He had the ability to look at the worst and find the best.  He could look at the worse situation, like the poorest of the poor, and find richness.

Think about it.  Jesus willfully put himself to the most repugnant and painful act possible, and he died on the cross.  Then he was able to find life out of it.  That's right, out of his own death he found goodness.  He taught us that we can look at any human situation and find life in it.  We can even look at death and find life in it, because through death life continues.

So when evil occurs it is of our own doing.  We are all in this world together, and it is together that we must rise above the bad and the evil to make things better.  It has been done before. 

We must keep optimism going like the flower that rises on a sunny day only to be snowed upon. Yes it may appear as though the flower may not come back up, yet it rises again. 

Man was put on earth thousands of years ago, and while there have been many things, and many people die, and while there have been periods where times were good and times where things appeared ominous and gloomy, new people always came along to make things better again. 

People die, yet new humans rise up.  In this way mankind always lives.  On Easter we are reminded o this.  by reading and celebrating about the resurrection of Jesus we remind ourselves that there is always life even when we don't see it.  Great times will rise again.  Happy Easter


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A nebulizer is not a microphone

Do you ever have a patient who starts talking as soon as you give her the nebulizer?  Sometimes they're so loquacious I have to leave the room just so they can get the treatment.  Yet other times the treatments not needed anyway, so I just stay in the room and enjoy the company.

I had a patient recently who truly did need the treatments when she's sick, although she'd been a patient a few weeks and was feeling great.  She's quite a loquacious lady, and as soon as I gave her the neb she started talking.  She made a neat observations:

"You ever notice how I use the neb as a microphone?" she said.  "As soon as I get it I start talking into it. It doesn't amplify my voice or anything, yet it does make me talk."

Gosh, could we call this loquacious-uterol or loquacious-olin. 

I suppose in reality a nebulizer is not a microphone, yet it's often used as one.  I guess in a way. considering 80 percent of treatments aren't needed anyway, it might as well be a microphone. 

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They only call you when you don't want them to

As soon as you sit for lunch the emergency room will want you.  As soon as you "finally" sit down to take a break a patient will need a breathing treatment.  As soon as you click on the Internet they will call. Yes it's true:  they only call when you don't want them to.

This brings us to RT Cave rule #48:

RT cave #48:  If you want someone to page you they won't.  If you're in a room and the patient won't shut up, and you can't think of a way to escape, your pager won't go off.  It's just the way it is

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Protein in raw mild may prevent asthma/allergies

Reuters reports on a new study that shows that children who drink raw milk were less likely to get asthma as compared to children who drank pasteurized mild.   The theory is that certain proteins destroyed during the pasteurization process are useful in helping the immune system stay strong and fit.

Reuters quotes one experts as saying this may present scientists with a double edged sword.  While pasteurization kills unwanted bacteria from mild, it may also kill necessary proteins we need.

Another reason that pasteurized mild might do is prevent infants from getting exposure to certain bacteria necessary for a proper immune maturation process.  The Hygiene hypothesis states that infants not exposed to certain bacteria may develop asthma.  This study may be added proof of this hypothesis.

While raw milk tastes down right terrible in my humble opinion, many people believe pasteurization is not needed and raw milk has many health benefits, such as preventing asthma and allergies.

While further studies will be needed, this study may be further proof that the modern Western world is causing asthma.  Other theories suggest our modern diet, genes, pollution, Tylenol, c-sections, lack of breast feeding, premature birth, among others may have a negative impact on the immune system that results in lung inflammation that results in asthma and allergies.

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RT apathy may be symptom of a greater problem

It is said that apathy is what destroys nations. After taxes were raised so high to support programs to help the needy, Ancient Roman workers felt they were working not to better their own lives but to support other people. There was no monetary incentive to do more than the minimum.


People thought things like, "What's the point of going out of my way to do anything when there's no incentive for me to do it?" I hear similar things said by RTs of today. Their wages are low, benefits are minimal, and their bosses simply tack on more jobs when you complain.

So, like Dave, you simply keep your mouth shut. You show up for work and the apathy sinks in deeper and deeper. It's attitudes like this that sink nations. It sank Ancient Greece and Ancient Rome and even Ancient Spain. Now it makes me wonder if RT apathy is a sign of a greater problem: Apathy of the American system.

Think about it. Your taxes are high, housing values low, bureaucrats abundant, people living off government programs abundant, national debt abundant. With the progressive tax system if you make more money the Federal government sifts it away, taking away the incentive to work harder.

The interesting thing about Ancient Rome, which I find eerily similar do what's occurring in America today, is that taxes are high and people try to find ways of skirting around paying them. This is a side effect of RT apathy.

Hence, RT Apathy may be a symptom of a greater problem.  What do you think?

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Dave the Apathetic Respiratory Therapist

Dave is a respiratory therapist who constantly complains about useless breathing treatments. So I drew up an RT Driven protocol thinking he'd help me push it through.  Yet he hated it.  He said, "All this is gonna do is create more work for us."

Dave is a quintessential example of an apathetic respiratory therapist.  Apathy in the RT cave spreads faster than the plague.  It's caused by education and experience.  The wiser an RT becomes the more apathetic he tends to be. 

With 30 years experience that followed two years of intense RT schooling, Dave has a plethora of RT wisdom in his cranium.  Yet many doctors are afraid to give up autonomy.  Plus doctors and nurses still believe the old myth that bronchodilators treat everything from dyspnea to rickets.  To read about the 12 myths of respiratory therapy click here.

Yet when Dave tried to educate the doctors and nurses he was told to shut his mouth.   Either that or the doctor became so frustrated with Dave the doctor doubles the frequency of therapy and adds IPPB and mucomyst just to piss Dave off.  So then Dave grumbled about studies showing IPPB merely works to over inflate good alveoli, yet Dave was told to shut up again.

Dave wrote up an RT driven protocol in the past, and the RT cave boss said it was a good idea and even hailed it as brilliant, yet other than that this boss did nothing to push it through.  The boss, in other words, blew Dave's protocol off.  The boss didn't want to make waves and he also didn't want to risk losing procedures.

Dave decided that no matter what he did he was either told what he wanted to hear or ignored.  He became frustrated.  While he loved to learn, he decided there was no point.  So when I approached him with my idea of a RT protocol, he had already gone down that route and rejected my idea.

He often says, "The only reason I work is to get a paycheck."  He's bored of his job, he has a sense no matter what he does it won't get better, so he's just along for the ride.  Like many respiratory therapists, he's apathetic.

Dictionary.com defines apathy as absence of passion, emotion, excitement, or interest.  Apathetic people don't necessarily hate their work, they simply feel too much of what they are doing is irrelevant to the course of improving the world or benefiting the patient. Apathetic RTs, like Dave, feel their is no incentive to go above and beyond the call of the basic duty.

In the case of respiratory therapists, they feel doing breathing treatments on every patient admitted to the hospital is a waste of time, and does nothing to improve the health of most of the patient's they're ordered on. It's a feeling that you know how to improve the hospital setting, you know how to really help patients, yet no one cares to hear your story.

It's hard for teachers to teach Dave anything because he no longer cares. There's an old saying that once you become apathetic you no longer care.  Dave no longer cares.  He now refuses to read up on anything new unless he's forced to do so. He didn't used to be this way, yet he is now.  He's become apathetic.

When people try to teach Dave something new he learns with an attitude.  He grumbles and gripes.  He's apathetic.

Now that I've dug deeper into it I understand Dave's behavior. What Dave has is Respiratory Therapy Apathy Syndrome (RATS).  You can read more about Dave's conditions by clicking here.
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