"Hey Respiratory!" RT Rule #53

I'm sure you've heard it where you work: "Hey respiratory!" It's the default way to get the attention of the respiratory therapist. "Hey respiratory guy!"

I hear a lot of respiratory therapists who feel they are so little respected that many nurses and doctors just call them by their profession: "Respiratory!"

Working for a small, close knit facility where I work this doesn't happen too often. Usually the people who call me that are new nurses or new doctors in the Emergency Room. Otherwise I'm usually referred to by my name.

That is, unless there's a page over head. Then it's "Respiratory STAT to..."

I think most RTs that are called by their profession are generally those who come from larger facilities. And the recommendation they give is this:

"I don't answer them if they say "hey, respiratory" or "hey, breathing guy". I just look at them and keep doing what I am doing until they call me by name. Seriously. Try calling them by saying 'hey, nurse'. See how they like it."

I really don't care what people call me. If you want to call me respiratory that's fine by me. Yet I understand where the frustration comes from.

RT Cave #53: Keep your respiratory therpast happy by calling him/ her by name. Do not refer to your respiratory therapist as respiratory. Do not say, "Hey, respiratory!"

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Mandelic Acid Acne Treatment

One of the remedies considered "natural" to fight acne and pimples is certainly represented by 'mandelic acid. It is a natural product extracted from the almonds. Unlike the 'glycolic acid, is not tolerated by all skin types and particularly irritating, mandelic what is "lighter".

The function is always the same, that of acting as mild skin exfoliant, a peeling remove for the top layer of the skin and thereby reduce scarring and marks left by an acne particularly difficult. As mentioned mandelic acid derived from bitter almonds and is part of the family of alpha hydroxy acids.

Most of the alpha hydroxy acids are particularly harsh on the skin, their use the reddens and irritates. The mandelic acid is different from the other acids because its molecules have a larger size and therefore is much slower to penetrate nelgli lower layers of the skin, ie, 'allows a more uniform treatment.

Mandelic acid is a wonderful ingredient to fight acne in adults for its antibacterial properties. Bacteria in fact, present in the clogged pores are the main cause of the formation of acne and pimples, pustules and points blacks.

The mandelic acid provides an excellent peeling effect, freeing the skin surface by debris, bacteria and dead skin cells which often clog the pores. You can buy it in pharmacies and herbal medicine, the higher the concentration, the greater the "effective" for a deeper exfoliation. After treatment with mandelic acid is recommended not to expose themselves to sunlight for at least 15 days.

What is acne rosacea?

What is acne rosacea? Acne Rosacea is a particular dermatitis affecting the face area and affects many people, many of which are not even aware of it. Acne Rosacea, in fact, is usually present at birth and manifests itself in adulthood affecting the central area of the face with redness and flushing caused by the dilation of blood vessels of the face.

It happens that the Acne Rosacea is commonly mistaken for common acne, but the difference between the two is clear and the disease first manifests itself in adulthood but unlike the second which is typical of adolescence.

Acne Rosacea usually occurs in people with fair skin (those with a complexion as an excuse, though he was not immune, have pigmentation less receptive to such irritation), and on them is easier find, although it is sometimes mistaken redness for a common and therefore not treated properly.

Genetic factors, exposure to sunlight can cause the appearance of acne rosacea, which is still considered incurable: it tends to come and go regularly, occurring in periods of sun exposure or stress conditions that can cause the dilation of blood vessels micro-level facial.

Acne Rosacea is not contagious and, unless the redness on the face, usually presents no other unpleasant symptoms: for this reason many people do not even realize that they have it and, once discovered, simply pay attention to greater protection face (usually with sun exposure), without resorting to special treatment. In some severe cases, acne rosacea treatment includes exposure to laser and a special exposure photodynamic, in order to alleviate the symptoms and allow the non-appearance of the same for prolonged periods.

Acne Rosacea is not an infectious disease or contagious: if it turns out to be affected, however, you should contact your doctor, who will provide the best advice on what treatment to follow in order to prevent the occurrence of possible complications or discomfort.

Natural herbal remedies acne

Natural herbal remedies acne. Acne is a chronic disorder of the skin due to excessive production of sebum, which causes points blacks and whites, pimples, nodules and inflamed cysts. Although many injuries requiring medical treatment, others can be cured with natural herbs.

Marigold
is among the most widely used herbal medicines for various skin disorders like acne. Its flowers anrancioni contain anti-bacterial and anti-inflammatory that can prevent acne, is used as a shrink. You can make a face pack made from calendula. Prepare some flowers in a tea cup with 250 ml of water for 10 minutes by applying it on the face for about 30 minutes. Rinse with continuous jets of cold water.

Peppermint
is a medicinal herb that contains menthol, is a natural analgesic and anti-inflammatory agent useful for pimples. Prevents points whites and blacks. Take the leaves of mint, mash them to release the juice to put on face for 10 minutes and rinse with cold water. You can also turn heat the leaves for 15 minutes and use them as a compress.

Turmeric
herb that has a long history of alternative medicine. Contains curcumin which is a potent anti-inflammatory. He works as an anti-septic as it removes bacteria from the skin. Those who suffer from acne, it can use as a compress for the face burning the roots of turmeric and boiling the ash in 250 ml of water and then apply it on face. You can also drink hot milk with turmeric powder for three times a day with excellent results.

What is a tracheostomy?

Your humble question: What is a tracheotomy and why is it needed?

My humble question: A tracheostomy is a small hole or stoma in your neck -- your windpipe -- that the person can breathe through. It's usually temporary, yet in some cases it can be permanent.

Your question: Who inserts a trach and where and how is it inserted?

My humble answer: The procedure is usually done in a sterile environment such as in an operating room by a surgeon, however an emergency trach can be inserted just about anywhere. Any hollow tube can be used in emergency procedures. An incision is made through the crichoid cartilage between the 2nd and 4th tracheal rings.

Your humble question: What are the indications for tracheostomies?

My humble answer: There are a variety of indications:

To create an easy passage for the person to breathe when there is an obstruction of the upper airways caused by disease (epiglotitis, cancer, foreign object, paralysis of vocal cords, and trauma).
Long term ventilation is required. This makes it easier to manage the airway and is more convenient to the patient than having an ETT in her throat. It's also improves infection control. It also makes it easier to wean some patients off a ventilator.
It shortens the airway and makes breathing easier by reducing airway resistance. This is essential for diseases such as chronic bronchitis, empysema, severe pneumonia or chest injury.
Respiratory muscle paralysis. This may be permanent as a result of a disease such as a neuromuscluar disorder such polio or ALS. It can also be temporary as with head trauma.
Diseases with thick secretions such as cystic fibrosis or chronic bronchitis associated with pneumonia. This makes it easier to clear secretions.
Inability to cough and remove secretions, as with a stroke or neuromuscular disorder

Your humble question: What are the advantages of a tracheostomy?

My humble answer: There are a variety of advantages:

More comfortable than an ETT
Makes it easier to wean a patient off a ventilator
Reduces need for sedation because it's not as uncomfortable as an ETT
Reduces risk of trauma to airway as might be causes by an ETT
Reduces airway resistance to make breathing easier for patients
Allows patient to breathe when upper airway is swollen or collapses (such as with paralysis caused by neuromuscular disorders or epiglotitis)
Makes it easier to suction the patient with thick, or copious secretions
A patient can talk with special trachs

Your question: What does a trach consist of? What does it come with?

My humble answer: Most trachs come with three parts: Outer cannula, Inner cannula, and obturator. The outer cannula holds the stoma open and it has neck plates that extend on both sides so it can be secured by a velcro trach collar or trach ties. The inner cannula has a lock to keep it from being coughed out. It is easily removed so it can be cleaned. Essentially, the inner cannula makes cleaning easier. The obturator is used to insert the trach. It slips into the tube and helps the doctor guide the trach into place.

Your question: What is a fenestrated trach? What are the benefits and disadvantages of it?

My humble answer: It's a trach with holes or fenestrations in the outer cannula that allow air to pass into the upper airway so the patient can cough to remove secretions and talk. Basically, it allows normal breathing and the ability to speak. It allows a trial of normal breathing and normal talking before a trach is removed, and may also necessary for long term trachs. To take advantage of the fenestrations the inner cannula must be removed and the cuff (if there is one) deflated.

Your question: What are the different types of trachs?

My humble answer: What trach to use depends on the patient, and trach should be 3/4 the diameter of the patient's trachea. The following are the types of tracheotomy tubes according to John Hopkins:

Cuffed with inner cannula: The inner cannula may be either disposable or reusable. Cuff should be inflated only for positive pressure breaths. It must be deflated to use a speaking valve.
Cuffless tube with inner cannula: T'he inner cannula may be either disposable or reusable. Good trach for people who don't need to be on a ventilator.
Fenstrated cuffed tracheostomy tube: This increases the risk for aspiration due to the fenestrations. The fenestrations also make it difficult to ventilate these patients. However, good for weaning off trachs and for some patients who want to use a speaking valve. This type of tube is good for long term ventilator patients.
Fenestrated cuffless tracheostomy tube: Only used for patients who have difficulty using a speaking valve with the other trach tubes. There are risks associated with using fenestrations, such as aspiration and glanulation formation around the site of the fenestrations
Metal tracheostomy tubes: Rarely used. Cannot use during MRI, and will cause alarm during airport security checks.

Your question: What is an inner cannula?

My humble answer: An inner cannula is a cannula inserted into the trach. It allows for easy maintenance of the trach especially if there are thick secretions. It also has a universal adaptor on it so the patient can be connected to a Ambubag or ventilator circuit to receive positive pressure ventilation.

Your question: How can a person with a trach speak?

My humble answer: The patient can speak either if the tube has a speaking valve or if the patient simply covers the opening with a finger. For this to occur, the outer cuff must be fenestrated.

Your question: When should the trach cuff be inflated? Deflated?

My humble answer: The cuff, if there is one, should only be inflated during positive pressure ventilation, such as with a ventilator, bagging, or BiPAP. The only reason a cuffed tracheotomy tube is necessary is when positive pressure breaths is indicated. A cuff will irritate the trachea, and therefore should not be used unless needed for positive pressure breaths. It also traps secretions (even when deflated) and can increase rates of infection. If a patient requires continuous positive pressure ventilation, the cuff should be deflated four times a day to prevent tracheal necrosis and the lowest possible pressure should be used to inflate the cuff.

Your humble question: What is a stoma?

My humble answer: Any opening between an internal body part and the external environment. A colostomy is a form of stoma because it allows feces to bypass the rectum and anis so it can be removed from the body into a clostomy bag. A tracheotomy is another form of stoma because air can bypass the upper airway. Stoma is Greek for mouth, in when we refer to a stoma we are generally referring to providing a "mouth" to some internal part. Generally speaking, when an RT refers to a stoma he's referring to a tracheostomy of any form, either when their is a trach present or when there is simply a hole in the neck. A tracheostomy is the opening or stoma made by the incision in the neck.

Your question: So what is a tracheotomy?

My humble answer: A tracheotomy is the opening or stoma made by the incision in the neck.

Your humble question: When a tracheotomy is removed, what happens to the hole?

My humble answer: The hole will seal and seal fast. It's for this reason if a trach slips out it must be reinserted as rapidly as possible. A person will continue to have a scar where the incision was.

MCAT question #37

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

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

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

Do we learn too much in RT school?

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

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

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What is genetic emphysema?

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

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

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

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

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

References:

How passionate are you about your job?

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

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

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

Based on responses, studies showed the following:

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

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

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

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

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

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

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

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

So, how passionate are you about your job?

(see natural progression of satisfaction)
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MCAT question #39

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

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

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

What is a slug patient?

Have you seen this patient?

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

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

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

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

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

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

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

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

Synonym: A sluggish patient

Antonym: The Spirited patient

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

What is bronchiectasis?

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

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

Exacerbations generally include the following symptoms:

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

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

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

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

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

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

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

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

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

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

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

References:

National Jewish Health

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How can I manage asthma around smoke?

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

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

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

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

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

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

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

Does McDonalds trigger asthma?

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

"Can eating high fat foods trigger asthma?"

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

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

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

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

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

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

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

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

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

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

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

The natural progression of satisfaction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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MCAT question #40

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

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

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

How long for baby acne to go away

how long for baby acne to go away? Neonatal acne usually appears during the first month of the child's life. Neonatal acne is characterized by small red dots. This mild form of acne is due to maternal hormones passed to the fetus during pregnancy that stimulate the sebaceous glands of the newborn than it should, causing the tiny pimples. How long does the neonatal acne? Generally it is already present in the infant at birth or appears after a couple of weeks.

Neonatal acne usually lasts one to two months. Some of the areas most affected neonatal acne are the face and back. Neonatal acne is not to be confused with so-called , a transient phenomenon consisting of small cysts hard and whitish. What do neonatal acne? In reality, nothing special in the sense that neonatal acne disappears spontaneously with the growth, after a couple of months. They are therefore not suitable lotions or creams to address the particular problem.

Alternatively, it is important, however, clean water every day neonatal acne affected areas. The neonatal acne, therefore, do not worry parents especially. Only if it is prolonged beyond the fifth month or you can contact is especially pronounced at the pediatrician to agree on any solution.

The DIY is instead absolutely recommended! If this is true often for adults, it is certainly more valuable for newborns and their delicate body.

Mud Therapy Beauty Salon

Purify the skin, inflammation, and drain off the liquid retention. The mud, soft clay mixed with a skilful mixture of water and specific ingredients are the most suitable for solving the most common beauty problems such as cellulite, acne, dandruff.

Because they work

Consisting of a solid part, based on organic and inorganic material, and a liquid, ie, mineral waters, sludge used for cosmetic purposes usually contain very fine soil material remaining in prolonged contact with hot water, it absorbs active ingredients, such as sulfur, vitamins and trace elements. Often, the formulation of sludge is enriched by the specific substances (plant extracts, salicylic acid, essential oils, marine derivatives) that modify and enhance its effectiveness.

The secret? The insulating layer

Their action is due in large part to the so-called osmotic effect: applying the sludge on the body, it creates an insulating layer which increases the temperature of the skin, and consequently, the pores open promoting the penetration of the active principles contained in the mixture, with results dependent areas of the body where the application takes place and the substances used: using the sludge can help remove excess sebum or prevent the formation of pimples and dirt, making the skin smooth and soft or reduce fluid retention, revitalize hair by regulating the production of dandruff or just give a nice color to the face. Who loves fragrances, scented mud can be found on the market: for example against cellulite there are some white because made of kaolin (a substance that is used instead of clay), and fragrant with cinnamon, or mint, or more star anise.

Many benefits, very few contraindications

Supersicuri, the sludge is only contraindicated during pregnancy and breastfeeding (but you can apply if the doctor gives the OK). In any case, keep in mind that a slight redness or tingling are normal reactions, due to the increase of the microcirculation of the skin, and usually disappear in half an hour or an hour away by rinsing. Beware though: if during the application of these feelings are very strong, you should reduce the installation time. Do not expose yourself to sunlight soon after treatment: During the summer months, it is best to apply them at night and wait until morning before sunbathing.

Cellulite: draining, shape the silhouette

Those who suffer from cellulite but leaves nothing unturned to oppose it, knowing that you have to do with an "enemy" subtle and insidious, and the various remedies for cellulite, there are also mud, draining and stimulating circulation.

The super algae

Highly effective are those based on seaweed, which for this purpose are collected, allowed to dry out and work so as not to alter the content in minerals, vitamins, carbohydrates, proteins, fats and other beneficial substances. Thanks to the marine and plant extracts, have a draining effect, which helps eliminate water retention and toxins typical of cellulite, and stimulates circulation. Apply on clean skin, then wrapping with plastic wrap. They hold on for twenty to thirty minutes, then rinse. To optimize the effect of the mud, you can use skin-coordinated, based on extracts invigorating and refreshing. You can buy them ready at any herbal and natural area with many pharmacies.

The alternative home

Mix green clay and enough water to obtain a spreadable thickish batter. The preparation add four drops of lemon essential oil (helps burn fat deposits localized) and as many of rosemary (stimulates circulation and helps to drain excess fluids). The implementing rules are quite similar to those of seaweed mud. Hold on for at least twenty minutes, then rinse with lukewarm water. Repeat the treatment twice a week.

For the face: moisturizer, soften

The skin is impure, opaque, off? The mud facials are a very valuable resource, because they have the ability to remove dead cells and impurities, thus giving new vigor and brightness of the skin, which is hydrated at the same time. Usually, you apply with a gentle massage, after a thorough cleaning and avoiding the area around the eyes and mouth, and leave on for ten to twenty minutes before rinsing thoroughly to remove any residual product.

The alternative home

If you love the do-it-yourself, try this mask, simple and fast. Mix equal parts of white clay and ground almonds. Add rose water, in quantities sufficient to create a batter to spread. Rub the mixture on face and neck (to take advantage of the exfoliating) and leave for 15 minutes. Finally rinse and tones with rose water or orange blossom.

On her hair: supernutrienti, weld split ends

Hair also can benefit from specific application of sludge. Some commercially available formulations designed to dry hair, oily or normal, suitably enriched with algae, vegetable oils, ventilated clay and essential oils to balance sebum production, nourish the hair by counteracting the formation of split ends and make them soft and silky. The packs are usually applied once or twice a week, wet hair and gently massage, leaving them posing in a few minutes before rinsing.

What do RTs really do?

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

Diagnosing lung and breathing disorders and recommending treatment methods.

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

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

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

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

Responding to Code Blue or other urgent calls for care.

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

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

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Misinterpreted study proves placebo effect

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

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

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

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

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

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

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

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

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

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

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

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

Advair Diskus versus Advair HFA

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

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

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

What happens when asthma goes untreated?

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

What Other Medical Problems Can Occur When Asthma is Untreated?

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

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

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

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

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

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

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

The following are the risks of untreated asthma:

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

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

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

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

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

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

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

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

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

The consequences of thought

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

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

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

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

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

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

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

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

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

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

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

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

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Risking Connection throughout Connecticut

I had a delightful experience this past week. I attended a Focus Group called together through the Connecticut CONCEPT grant. This is a federal grant that Connecticut has received to make the system of care more trauma-informed. This focus group was to question providers about their thoughts on the ways in which the system of care was trauma-informed, and how it could be improved.

The Focus Group consisted of about 15 providers, among whom I only knew a couple.

What was so moving is that when the questioner asked questions around agency practices that were trauma informed, almost all the agencies started talking about Risking Connectionâ. The providers spoke of using Risking Connectionâ as their main staff training vehicle, and requiring it for all staff. They described how RC had changed the way they operate with regard to clients. They spoke so enthusiastically about how important their participation is to them.

Another thing that was important to me was that when the questioner asked about attention paid to vicarious trauma, the providers again spoke of Risking Connectionâ. They credited RC for having brought their attention to these phenomena. They described many interventions their agencies had instituted to pay attention to VT and to make space for workers to discuss how the work was affecting them.

People also mentioned that having their trainers participate in our ongoing training and consult groups was important.

I didn’t expect any of this when I went to the Focus Group. It was so refreshing to hear how strong the influence of Risking Connectionâ is within Connecticut.

ISO bans use to RT cheat sheets to improve quality

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

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

(Here's my cheat sheets)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MCAT question #41

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

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

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

The Tobacco Atlas: Smoking causes preventable deaths

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

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

2. Tobacco is responsible for 7 of female deaths worldwide

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

Cancer
Heart Disease
Diabetes
COPD

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

To read more check out the links above.

When a Treatment Program Becomes a War Zone

I have written before about the development of a siege mentality in treatment programs (10/06/15). In that blog I described trauma-based thinking and its effects on both the clients and the staff. I also wrote a blog post on 9/11/10 entitled When Chaos Breaks Out in which I examined how to address a program that is in trouble. I would like to revisit these issues in a systematic way here.

In this post I would like to specifically address the situation in which a program has become demoralized and overwhelmed, and is just trying to make it through the night. Programs in this state rely excessively on the use of force, restraint or intervention teams. Structure and programming are lost. The staff are in a state of fear, and just move from one crisis to another. The staff are often responding to their fear of what could happen if this situation got worse, not what is happening at the moment. The clients are not feeling safe, and thus are acting more aggressive. For both the staff and the kids there is a sense of imminent catastrophe.

How Do Good Programs Become War Zones?

There are many factors that can contribute to the development of a battle mentality in a program. The process is cyclic and can start with any combination of these factors.

· Influx of a new, more difficult population

· A new type of client for this agency without enough specific training

· Significant staff turnover, in child care staff, therapists and/or leadership.

· Not enough training for new staff

· Understaffing and resultant over working of staff

· Change in available resources.

· Implementation of a new treatment approach.

· Lack of integration of therapists into treatment program

· Changes in regulations governing care, such as limits on the use of restraint and seclusion

· Serious incidents of staff assaults

Signs that a Program has Moved Towards a War Zone Culture

· Staff injuries increase.

· Child injuries increase.

· Lack of structure, few activities planned or carried out

· Inconsistent application of limits

· Increasing numbers of power struggles leading to restraints

· Over-reliance on control.

· Over use of calls for assistance, relying on a paging system the clients can hear

· Living areas look bad, damage is not repaired, areas are not clean

· Treatment plans are not communicated or followed through

· Staff do not feel they are part of the treatment. They do not see the connection between their work and the child’s goals

· Therapists are staying in their offices and not interacting with child care workers or hanging out in program spaces

· High turn over

· Supervision does not take place

· Individual therapy does not reliably take place as therapist is handling emergencies

· Routines are not followed

· Use of sick leave increases

· People speak of the clients in hopeless, blaming terms

· Splits occur and deepen between parts of the team, and staff blame each other and administration for the problems that are occurring. There is an “us vs. them” mentality.

· Staff reduce interactions with clients, stay in the office more, start texting their friends during work.

· People are not sure how to intervene when problems begin (because they know they are trying not to use restraints or rely heavily on consequences) so they do nothing and feel helpless as they watch a client becomes more and more escalated.

How Can the Program Regain Its Treatment Focus?

When an agency becomes aware that one (or more than one) of its programs has deteriorated towards a war zone operation, there are roles for each group pf people that the program may want to start immediately. Follow through mechanisms should be established to track implementation. Data about restraints, staff and child injuries, hospitalizations, arrests and negative discharges can provide reliable information to evaluate the impact of interventions.

Senior Leadership

· Begin the conversation- start talking about what is going on and the reasons for it.

· Convey hope in the possibility of turn around

· Establish contact with every staff member who is hurt.

· Speak warmly and hopefully of the youth.

· Recognize staff achievement.

· Remind staff about their reason for doing this work, the mission, the importance to the youth.

· Make resources available for change effort.

· Articulate over all program expectations, such as what is meant by imminent danger and when restraint can and cannot be used, or when to call the police.

· Congratulate team members on their stamina in sticking with a certain child, reminding them that it is the most important thing they can do.

Mid-level Leadership

· Lead change effort

· Establish clear expectations and methods to measure them, and regular review periods to evaluate progress, including who will be responsible. Be careful not to let sympathy for the difficult time staff is experiencing result in a relaxation of the expectations. If there are reasons the expectation was not met, how will be overcome those reasons during the next time period? If the administration just accepts the reasons and communicates: “oh well I guess there is nothing we can do” they are replicating the paralysis felt by staff and thus increasing it.

· The following table illustrates some areas in which expectations can be clear and monitoring mechanisms established. This is not an exhaustive list, it is just meant to illustrate the kind of clarity that is important.

Child Care Staff Expectations	Person Responsible for Implementation	Monitoring Mechanism
There will be two planned activities per weekday and three per weekend/vacation day.	Unit Supervisor	Schedules passed in, comments written on each activity, spot checks
Each child care staff member will have a chore towards the cleanliness of the unit and will complete it on each shift they work.	Unit Supervisor	Chore list passed in, spot checks
Each child care worker will be assigned three youth as their special responsibility. They will spend at least ½ hr. individual time with each of these youth per week.	Unit Supervisor	Progress notes
Therapist Expectations	Person Responsible for Implementation	Monitoring Mechanism
Therapists will attend staff meeting weekly	Clinical supervisor	Meeting attendance sign in
Therapists will make sure that the child care staff understand the children’s goals and how that is translated into what the child care worker does	Clinical supervisor	Therapist and staff report
When a child is in crisis therapist will connect with child and staff within 4 hours or will designate someone to do so	Clinical supervisor	Observation, progress notes

Further interventions for middle management:

· Added resources in a targeted way. For example, have a cleaning service do a thorough cleaning of a unit as soon as the staff and kids have created a cleaning schedule to maintain the cleanliness.

· Articulate and model the expected method of interacting with the kids- be involved, caring, flexible, respectful.

· Clinical management can be clear with therapists, from the hiring onwards, that they are expected to be part of the team and not doing outpatient therapy in their office. Teach and give examples of how to translate treatment goals into unit activities for staff.

· Clinical management guide and model for therapists how to lead team in clinical thinking. The therapists and clinical management establish clinical thinking by responding to every attempt to discuss a problem behavior by asking: how do we understand this behavior? When we understand the adaptive nature of the behavior we can respond by helping the child to learn to meet these same needs in a more positive way. The clinicians also make sure to share the formulation with the team, to establish a treatment theme, to connect problem behaviors to past history, and to suggest restorative responses based on the team’s understanding of the skills a child needs to learn.

The Child Care Workers and the Therapists

It is counter-intuitive but the essential that when a unit is in crisis, the staff must move towards the youth, not away from them. The natural human response to harmful behavior is to move away. This can manifest by emotional distance, by increased strictness, by lack of activities, by staff spending more time in the office, or simply by frowns and disapproving looks. By their behavior the youth are telling the adults that they do not feel safe or connected. We have to make plans to increase their connection to adults. How do we do this?

· Schedule time for staff to spend with one-to-three clients, doing a pleasurable activity.

· Organize team building activities, using consultation from recreational therapists if available.

· Have as many fun activities as possible.

· Use music, dance, singing, jump rope rhymes, hand games to knit the community together.

· Develop a cottage song, a mascot, a logo, a saying.

· Celebrate anything good that happens, even if small.

· Have a box in which anyone can put a note about a good thing they saw a kid or a staff do, read it out at community meetings. Give awards, but not competitive ones, ones that anyone who meets some criteria can receive.

· Have community meetings. Have all participate. Talk about what is happening, what kind of place we want to live, what we can do about it.

· Decrease room time. Spend as much time together, doing activities.

· Do the kids’ hair. Have a spa night. Feed them. Do anything to care for them and make them feel better.

· Clean and decorate the unit. Involve the kids.

· Fix any damage. Involve the kids.

· In Treatment Team talk about the kids that are the hardest to connect with. Review their history- why did they have to learn to put up such walls? Encourage compassion. Discuss their strengths and interests. Can staff find a way to participate in these interests with them?

· Keep a notebook about the most difficult kids called “Moments of Hope” and ask staff to write down any good things that happen with that child.

· Congratulate each other on the team’s stamina in sticking with this child.

· Make specific plans to support that stamina, like trading off who reaches out to the most hostile kids.

· Remind each other about other kids you have known who seemed to reject all efforts and later came around.

· In treatment team develop restorative ideas for each child that are significant, require thought, and are related to their treatment.

· Teach specific feelings management skills.

· Use feelings management skills yourself and label out loud that you are doing so.

· Validate the feelings behind the behavior.

· Express an understanding that this is the best the kid knows at the time- and the hope and confidence they will learn better.

· And tell them, and show them, over and over again, all the good things you see in them and how delighted you are by everything positive (and even neutral) that happens.

Even this partial list of interventions seems like a daunting task. It is. What is more daunting is not doing it and remaining in paralysis. A specific plan with clear responsibilities and methods of measurement will begin to create change. As people notice change, there will be an increase in hope. Hope brings the energy to make more changes. And fairly soon people will be feeling pride in their workplace again, and the kids will be gradually getting better…slowly…with many backslides…but they will be demonstrating that they feel more connected and relaxed. Then real effect treatment will be occurring.

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