New Treatment Ways: August 2012

Does BiPAP force pulmonary edema from lungs?

Your Question: Is it true that BiPAP pushes pulmonary edema out of the lungs?

My humble answer: The idea that the BiPAP pushes fluid out of the lungs is a fallacy. It does nothing of the sort. I contemplated this and did some research. The best answer I could find came from Jeffrey Sankoff, MD, from Emergency Physicians. I will post what he wrote about this topic below and the next time you have a doctor say that you can show him this report:

Contrary to popular belief, NIMV does NOT push edema fluid out of the lungs. Patients with acute CHF have an imbalance in the CO (cardiac output) of the right and left sides of the heart. With the inciting event (detailed above) the left ventricle becomes compromised but the right ventricle usually does not. So the right ventricle continues to pump forward a normal volume of blood but the left ventricle becomes unable to keep pace. Fluid backs up into the lungs resulting in capillary leak and pulmonary edema. With NIMV, the resultant positive intra-thoracic pressure decreases venous return (blood flowing back to the heart). This reduces right-sided CO to a level that the left heart can equal or even exceed. Fluid ceases to back up and will even begin to be reabsorbed as left ventricular CO improves. Pulmonary edema ceases to worsen and may even diminish, often rapidly.

Two ways to hire doctors: Part 2

The following is a guest post from Will Lessons, retired RRT:

Last week I wrote about the two ways of hiring doctors. Basically you have large hospitals that have a large pool of doctors to choose from, and they get to pick the best of the crop. Small town hospitals don't have a large crop, and they pretty much get the leftovers.

Many small towns, therefore, tend to hire any doctor that is available, and this sometimes results in doctors that otherwise never would have been hired. This often results in doctors who are power control doctors who want things done their way or the high way.

They tend to frown upon respiratory therapists as ancillary staff who do what they are told. This often results in RTs who have low morale and a bad working relationship with these physicians. Now there are exceptions to the rule, yet for the most part this is my observation.

Again, I must say that most doctors are awesome, yet the 10% of doctors who are generally your rejects tend to work for your small town hospitals. That's just how it is. And, again, this is my speculation.

So that's the problem. Now what can be done about it? It's almost a no brainer here. I think the best way to remedy this dilemma is for hospitals to hold doctors to the same standards as when hiring any of their other staff. Doctors should take the same personality test. Doctors should be asked the same questions. Whomever is doing the hiring must make sure the doctors hired fit the personality of the hospital.

A second thing I think would help is to involve other people in the hiring process. If you're hiring a urologist, ask the other urologist to participate in the interview process. If it's an ER doctor, ask your nurses or doctors or respiratory therapists their past experiences with this doctor. Often you can get a feel for how a doctor will fit in by simply talking with the people who already work for you.

Surely there's no way to fool proof the hiring process. You can have the best interview, and it may seem you're hiring the best person for the job, and still you you could hire a buffoon. I've seen it happen by the best of interviewers. When I was Supervisor for an RT department once I hired a couple people on the same day who looked to be very fine RTs, and they both flopped. Yet on the other side, I hired one against my better judgment and on a recommendation from a fellow RT, and this person turned into an elite RTs.

So perfection is not possible. Yet still you could come up with a technique whereby you can pick out most of the weeds.

Thanks again Will.

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Can dogs and cats really prevent asthma?

Your question: I read about a recent study that showed that exposure to a cat or dog can prevent asthma or allergies. So why don't doctors recommend that all parents get a dog or a cat to prevent asthma and allergies. I know it sounds goofy, but...

My humble answer: I'm going to give you the oposite answer that you'd expect me to give. I'm the kind of person who doesn't like to jump on the popular bandwagon. I don't like to support something just because everyone else does. By this I'm going to imply, that even thoug I wrote an article about it called "Having a dog or a cat may help prevent asthma," doesn't means I think the study is even viable. In fact, if you think about it, asthma is a hereditary disease. By this you must realize that most people who have asthma and allergies are more likely than those without asthma to have pets. So it's only fitting that such a study would show that people who have a dog or cat are more likely not to have asthma. So I'm going to say that there is no evidence a dog or cat will prevent asthma, and suggest that if you have a family history of asthma that you don't get a dog based on studies like this.

Can a dog or cat prevent asthma?

The following was published on myasthmacentral.com/asthma on July 7, 2011.

Having a dog or cat may prevent asthma

Some people think that if you have a family history of cat or dog allergies you should not expose your kids to cats or dogs. The belief is this will prevent cat and dog allergies.

Yet that theory may soon -- if it hasn't been already -- be thown into the large, heaping pile of asthma myths, along with the myth that you grow out of asthma or that asthma is a disease of the mind.

In a recent study researchers followed 565 kids from the ages of birth through age 18, and learned that those kids who were exposed to cats had a 50 percent less chance of developing a cat allergy. Boys exposed to dogs in the first year of life were likewise 50 percent less likely to develop a dog allergy.

Yet exposure to dogs the first year of life by girls caused no significant change in their risk of developing allergies. The reason for this remians a mystery.

According to the Washington Post "Study shows early exposure to cats and dogs does not make children allergy-prone," it's not the dog per se that causes allergies, but the dander, and flakes of skin the animal sheds, that cause the allergy response.

These allergens "get on the skin when the animal licks itself, the substance dries and eventually the skin flakes off. Common symptoms of a pet allergy are sneezing and a runny nose, although some people also have trouble breathing."

Healthcay Reporter Serena Gordon, in "Early Exposure to Pets Won't Up Kids' Allergy Risk: Study," made another important connection, and I have to say I was thinking the same thing when I first read this study

She wrote that this kind of goes along with the hygiene hypothesis which surmises many cases of allergies and asthma are caused because we are overprotective of our kids -- we are too clean. That exposure to germs while the immune system is developing -- in the first year of life -- makes our immune systems stronger.

Thus, a stronger immune system will be less likely to create antibodies to identify and destroy things that are considered normal -- like cat and dog dander.

Surely this is only one study, yet I have seen other studies that came to the same conclusion. This might be proof positive that early exposure to cats and dogs will allow our kids to be among the 70 percent of Americans who own a cat or a dog.

Early exposure may allow our kids the opportunity to enjoy these fun animals later in life without being zo zduffy and mizzable.

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It Aint't East Being RICH

Any one who has taken the Risking Connections â training knows that a key element is that the path to healing is through a RICH relationship- one that includes Respect, Information, Connection and Hope. This is such a central point that the publisher, Sidran, has copy write protected the concept independently. In our training we ask participants to share ways in which they are currently demonstrating RICH with the clients, and also with each other in their team. Because amazingly it turns out that what the clients need in a relationship is the same as what we need for ourselves.

For the next four weeks or so I am going to right about the dark side of RICH- by which I mean the difficult and complex aspects of creating RICH relationships. These are the areas where we struggle, stumble, and sometimes become less than helpful to our clients and each other. Let’s look at each part of RICH and discover what is hard about it and how we can overcome the challenges.

The first week I will start with Respect.

The dictionary defines respect as: esteem for or a sense of the worth or excellence of a person, a personal quality or ability and as: deference to a right, privilege, privileged position, or someone or something considered to have certain rights or privileges; proper acceptance or courtesy; acknowledgment. The RC manual states that it is demonstrated through forms of address, respect for confidentiality, punctuality, language used, assuming the client has a valid point of view, and validation of the client’s experience. The therapist believes and believes in the client.

These definitions do not really capture the essence of respect for me. To me it almost carries some aspect of admire. So, if we truly respect our clients we actually, deeply honor the way that they have survived all the pain life has handed them. We look up to them, are in awe of them, for having come through alive and kicking. We actually let ourselves feel how profound the pain was, how deep the losses, how scary the world. And we respectwhat these kids had to do to survive.

Of course anyone who is caring for someone with problem behaviors (be it one of our kids or your aging mother) knows that it is easier to maintain these lofty attitudes when you are away from the person and their demands. When some kid is yelling at you, or trying to hit you, or refusing to comply with the simplest request, it is hard to see their behavior as an admirable attempt to survive. That is why we all need down time, a time to step back and think about the work, often with the help of a supervisor. We can then let ourselves remember the painful truths of our clients’ histories and respect the creativity of their adaptive behaviors.

Here’s another aspect of the word Respect. Martha, a therapist in our special ed school, tells me that when she asked Tyquan what led up to his throwing several chairs and then leaving the classroom, Tyquan told her that his teacher, Miss Mitchell, was disrespecting him. Miss Mitchell reports that she just asked Tyquan to end his conversation with his friend Marvin and take out his math book. And she probably did so pleasantly. Martha tells me that feeling disrespected is a common complaint of the youth. Now of course our staff may at times speak in a sarcastic or belittling way to the kids. But let’s assume this time Miss Mitchell spoke conversationally. What went wrong here?

Maybe Marvin is the best friend Tyquan has had in years, and having a friend is finally making him feel a little safer. Maybe he is just tired of adults telling him what to do and putting their needs before his. What do you think?

School work is often associated with humiliation for our kids. Tyquan can’t do math. It makes no sense to him. Maybe the fact that when most kids were learning math he was trying to protect his mom, his sister and himself from his step father’s angry rages has something to do with it. It could be that his brain hasn’t developed the ability to think sequentially or use logical problem solving, because no one has ever modeled such a process for him. But anyway, he knows he is in for another period of feeling stupid and hopeless, and that maybe the other kids will see how dumb he is. Marvin’s pretty smart in math- he will probably give up on Tyquan as a friend when he sees how lame Tyquan is.

So, when Miss Mitchell says in her happy voice: “Tyquan, time to end your conversation with Marvin and take out your math book.” Maybe Tyquan hears: “Tyquan, time to stop doing something pleasant that you enjoy and to do something you can’t do, although everyone else can, and to show the world how stupid you are.” This feels deliberate to Tyquan. She is trying to humiliate him. So naturally he feels disrespected.

Does that make sense to you? If anything like that is going on, what does Tyquan need? How can he feel respected in this situation? (I have some ideas, but what are yours?)

One thing we do know is that the more fragile a person’s sense of self is, the more frantically they protect their image from external threat. If you feel fine and happy about yourself, and someone teases you, it’s relatively easy to let it go. If you are already feeling pretty lousy and fairly sure you are doing everything wrong, the teasing arouses such panicky feelings in you that you attack with all the ammunition you can find. And others say you are “over-reacting”.

Which brings me to the final concept of Respect that I would like to explore- and that is its use by staff. Teacher Mr. Hoover says: “I told Luis to stop talking and he went right on talking. He does not respect me!” Crisis worker says: “If I am not very strict with the kids they will lose all respect for me.” Therapist Ron says: “I just will not tolerate the kids swearing at me. It is a sign of disrespect.” Merva, a foster mother, tells her case worker: “We told Natalie to go to bed and she keeps coming out of her room. We can’t read her stories or any of that nonsense. That’s just catering to her. She just has to respect us and do what we say.” Laura, a Child Care Worker says, “I told him he had to go through the front door. He insisted he had to go through the back door. I know it’s trivial, but I will not back down. They need to respect what I tell them to do.”

The first thing that comes across in all this is that the staff seems to feel it is all about them. They want the kind of respect that is evidenced by obediance. Often times a person's position will get them this kind of respect (such as in the military or many offices). But that creates no lasting change. As soon as that person isn't looking, the subordinate does whatever they want, Much more important is to have influence; to be respected for person characteristics and for how you have treated the other.

What the kids are doing is not primarily about the staff. Of course, how a given kid feels about a certain staff does affect their actions. Nothing like relationships to influence behavior. But a lot of times other factors intervene.

Like the youth is dysregulated and no longer even sees the staff for who he is. Or he is caught up in old feelings of mistrust. Or she is testing the staff- will you stay with me even when I show you how bad I am? Or he is desperate for some control in an entirely out-of-control life.

How can we help our staff feel calm and good about themselves so that they do not need the kids to act a certain way in order that they may feel respected?

Wow, a lot for one word- Respect. And we have three more to go. PLEASE share your ideas by clicking “comment.”

Adding water to an Albuterol treatment???

Your question: I live in a nursing home and my nurse adds a bullet of saline to my Albuterol. Will I get the same benefits from the medicine? Thanks

My answer: To add an amp of saline will still allow you to get the same effect from the medicine. I see no benefit of doing so, unless you want the treatment to run twice as long.

Action Cures Fear

Every once in a while I get an RT student who's afraid to do anything. She or he may be afraid to do an ABG, or an EKG, or even a simple breathing treatment. Yet my rule for new RTs who are supposed to do certain therapies is the following:

Show you once
Watch me once
Do it

Most RTs, at least the ones I work with, are really good teachers. We understand the different personalities, and we cater our "how to do it" lecture to the patient. Yet there comes a time when there's nothing else you can teach, and the only thing left to do is to just do it.

Yet what do you do for the RT student who is still hesitant? What I say is this: "Action Cures Fear. If you're afraid of something, tackle it. Then you'll feel better about it."

That's something I read in a book written many years ago called, "The Magic of Thinking Big," by David J. Schwartz (1959). It was a self help book a sales professor encouraged me to read back in 1993 when I was still in college and not sure if I had the confidence to succeed in the business world. The book had many useful tips, the most important of which was the chapter on: "Action Cures Fear."

I can see this advice being used in a variety of situations, which would include any person who has a fear of just about anything. If you're afraid of it, just do it. I think we all have our own experiences in this regard, including myself. What about you?

10 things I would say at work if I won the lotto

Recently there was a Mega Lotto jackpot worth greater than $500,000,000. The pot grew to over $800,000,000 before it was won by three lucky (or unlucky depending on how you look at it) people. It gave millions a reason to dream. My coworkers dreamed they'd quit their jobs. But when I was asked if I'd quit my job I said, "No way!"

"Why?" they all asked. "It's not like you never complain about it."

I explained to them that if I won the lotto it would take the monkey off my back. I could go to work and be myself instead of the person they make me to be. If I won the lotto I could go to work and do what I think it right, and speak the truth, without fear of losing my job.

Now I wouldn't purposely try to stir up dirt and trouble. No. I'm not that kind of person. In fact, I like to avoid controversy. And losing your job is controversy and stress. But if I didn't need to work, if I didn't need the paycheck and the insurance, then I could go to work without a monkey on my back.

The following are the top ten things I would do if I won the lotto, all assuming I would continue going to work:

1. When an ER doctor orders a continuous Albuterol breathing treatment while the patient is still in the ambulance, I'll say: "I see your ESP is working again."

2. When a doctor orders a breathing treatment on a fulmonating pulmonary edema patient, I'll say: "Just what we need, more fluid in already overfull lungs."

3. When a nurse insists I give a breathing treatment on a patient just because the sat is low, I'll say: "Sure, I'll give the treatment with oxygen so her sat goes up for five minutes."

4. When a doctor tries to convince me a treatment is needed because she sees an infiltrate on the xray, I'll say, "Should I blow the mist over that x-ray spot?"

5. When a doctor orders a bronchodilator just because the patient has pneumonia, I'll say: "I didn't know there were smooth muscles and beta receptors in the alveoli. I didn't know albuterol could get small enough to get into the lung parychema. I didn't know albuterol treated inflammation. You're so smart to know stuff I didn't."

6. When a breathing treatment was scheduled and I was not able to do that treatment because I was in the emergency room doing CPR on a patient, instead of lying and charting "Patient refused," as my bosses want me to, I will chart the truth: "Treatment not given because RT too busy."

7. When a doctor pulls me aside to tell me I'm not qualified to give her advice on how to treat a patient, I'll say: "Respiratory therapy is beyond your scope of knowledge, and that's what I'm trained in."

8. When my boss leaves me a note saying I forgot to chart atrovent when I gave an albuterol breathing treatment, when I forgot to give it, I'll say: "What, do you want me to do? lie?"

9. When payroll requires me to lie that I ate 6 servings of fruits and veggies every day, drank 8-10 glasses of water, did stretches, did aerobic activity, did physical activity, and voted for Micky Lolich for president (I was just seeing if you were paying attention), I wouldn't have to lie that I did all those things to get my 75% discount on my health insurance. Instead I'd say, "I'm not doing that BS. I'm tired of lying."

10. When a doctor leaves a patient room without even listening to the patient's lung sounds, and then charts, "Lungsounds are clear," I will say: "Would you like to borrow my stethoscope so you can write the truth about those lungsounds, because I heard a crackle in the left base."

How about you? What would you do if you won the loto?

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Are RTs therapists or technicians?

Sometimes I wonder if we are really respiratory therapists where I work. We are paid like respiratory therapists, yet in actuality the work we do is the work of a technician.

Consider the following definitions:

Therapist: A person who provides therapy.

Technician: A person who does procedures ordered.

By interviewing RTs who work at other institutions I know that many RTs are truly therapists. They are provided with orders such as, "RT Consult." The therapist then assesses the patient and performs the appropriate therapy.

Yet where I work we don't provide therapy at all. In short, we are simply techs doing procedures ordered. In this sense, we aren't therapists at all, we are well paid techs. In this sense, it is much more understandable how so many of my coworkers present with the symptoms of Respiratory Therapy Apathy Syndrome (RATS).

For example, yesterday I came to work and there were 14 patients on our board, and my coworker told me that none of these patients required the services of an RT. There was not one of these patients who needed breathing treatments or chest percussion.

Many of the patients would have benefited from education about their disease process, yet we "techs" are so busy doing procedures that aren't needed that we don't have time to sit down and do the job we went to school for: provide therapy.

I also had the emergency room yesterday, and I kid you not that I did at least 25 EKGs. We are doing EKGs on every patient admitted with chest pain, rickets, stroke symptoms, hangnails, diabetes, high blood pressure, low blood pressure, no blood pressure, asthma, COPD, and cough.

It's pretty much to the point we are doing EKGs on every patient who hits the ER door. Many are needed, yet there are so many ordered that I think nurses just order them out of habit. Heck, I don't even thing nurses order them any more. I think they are just ordered as part of an order set.

Where I work we are not respiratory therapists at all.

If you're a new or aspiring RT, I want you to know it doesn't have to be this way for you. When you are looking for a job, make sure you choose an institution that provides respiratory therapy. Most of your teaching hospitals provide such therapy. Many smaller hospitals do too, yet not mine.

A good way to know if your hospital provides therapy is to interview the interviewer when you are interviewing for a job. Ask questions like the following:

Do you have RT driven protocols
Do you have an RT Consult
Do your doctors allow RTs to change or alter therapy without a direct order
Do your doctors allow RTs to adjust ventilator settings without a direct order

Two ways to hire doctors

The following is a guest post from Will Lessons, retired RRT

One of the nice things about being a retired RT is I can now come out into the open and say some of the things I've been holding back for fear that the truth might get me fired. So this will be the theme of a series of posts I've chosen to write for RT Cave. This post is about how a hospital hires doctors.

I think I'm a credible author on this subject because I worked for a very large hospital and a small hospital. Out of respect for both I won't name them here. Also out of respect I will say that both hospitals are fine institutions with many wonderful people, and I also would like to add that most, perhaps as many as 90 percent, of the physicians I've worked for over the years are great team players and wonderful people. Yet the premise of this post is that you are more likely to find the flub, arrogant, egotistical doctor who's a control freak working for a small town hospital as opposed to a larger, teaching institution.

The reason is because each such hospital has a unique method of hiring physicians. The smaller hospital has trouble drawing doctors to the region. The larger hospital has no such problem. The smaller hospital has to hire any doctor who comes asking for a job, the larger hospital can choose from an array of doctors. The large hospital has a large pool of doctors to choose from, the small hospital usually gets the rejects. Right there lies the problem. (No, I am not saying all doctors in small town hospitals are rejects, yet the percentage is higher than larger hospitals. I want to be clear here, hence the parenthesis).

Try this. The small town hospital doctor has to be on call 24-7 because there are no similar such doctors, or the pool of such doctors is small. An example is the local urologist. He's the only one. He has the unfortunate task of taking call for himself even when he's on vacation to Europe. The large city hospital only has to take call once a week, and in some cases once a month. So you can see there is a huge incentive for a doctor to work for the large town hospital right there.

So because of this the hiring process for each institution is unique. The small town hospital I worked for had an idiot doctor working in the ER. This doctor quit and we were all excited because the hospital now had an opportunity to get a good doctor. Yet he was aptly replaced by another idiot doctor. It seemed at times we were getting large hospital rejects. And, for lack of a more sophisticated way of saying it, we probably were getting other hospital's rejects.

So that said, the types of doctors working for smaller hospitals tend to be more of your "I want to have complete control," type doctors. They don't want RTs making changes without telling them first. They often go on power trips. If you do something wrong -- even though we are all humans and are all likely to make mistakes -- they will treat you like you are a moron, idiot buffoon. They will put you in your place at the bottom rung of the totem pole. They will drive your ego right up your butt, and hopefully -- they think hopefully not me -- your confidence too.

Larger hospitals are more likely to have doctors up to date on their doctor wisdom, such as newer ideas that the hypoxic drive theory is a hoax, and that breathing treatments are only for bronchospasm and not for all that makes an annoying wheeze. They tend to be more in favor of protocols because they know respiratory equipment exceeds the bounds of their medical knowledge. They want to be team players, and part of being a team player is keeping up the morale of the RT staff.

Yet the opposite is true of small town hospitals. Totalitarian control freaks are not welcome in most larger hospitals, and therefore have to work for the smaller hospital run by people who've decided they have no choice but to hire said doctor. They hire doctors who may be but aren't necessarily up to date on the latest doctor wisdom, and for this reason may be more prone to order IPPB therapy that was proven useless back in the 1970s and proven useless back in the 1970s. They may be more likely to not fit the personality of said hospital, and may not even pass the hospital's personality test for hiring that all other workers have to take.

So there you have it. Allow me to state again that I love every place I've worked. I love the people. I love the bosses. I even love the doctors. I even love some of the idiots. However, there comes a time when honesty must be spoken. It's kind of like Rick wrote once that by not allowing RTs to use their thinker they are becoming apathetic. This is not good because an apathetic RT is not at the top of his game. Institutions must work to improve morale of RTs, and how to do this is the subject of my next post of which Rick says he'll publish next week.

Thanks Will.

Are all COPD patients CO2 retainers?

Your question: I have observed that many doctors treat all COPD patients as though they were susceptible to oxygen induced carbon dioxide retention. I think this prevents many patients from getting the oxygen they need. Do you have any idea what percent of COPD patients are actually at risk for oxygen induced hypercarbia? Do you know of any articles I can show our doctors?

My humble answer: Great question. I think a better method of tackling this question is to turn it on the doctor. Ask him where his proof is. He'll site that it's common practice among the medical community, yet this is not proof.   It's easy for something to become common practice just because it sounds good. Yet "sounds good" is not proof.

Now I wouldn't recommend doing this to just any doctor, lest you'll get on his bad side. Yet a wise doctor would enjoy engagement in such a discussion. I will also post some links to other articles I've written about the hypoxic drive theory you can read. In the first two links you will find several outside links to studies and articles on the subject.

In my post "A history of the myth" I write the following:

Dr. EJM Campbell gave a lecture to pulmonologists in 1960 about the dangers of giving too much oxygen to COPD patients. This essentially gave birth to the hypoxic drive theory. Of interest here is that the study Campbell referred to in his lecture consisted of only four COPD patients. Because the hypoxic drive theory provided the first best example of why a COPD patient might stop breathing in the presence of oxygen, the theory has been taught from one generation to the next. Despite scientific evidence, it has become the gold standard when treating COPD patients.

Yet this in no way proves the hypoxic drive theory nor that all COPD patients are CO2 retainers susceptible to oxygen induced hypercarbia.  It should also be noted that this study was performed before ABG testing was the norm, before oxygen saturations were monitored, and before any adequate studies scientific studies were ever performed on the subject.

The truth is, there has never been any study to prove the hypoxic drive.

So what percentage of COPD patients are CO2 retainer. Will Beachy wrote a good editorial on this subject, "Breathing Control in Chronic Hypercapnia," RT: for decision makers in respiratory care, June/ July, 2000. He writes:

" The ubiquitous diagnosis of COPD does not automatically imply the presence of chronic hypercapnia or the potential for oxygen-induced carbon dioxide retention. Health care personnel often uncritically assume that patients diagnosed with COPD are 'carbon dioxide retainers,' and susceptible to 'O2-induced hypoventilation,' when in fact, this is true of only a small percentage of end-stage COPD patients. Therefore, concern about O2-induced hypercapnia is not warranted in most patients with a diagnosis of COPD.

"Before we can rationally evaluate the merits of a debate about the control of breathing in chronic hypercapnia, we must understand the chemical control of ventilation in normal, healthy humans. At issue is not the existence of a hypoxic drive in hypercapnic COPD patients, but whether oxygen administration suppresses this drive sufficiently to account for the commonly observed rise in PaCO2. An additional pertinent question is whether an acute rise in PaCO2 still stimulates the medullary chemoreceptors in these patients."

He then concludes his article by writing:

"The important clinical fact remains that regardless of the mechanisms involved, oxygen therapy in chronically hypercapnic COPD patients can induce further hypercapnia and acidemia. However, tissue oxygenation is of overriding importance; oxygen must never be withheld from an exacerbated, hypoxemic COPD patient. This means one must be prepared to mechanically support ventilation if necessary."

So, I don't think you can word it much better than Beachy does. There are very few COPD patients who are truly retainers susceptible to oxygen induced hypercapnea, although very few is as close to an accurate number we can get. I like to say that 10 percent of COPD patients are retainers, and 10 percent of retainers are susceptible to oxygen induced hypercapnea.

Campbell, American Reveiw of Respiratory Disorders, 1967 (96, 126) noted that 90 percent of patients in severe respiratory distress were at risk for worsening CO2 retention and decreased level of consciousness. However, his study included only four patients.

However, it was his study and his review that resulted in the hypoxic drive theory become so popular, and even despite several studies proving Campbell wrong, it was almost too late to turn the tide. Despite facts, many doctors still believe the report of Campbell.

Maloney, Kiely, and McNicholas, "Controlled oxygen therapy and carbon dioxide retention during exacerbations of chronic obstructive pulmonary disease," Lancet, 2001, reported on a study of 24 patients with severe airflow obstruction who received 24-40% oxygen by venturi mask, only three had a significant rise in PaCO2 (8-26 mmHg).

In the study the patients with the greatest degree of retention were more severely hypercapneic. When all was said and done, only 13 percent of the patients suffered from oxygen induced hypercapnea. This falls right in line with the numbers I estimated earlier.

Further reading:

1.  Articles that disprove the hypoxic drive theory (coming soon)
2. The history of the hypoxic drive
3. The hypoxic drive theory: why do we breathe
4. Siobal, Mark, BS RRT, "Hypoxic Drive in COPD: Is the fear of oxygen therapy based on fact or myth?" UCSF Sanfransisco General Hospital, slide show
(12-17-2012 my hypoxic drive post will be published)

The Microflora Hypothesis

The following post was published July 11, 2011 on MyAsthmaCentral.com/asthma.

The Mocroflora Hypothesis of Allergies and Asthma

It's a proven fact asthma rates are on the rise in Western nations like the U.S. and U.K. In the past pollution was blamed. Yet with pollution on the decline and asthma rates still rising, many experts are looking at other theories.

Two theories gaining acceptance are the hygiene hypothesis and the microflora hypothesis.

The hygiene hypothesis pretty much proposes allergies and allergic are caused because we're too clean.  In the absence of bacteria our immune system gets bored and attacks things we consider normal -- like allergens.

I simplified the hygiene hypothesis in a previous post. If you're not familiar with it I recommend you click here. In this post I'd like to introduce you to the microflora hypothesis.

First a few definitions:

Normal Flora:  According to the Online Textbook of Bacteriology these are tiny little microbes that cover the surface areas of your body, including your skin and mucus membranes. This consists of some fungi, but mostly bacteria. Their main job is to prevent the growth of bad bacteria.

Microflora: According to thefreedictionary.com these are normal flora of a specific location, such as the intestines.

Probiotics: This is simply a synonym for normal flora.

So what is the microflora hypothesis?

It's actually similar to the hygiene hypothesis only it goes a step further. It states microbes in your intestinal tract (microflora) work together with your immune system to keep your immune system working right.

An imbalance of these microbes any time in your life can cause your immune system to develop an inappropriate response.  This may best explain why asthma can be developed at any time in your life.

So what causes microflora to become imbalanced?

Two things in our modern, industrialized way of life are suspected to cause such an imbalance:

1. Antibiotics
2. Dietary changes

So, how might antibiotics cause an imbalance of microflora?

Antibiotics: These were considered to be a godsend to the medical field when they hit the market in 1944, as they allowed doctors to treat and prevent infection. While these are good, there are consequences to antibiotic abuse:

Some bacteria are smart: They catch on and develop resistance to antibiotics and this forces us to invent more powerful antibiotics.
Some antibiotics kill too much: Instead of killing just the infecting bacteria we were also killing the good bacteria we need to maintain balance
Antibiotics only kill bacteria: Actually we knew this all along, but I just thought I'd add it here to make a point.

While antibiotics are only able to treat bacterial infections, they were -- and often still are -- prescribed to treat any infection, even viral. Often they are ordered just so you think the doctor is doing something. You have asthma symptoms; you have a cold, so you expect antibiotics.

In fact, this study shows that way too many asthmatic kids are being prescribed antibiotics to treat asthma even though doctors know they aren't recommended in the treatment of asthma. It's expected many doctors order them just to "cover their bases."

Yet it's a common fact the most common asthma triggers are viral infections. So treating your sickness with an antibiotic is useless unless you really have a bacterial infection.

The most common antibiotic prescribed would be broad spectrum antibiotics. These kill more than one type of bacteria, yet the hope is they'd kill the culprit. The problem with these is they kill the good along with the bad.

Narrow spectrum antibiotics can also be prescribed. These are antibiotics that only kill the desired bacteria. Yet to prescribe them in the office without further testing would be a crap shoot. To pick the right one you're sputum must be tested to identify the bacteria. If no bacteria are identified, antibiotics will be useless.

If bacteria are identified further testing can be done to see what antibiotic kills it. In this case, a broad spectrum antibiotic can be selected. The problem with all this is it takes time and money.

So most often your doctor will skip all this testing and just give you the antibiotics you want. You're happy, he's covered all his bases, and you eventually get better.

The solution to this problem might be simple:

Avoid antibiotics use.
If antibiotics are needed,narrow spectrum antibiotics should be used.

Modern diet: According to The Probiotic Revolution, "people in industrialized countries eat significantly more fast food and refined foods, and much less fiber. They're also less likely than people in the developing world to rely on fermentation to preserve goods -- thus depriving themselves of a ready source of probiotics."

The solution to this problem might also be simple. Eat more of the following:

Whole grains
Nuts
Fruits
Vegetables
Probiotic supplementation

Probiotic supplementation: As far as a cure for asthma and allergies, some studies have been ongoing to determine certain therapies can be done to restore the imbalance of probiotics in the gut. Studies are ongoing to see if this prevents or treats allergies.

Since 75 percent of asthmatics also have allergies, the hope is probiotic supplementation will also prevent and treat asthma as well. Studies are ongoing, and we'll have to wait and see how they turn out.

So there you have it: the microflora hypothesis. It's one of several theories of what might cause one to develop asthma. What do you think?

Click here for a more in depth discussion of this hypothesis.

Proverb 10:8

“The wise in heart will receive commandments: but a prating foolshall fall.” Proverbs 10:8

I think of this proverb every day as I'm working. I think of it every time I get an order from a doctor I think is unwise. I think of it every time I keep my mouth shut and just do the task I'm ordered to do. I think of it throughout the course of every day I work.

I try to be wise in my profession, and so to do most of my fellow RTs and RNs. I read and learn as much as I can so I make the best decisions to help my patients. I also read so I have material to share with my patients, even non medical. I learn about politics, music and even art. With the right patient I share my wisdom, and my patient shares his.

I believe that even while I don't always understand my role as an RT, every thing I do, every good thing I do, every life I touch, will be seen it it's true character by God.

On the other hand, some are wise in profession, may be the smartest doctors in the world as an example, but make decisions that are not practical. In their mind they are doing something practical, but they are not. A good example is the decision not to oxygenate a patient based on a myth that oxygen will knock out their drive to breath, or order breathing treatments on every patient out of myth and habit.

When I question them they remind me of the myths. They tell me I am the fool for not believing. They tell me I'm the fool because I listen to lies. Yet by Proverb 10:8 I know that their very rebellion, while it may flatter their proud hearts, will be against their own best interests. For a "prating fool" is literally, "a fool of lips" ("prate" one who talks idly and at great length)

The fool lacks heart, so he will continually mouth off the things that he knows not of, but his folly shall ultimately be known. (2 Timothy 3: 7-9). A person who knows not what the truth is yet thinks he does will mouth off foolish words and write foolish doctor's orders.

Gratitude

Sonia and Ralph were talking on their break.

“These kids.” Sonya says. “They are just not grateful. Here we have done all these extra things for them this summer. And they do not seem to appreciate it at all!”

“I know,” replies Ralph. “Very few of them even say thank you. We have taken them to the beach, to Six Flags, to go-carts and mini-golf. And they are just as obnoxious as ever when we get back!”

“Just yesterday” Sonia chimes in, “I took the girls out for ice cream. I didn’t have to do that. We stayed for quite a while- it was so hot out. And then when we got back, I asked them to go to their rooms and chill out for a while. Several girls had the nerve to talk back to me, and Lisa and Tanika started to get into a fight with each other!”

“You’d think after all we do for them they could at least respond to a simple request. It makes me not want to do any extra activities at all.”

“Yeah. Maybe if they see what it is like to stay on campus all the time they will be a little more grateful for what they do get.”

Ahh yes. Grateful.

How our assumptions do leak through in the most casual of conversations.

What does grateful actually mean? Dictionaries define it as: Warmly or deeply appreciative of kindness or benefits received; thankful. Gratitude is a positive emotional reaction in response to the receipt of a gift or benefit from someone.

Gratitude, thankfulness, gratefulness, and appreciation are feelings, emotions or attitudes in acknowledgment of a benefit that one has received.

And how is one to know whether the other person is experiencing these emotions? Of course one indicator is what the person says. Do they say thank you, do they express how wonderful the experience was, acknowledge the effort of the other person, describe how good it felt to them, etc. And it would be reasonable to expect that the person who was feeling especially grateful or thankful would treat the giver well, want to reciprocate in kindness, and would demonstrate a pleasant attitude. And maybe we could expect…well, hope…that the person would stop some of their most obnoxious behaviors after they have had this fun experience.

Where has this process gone wrong between these staff and these clients?

There are many possibilities. We start with some basic understandings:

Our children’s experiences with relationships have left them with a deep ambivalence about getting close to someone. If a staff member is taking me on a trip, will she meet my needs, stop for a bathroom break, keep me from getting lost? What can I expect at this place where I have never been in the care of these people I don’t really know? A wonderful time together can be scary- can I really trust this person? If I open up to her, will she hurt me?

The brains and biology of our children have been altered by early abuse, neglect and attachment disruption. Sensory data may be difficult to integrate. What seems fun to others may seem overwhelming, confusing and scary. Who knows who could be at this place? Needing to constantly scan for danger can be exhausting.

When the staff take the children on enjoyable activities, they are literally rebuilding their brains. The children have deep seated expectations that interactions with other people will hurt; this is being changed when they experience pleasure associated with other people. New connections are being built between parts of their brains when they successfully master an amusement ride or survive a go cart. Yet, the changes do not happen fast. One pleasant afternoon does not create a pleasant child. Or even ten pleasant afternoons. Many, many repetitions are needed to build a new brain.

Our youth do not know how to modulate and manage their feelings. If they start to feel lost, confused or overwhelmed- or even hot and cranky- they can rapidly spiral into a sensation of complete hopelessness.

When a person does not feel worthy of life, feels like a bad person, she may not feel she deserves pleasurable activities. She may need to sabotage good feelings. She may need to push away any one she has had fun with.

If someone has not developed an inner connection to others, any separation can seem like forever. We just had all this fun together and now you are leaving?!? Who knows if I will ever see you again? I knew I should never have relaxed and enjoyed myself (back to the beginning).

And then there is another, more worrisome over tone in this expectation of gratitude. I will illustrate with an example:

Kayla was 8. She was absolutely adorable with big blue eyes. After early abuse and neglect, she had been recently taken in by Mr. and Mrs. Whitmore. About five months after she was placed, the couple went on a cruise to Alaska, asking DCF to find two weeks respite for Kayla. She stayed with a nice family she had never met before. The parents returned and brought her back a stuffed seal, which she promptly threw away. Mrs. Whitmore complained to her social worker that Kayla did not seem grateful that they had brought her this nice present; in fact she did not seem grateful that they had taken her in. She didn’t seem to understand what a terrible life she would be having if they had not done so!

This is expecting children to be grateful that they are now getting some small part of what they should have had all along; what every child deserves; love and safety. This is seeing the children as less than, as poor unfortunates who should be glad for any scrap. How about the idea that they should be angry about the unfairness of their lives, and protest loudly that they have been wounded through no fault of their own?

Some of this tone can sneak into all our thinking on the hottest days.

As Sonya and Ralph read the above, I can hear them saying: “Oh for heaven’s sake. We know all that. But can’t the kids just say thank you? Can’t they just express some appreciation of the effort we have made, or some happiness in the experiences we have shared?”

Yes. And they will. They will share this with you with they come back and visit in three years, or ten years, or bring their daughter to “see the place that Mommy became a person.” At that time you will be amazed how they remember every detail and say things like: “it was the first time any one celebrated my birthday” or “I was so scared on that roller coaster and I remember that you held my hand.”

And that will give you the stamina to take this present surly group out for one more ice cream cone.

DR. Creed: How to treat pulmonary fibrosis

Page85

Section B5

However, If you are of the belief that bronchodilator therapy will not unstiffen fibrotic parenchemal tissue in the lungs of pulmonary fibrosis patients, then you should not recommend bronchodilator therapy for home use. However, if the patient presents to the emergency room, bronchodilator therapy should be initiated immediately.

Dyspnea alone is indication enough for bronchodilator therapy. However, if you want to get creative, you may consider treating overlying condition, such as pulmonary edema or pneumonia. The interesting thing, however, is both edema and pneumonia are treated the same as any other pulmonary condition -- with aerosolized bronchodilators.

If the patient questions why she needs aerosolized bronchodilator therapy to treat dyspnea when admitted in the hospital yet not to treat dypsnea at home, you should repeat the following line:

"Your pulmonary fibrosis doesn't look any worse on x-ray. What we do see is water on your lungs or an infection, and a bronchodilator will help with that."

Any further questions see page 80.

RT Cheat Sheets are illegal???

So the purpose of ISO and JAYCO is to make sure that quality is met and that the hospital meets a certain set of criteria. While I'm not familiar with JAYCO, ISO has a policy that only forms approved by the institution may be available tot he staff in the hospital.

This is a policy that I have great exception to, as I believe the policy itself is the antithesis of good quality to patient care. I believe that having cheat sheets available to clinicians if among the best methods of obtaining the best quality.

Especially under stressful situations it's nice to have a handy cheat sheet to use as reference. One particular area I find a cheat sheet useful is when it comes to managing neonates who are in respiratory distress.

Considering we rarely get such patients, it's nice to have a reference to help one decide the following:

What size ETT is best
The best place to secure the ETT
The best pressure support
The ideal tidal volumes

So your humble RT created such a cheat sheet, and it has become readily available and used by the rest of the RT staff where I work. I even have it on this blog here.

Yet recently I redid my cheat sheet so that it will be available in pocket size form. My coworker and I were sitting around deciding what colors to use, when my boss came around. He said, "Now, if you're going to use these they need to be approved by the forms committee."

I said, "We dont' plan on leaving it lying around, we're just going to have it in our pockets so we can be better therapists when we have a sick baby."

"It doesn't matter," he said, "If a baby dies and ISO finds that you used one of your cheat sheets, they could say that your cheat sheet wasn't approved and impacted the quality of the patient's care."

I rebutted this by saying, "Yes, but the situation you describe would never happen. If anything, the opposite. Not having the cheat sheet will decrease the quality of patient care and increase the risk of causing damage to the baby. It's only common sense that you let us use these. It's only common sense that ISO would want us to use these."

I have have carried a sample pocket sized cheat sheet in my pocket the past eight years, and so have many of my coworkers. The boss said we can't. He said ISO officials can make us flip our pockets out. I said, "If they do that I will refuse." My coworkers agreed with me.

Yet we lost the battle. The cheat sheet probably won't pass forms committee because the information on my cheat sheet come from an variety of sources, I just put them together in a neat little package. To find my sources and determine where they came from would be too much work and I'm not going to do it.

Despite this unfortunate situation, my coworker and I are proceeding with our efforts. We will print out the new cheat sheets, laminate them and give them to all our coworkers as a nice little Christmas gift."

The irony of this entire situation is I gave this same boss a copy of my cheat sheet five different times over the past eight years to get it approved by forms committee so we could put a copy of it wherever we needed it: in OB and ER. Yet he ignored our requests every time.

This is just more proof of the idiocy of ISO and what's wrong with the medical industry.

ABG errors and how to fix them

Most ABG machines are so sophisticated that they rarely make errors. Most studies seem to confirm this, noting that as many as 68 percent of ABG analytical errors are handling errors that occur between the time of the draw and insertion of the syringe in the ABG machine, according to John J. Ancy in his RTmagazine.com article, "Blood Gases and Preanalytical Error Prevention."

The following are possible preanalytical errors:

1. Exposure to air:

Problem: Whole blood continues to metabolize after the draw, and for this reason it's important to have proper handling of the sample. There is a bubble in the syringe.
Error: Trapped air in the syringe causes the PO2 to move toward 150, which is the PO2 of room air. So if the actual PO2 is less than 150, the PO2 reading may be inaccurately high as it moves up towards 150. If the actual PO2 is greater than 150, the PO2 reading may be inaccurately low as it moves down toward 150. CO2 become slightly lower with a slight rise in pH.
Solution: Tap bubbles from syringe and aspirate air into a filter immediately after the draw.

2. Improper mixing of heparin:

Problem: If dry heparin is not mixed with the blood clots may form and readings may not be accurate
Error: Clotting cannot be reversed. Clots may cause to machine to break down.
Solution: A small amount of dry heparin will prevent clots. Make sure to mix the syringe, roll it between your fingers, for about one minute, and then expelling a few drops into a gauze pad, both prior to inserting the syringe into machine. The flea in capillary blood gases should be used to mix the sample for five seconds.

3. Ice storage

Problem: Past policies recommended storing the post draw ABG in a slurry of ice, although new recommendations frown upon this. It's difficult to get outdated hospital policies changed.
Error: It reduces metabolism of the blood in the syringe, but the new plastic syringes are permeable to outside oxygen molecules. Cooling increases hemoglobin's affinity for oxygen, and this may attract oxygen molecules from ambient air to these hemoglobin molecules. This may artificially inflate PO2.
Solution: Do not use an ice slurry. Instead, assure that the blood is inserted into the analyser within 30 minutes of the draw. New recommendations suggest only placing the ABG on ice if the time from draw to ABG analyzer is longer than 30 minutes. I wrote more about this here.

4. Art line draw:

Problem: Heparin is needed to keep blood from clotting in the art line system
Error: Heparin in the syringe may cause inaccurate results
Solution: You must waste two times the dead space in the system. How do you know the dead space volume. Ancy explains: "If vascular line dead space is unknown, turn the stopcock to the sampling port and withdraw flush solution until blood appears in the hub of waster syringe. The volume in the syringe at that point will be equal to the dead space, double that volume for the waste draw."

5. Changes:

Problem: Changes in patient settings may affect ABG results: Peep changes, oxygen changes, suctioning, ventilator settings, etc.
Error: ABG results may be artificially high or low
Solution: Most recommendations suggest waiting 20-30 minutes after changing oxygen, ventilator settings, or PEEP/CPAP.

6. Temperature Correction:

Problem: Some experts recommend if a patient has a fever the temperature on the analyzer should be adjusted to match the patient temperature. It's difficult to change past hospital policies, and it's difficult to get doctors to understand that methods of interpreting corrected and uncorrected temperature readings may be different. For this reason, most medical experts recommend NOT making any corrections in temperature. In other words, there are no reference ranges for other temperatures other than room temperature. I wrote about this here.
Error: Temperature can inadvertently affect ABG results by speeding up metabolism.
Solution: At present, the recommendation is not to make any temperature correction. Ideally, there should be reference ranges for ABGs at all temperatures. Temperatures should be corrected only at the recommendation of the physician, and any changes in temperature should be reported in the comments. Interpretation of the results is to be done by the physician who requests them.

Related:

ABGs interpretation made easy

The argument against ABGs

1864 Cough remedy

Here's an interesting recipe I found in the 1864 Pacific Medical and Surgical Journal (Volume 7, page 154):

For Coughs
Tronchin's Cough Syrup

Rx Powdered gum arabic........................8 ounces
.......Precipitated sulpheret of anatomy.......4 scruples
.......Anise...................................4 scruples
.......Abstract of Liquorice...................2 ounces
.......Extract of Opium........................12 grains
.......White sugar.............................2 pounds
Mix and form lozanges of six grains, one of which isto be taken occasionally in catarrh and bronchial affections.

I just though it was interesting the use of opium in cough syrup, and how nice a remedy that would be for a simple cough.

Asthma control defined

The following was published June 27, 2011 at myasthmacentarl.com/asthma.

What is good asthma control?

Most asthma experts will now say that thanks to modern asthma wisdom and medicine most asthmatics can gain control of their asthma. So how do you know your asthma is controlled? What is good asthma control?

According to the Global Initiative For Asthma Asthma Guidelines, your asthma should be classified as either controlled, partly controlled, or uncontrolled. So what does this mean for you and me.

Let's define the above terms:

1. Controlled:

No daytime symptoms (shortness of breath, chest tightness, etc.)
No limits on activities (you can walk, exercise, attend school, work)
No nighttime symptoms (no waking at night due to asthma)
Minimal use of rescue medicine (less than twice in two weeks)
Lung function (FEF or FEV1 are normal)

2. Partly Controlled:

Daytime symptoms more than twice a week
Some limitations in activities (trouble exercising, missed days work/school)
Wake sometimes at night due to asthma symptoms
FEF and FEV1 less than 80% of predicted
Need rescue medicine more than twice a week

3. Uncontrolled: Three or more features of uncontrolled asthma. Asthma is limiting your lifestyle, effecting your morale and general satisfaction.

The National Heart Lung and Blood Institutes (NHLBI) Asthma Guidelines define control pretty much the same as the GINA guidelines: Control is the degree the above guidelines are met plus the degree YOUR goals of therapy are met.

Your goals may be:

I just want to be able to walk
I want to be able to exercise
I don't want to miss any more school or work due to my asthma

Another means to monitor control is your own personal satisfaction. Are you satisfied with your life given your asthma severity?

I'll use myself as a for instance here. I still use my rescue inhaler a few times per day yet I'm still able to live a normal, active life. I never miss work due to asthma, and I can exercise and even run.

I feel my asthma rarely stops me from doing the things I want to do. Therefore, my doctor and I have decided my asthma is controlled -- or at least as controlled as it's going to be.

So essentially there's a few tools to help you and your doctor determine if your asthma is controlled:

Guidelines like those listed above
The degree to which your goals of therapy are accomplished
Your personal degree of satisfaction

If your asthma is controlled, GREAT! Continue to see your doctor as often as he recommends, and no less than at least once per year. And most important, continue being a gallant asthmatic.

If your asthma is partly controlled or uncontrolled, you'll want to continue to work with your doctor. He may continue to tweak your asthma regime until your goals are met and you're satisfied.

Remember, all asthmatics should be able to obtain asthma control.

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Reactions to My Book

Please pardon the shameless self promotion, but I would love for people to read my new book Trauma Informed Care: The Restorative Approach (www.nearipress.org) and let me know your thoughts.So to inspire you to do so I am sharing some reactions from people I admires and respect:

From Laurie Anne Pearlman, Ph.D. Co-author, Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse:

“Trauma-Informed Care: The Restorative Approach is a solid contribution to clinical work with children and youth in congregate care and their families. Patricia Wilcox offers a smart relational approach grounded in trauma theory and brain-behavior research. She presents the theoretical basis for the restorative approach, describes the approach clearly and succinctly, and illustrates its application lavishly with clinical examples. Her style is conversational and collaborative. Wilcox’s vast experience with this population shines through in both the examples and the comfortable way she raises and addresses potential objections to using the restorative approach. It is a must-read for trainees and workers new to this field and a wonderful resource for administrators, families, policy makers, and staff at all levels of experience. Anyone who works with this population or who is treating or raising kids can benefit from reading this fine volume.”

From Karen W. Saakvitne, PhD

Author Trauma and the Therapist, Transforming the Pain, and Risking Connection
President, TREATI

“Pat Wilcox conveys the accumulated wisdom of her years working with children too often overlooked by others in this remarkable and inspiring book. The Restorative Approach has the potential to radically change child mental health treatment (and parenting) for children with challenging behaviors and histories of trauma. Integrating current research on trauma and treatment with practicality, compassion, and ethics, Wilcox presents a compelling case for the Restorative Approach as a best practice in trauma-informed child treatment. The book is exceptional in its many detailed clinical examples of effective interventions making it immediately accessible and useful to all staff. Wilcox’s full exploration of all objections to the Restorative Approach convinces the reader of her complete understanding of the real conditions under which most child mental health settings function. Ultimately this book is inspirational; it offers hope for children, their families, and mental health professionals working with them. It should be required reading for all staff working with children in mental health systems.”

And from: Roger D. Fallot, Ph.D.
Director of Research and Evaluation
Community Connections

“Pat Wilcox has written a book full of compassion and common sense. She integrates the restorative approach with a trauma-informed one, enriching both in the process. Her vast experience with children, youth, and their families is fully apparent here, as is her creative way of thinking about and working with them. Pat tells important stories about young people and their traumas, about their responses to being traumatized, and about how a particular kind of setting with a particular set of staff behaviors might be most helpful. Her bulleted lists of ideas are priceless and the volume’s valuable appendices are an additional highlight. Pat’s deep caring for children and youth, their families, and the staff who serve them is evident throughout this important, new work.”

With testimonials like that, how can you resist it?

Why are you a respiratory therapist?

Respiratory therapists and nurses have a greater calling far above helping people feel better and saving lives. So if those are the reasons you are entering the medical profession then you may be utterly disappointed. There is a greater calling, you see. So read on and learn with me.

I have a unique position in the medical field, all us RTs do, and that is that we are seemingly everywhere all at once. We have the ability to wander the hospital and we experience life in all departments. We hear all gossip and we tend to know the milieu of all departments. We hear all good, and we hear all bad.

One of the things I hear by some of my coworkers all over the hospital is "Why am I here? What is the point of my existence." I hear this of nurses who go around doing nothing but giving pills all day to patients who have no clue. They place people on ventilators who are essentially lifeless. They do breathing treatments that are pointless.

"There is," a nurse said, "no point. I am waiting to learn the reason for my plight. I yearn to know what is my calling, why am I here on this earth?"

I said, "Do you expect someone to come up to you and say, 'You're going to be the next prophet?' Do you expect someone to come up to you and say, 'You're going to be the next Senator' Do you expect someone to come up to you and say, 'You are going to write a best selling book?'

My friend said, "Well no."

"Good, because chances are no one ever will. Why? Because very few people get jobs that make them famous. Think of it this way, only one person will be President of the United States, that leaves more than three million people to do every other job. If you spend you're entire life waiting for one of those types of jobs, chances are good you're going to die severely disappointed."

"I see your point."

"My point is, you already have a purpose. You already have a gift. Think of it this way, if you're President of the U.S. you influence many people. Yet the President had may people influence him through the course of his life, even in small ways. He may have been touched for five minutes by a respiratory therapist or nurse, someone who influenced him, touched him, in a small way.

"I see your point."

"Even your minor role, even those few minutes you spend with a patient, influences that person. You never know what person will go on to influence someone else based on what he learned from you. Or maybe you saved his life so he can influence others. Then you have shared your gift. And I sound like a Rabbi or something."

My friend and I shared a laugh.

"So my point is," I continued, "that even though I don't understand why I do 90% of what I do, while I think most of what I do is pointless and maybe you do too, we touch people's lives. We influence them in some way. We, thus, are using our gift every day. That alone makes me proud to be an RT."

Whenever you feel there is no point, whenever you wonder what your role is on this earth, remember that you are but one small important clog in the world. Every clog is a gift that keeps on giving so long as you choose to smile and accept your role.

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MCAT question #44

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):

44. You have an end stage pulmonary fibrosis patient with marked dyspnea. She smoked a pack and a half packs of cigarettes per day, although she admits to quitting 48 years ago. Her current ABGs reveal the following on an FiO2 of 40% on 12 lpm venturi mask:

pH 7.44
CO2 53
PO2 47
HCO3 36
SpO2 84%
BE 10.4

What would be the first best thing to have your respiratory therapist do at this time?

a. Intubate
b. Decrease oxygen to 35% venturi mask
c. Decrease oxygen to a 4lpm nasal cannula and add a bubbler
d. Increase oxygen to 50%, monitor the patient, and redraw the ABG in one hour
e. Either b or c will suffice due to fears of knocking out her drive to breathe

10 Great things about being a respiratory therapist

Nearly every night I work I hear discussions along the lines of "Why don't respiratory therapists get more respect?" A great question, and I answered it here. I would like to counter that discussion by listing the 10 greatest things about being a respiratory therapist.

1. It's a good, clean job. We work inside where the air is fresh and clean. The air is warm in the winter and cool in the summer.

2. We work 12 hour shifts. This is nice because you get more days off to either spend with your family or, if you want, do a second job.

3. It's a fun job. When your work is done there's plenty of time to socialize, gossip, eat, play games, surf the net, pay your bills, or watch TV.

4. It's rewarding. It's simply a rewarding feeling when what you did, or said, made someone feel better. It's also rewarding knowing you did your part to save a life.

5. We bring joy to people. Sometimes just by you lending an ear to a sick patient, or having that discussion, is all it takes to make some one's day.

6. We are ubiquitous. Seemingly, we are everywhere in the hospital all at once. We have free reign. This beats being stuck in one spot all day, in one room, with one patient.

7. A great variety. We do all sorts of tasks, and offer a variety of skills. And every day offers a new challenge.

8. Teamwork is fun. Skills you've obtained through education and experience come in handy as you participate as part of a team to benefit a patient.

9. We are educators. We educate about lung diseases, and are trained to guide people through the changes they'll have to make in their lives to overcome their illness.

10. You develop skills. Your expertise on managing the airway is essential to saving a life, and keeping someone alive so the doctor has time to work his or her magic.

What do you like best about being an RT?

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