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What is agonal breathing?

Your question:  What is agonal breathing? 

My humble answer:  Agonal breathing is inadequate breaths or gasps.  According to the Medical Priority Dispatch System agonal breathing is determined by watching a person breathe.  "If the time betwen breaths is 10 seconds or more, this should immediately be considered INEFFECTIVE BREATHING that is likely a fading, AGONAL (dying) respiratory pattern."  Agonal breathing is a sign of a very recent cardiac arrest.  If you observe agonal breathing you should consider the patient in complete respiratory arrest and treat the patient by providing positive pressure breaths with an AMBU bag. 

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Are lungs affected by stress?

The following is from healthcentral.com/asthma.

How Are the Lungs Affected by Stress? (originally published on 4/26/11)

"You're just like everybody else... Pressure!"

So sang Billy Joel in  his 1982 hit.  Joel also has asthma.  Perhaps he didn't know pressure (stress) can affect the lungs, or he might have added this little tid bit to his song.

"His asthma hit... He felt like a fish out of water... Pressure!"  He may have added to the song.

Yet while asthma can cause pressure, pressure can also be an asthma trigger.  New studies also show that pressure can also cause one to develop asthma.  How could this be, you wonder?

Well, it's really not a new theory, as in the 19th century and until the 1950s many asthma experts (like Henry Hyde Salter) believed asthma was all in your head, that is was caused by stress, anxiety and depression.

Thankfully modern wisdom has proven asthma is not all in your head.  Yet as we look at some newer studies, experts like Dr. Salter weren't as wrong as some of us might want to think.

Consider the following studies:
  • This 2009 study shows that kids with stressed and anxious parents were 50 percent more likely to develop asthma, or at least when exposed to pollutants.
  • This 2010 study shows that stress from work increases your risk of developing asthma by up to 40 percent over those who are not stressed at work.
  • This 2004 study showed a link between the levels of high stress and asthma
  • This 2008 study links child abuse with asthma, showing that children stressed due to child abuse were twice as likely to develop asthma as compared to non-abused children.
  • This 2010 study found that prenatal stress can increase the risk of a child developing asthma later in life.
  • This  2010 study shows that asthmatics are 50 percent more likely to have anxiety and depression compared to those who do not have asthma.   
Why the link?  Experts believe increased stress and anxious thoughts cause the body to release harmful chemicals that increase inflammation in the lungs.  Thus, if a child is continuously exposed to a stressful environment, this inflammation can become permanent.  This is asthma.

Likewise, this sets up an environment inside the lungs so that when the person is exposed to asthma triggers (like pollution) later on, these kids are more likely to develop asthma or allergies.

A similar theory is that stress caused by abuse depletes supplies of the hormone cortisol, which helps reduce inflammation in the lungs.  With low levels of cortisol, the harmful chemicals released due to stress are likely to have free reign.

Prenatal stress, on the other hand, effects an unborn childs immune system development, and, later in life, this can cause the child's immune system to have an un-natural response to environmental triggers (like pollution or allergens), and this increases the risk of developing asthma later in life.

We all face challenges, and that means we all face pressure. Without challenges comes no stress. Yet without challenges life would be boring. So to make life interesting we all need stress.

Some stress is avoidable.  Yet other stress is not.  For instance, there is a high rate of asthma in poverty situations.  It's possible one of the reasons is that poverty increases stress.

Still, while you can't get rid of all pressure in your life, you can learn to cope with it. Here are some tips to help you relieve stress to help your lungs:
    1. Exercise: This may be the best stress reducer.  It's also proven to reduce feelings of depression and anxiety.
    2. Eat healthy: Junk food can make you feel, well, junky
    3. Get enough sleep: Experts recommend at least seven to eight hours of sleep
    4. Get organized: Plan your day.  Feeling in control can help you feel better about yourself.
    5. Learn to relax: Something what really helps me is progressive relaxation.
    6. Avoid stress: You can't avoid it all, yet you can avoid those things that cause the most stress in your life.
    7. Seek help: Talk to family and friends and try to find ways to reduce stress.  Or talk to experts.
"You have to learn to pace yourself... Pressure!" Joel's song notes.  So true! This simple advice might actually prevent asthma.
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Saying Goodbye

At Klingberg we are saying goodbye to many people and many things at many levels. We are closing several of our residential programs, discharging our kids, and laying off some of our staff. It is a sad time.

I am completely committed to the principle of supporting kids in family homes whenever possible. We are developing several new programs to aid that effort. I am excited about these new possibilities.
However, it is the end of an era for us. We did very good work in our residential programs. We used a trauma-informed, Risking Connection based approach. We love our kids. We have been looking through old pictures and marveling at all the wonderful things we did together: Boston trips, picnics, camping, fancy dinners, and all the everyday moments. As we look through the pictures we remember how much we learned from each child.
Klingberg has a reputation for excellent treatment of the most severely wounded children in our state. The children who came to us were lost in a morass of self-hatred and hopelessness. Because of their pain they often had to resort to extreme behaviors. We were okay with that. When David came out with blood streaming down his face from self inflicted wounds, the nurse calmly cleaned and bandaged his wounds, and his team mate calmly asked him what was wrong. When Autumn ran away, we welcomed her back and began working on safe places she could go when she was upset. When Dawn was aggressive and mean to staff, we made safety plans, and we didn’t turn against her and carefully reviewed her diary card about what led up to the event. When Sharon recently felt that her discharge plan was shaky and pulled the fire alarm, we understood that she was trying to get our attention in the best way she knew how. Because of the assets we have, we were able to stick with kids more or less whatever they did. And this led to an incredibly high number of ultimate positive discharges (around 90%) when they were finally able to feel safe and worthwhile. It is sad to see the treatment system we worked so hard to create be dismantled.
We are saying goodbye to some talented staff, and wish them well at our sister agencies that have been lucky enough to hire them. Some staff have moved to other Klingberg programs.
We are saying good bye to our present kids, some to placements we are confident about, some to ones we wonder about. For all we have sent them off with hope and support.
So many kids come back to Klingberg to visit and talk about what their stay meant to them. Jennifer brought her daughter and was overheard to say to her: “this is where Mommy became a person.” Now when the kids come back, who will they find?
It is sad to see the empty rooms.
We are trying to do good, careful goodbyes with everyone. We are acknowledging each others’ sadness. We are working hard on moving into the future.
One of our former Directors always used to say: “Change is hard. Change is good.”
I hope so.


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Welcome the easy solution with open arms

Dealing with anxieties that come with life can seem overwhelming at times.  Yet if we dig deep down to the basics of life, the solution may be easier than what we might think or feel at the time.

We as humans can take the things that happen to us and allow them to effect our lives.  We might even blame God and lash out at Him. Yet he thinks of us as children (Isaiah 49: 14-15) and welcomes us back with open arms and a smile.

As I sat in church today listening to the Priest, and my daughter was throwing a fit, it tended to make me want to beat the crap out of her.  Yet I didn't.  I did as the Priest described the Lord would do if I were to throw a fit and decide I hated him for letting something bad happen to me.  He would welcome me back with open arms.

This hit home with me only moments after the Priest talked about it, considering my daughter was sitting next to me refusing to sit the proper way, kicking her boots off and putting her coat over her head.  Yet I looked at  what was the #1 priority in my life, which is my relationship with God.

I decided that the most important thing for me to do in life is to keep my relationship with God strong. If you don't believe in God, then you can use God as a metaphor for values and virtues.  If you have values and virtues, if you have a strong relationship with God, everything else will fall into place.

We must not let the little things in life overwhelm us.  We must not let that our kids overwhelm us. We must not let a recession overwhelm us.  We must not worry about that of which really in the end doesn't matter -- like annoying doctors.

As Matthew writes (Matthew 6: 24-34), "This is why I tell you: do not be worried about the food and drink you need in order to stay alive, or about clothes for your body.  After all, isn't life worth more than food?  And isn't the body worth more than clothes?  Look at the bird:  they do not plant seeds, gather a harvest and put it in barns; yet your Father in heaven takes care of them!  Aren't you worth much more than birds?  Can any of you live a bit longer by worrying about it?"

All the stuff we worry about doesn't matter.  What matters most is our relationship with God.  In our times of trouble we must back up, take a deep breath, and reassure our faith with God.


Matthew 6 (24-34
Corinthians 4 (1-5)
Isaigh 49 (14-15)


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Faux Diagnosis Lexicon

Faux Diagnosis's:
The patient doesnt look quite rite, just make it up (faux it):


Idiopathic:  You have no clue of the cause. 

Nosocomial disease:  You developed it in the hospital.  Beware, the doctor may have faux't it.

Faux't it:  What a doctor says when he's tired of dealing with nagging and persistent patient's who insist there's something wrong with them.  It's the spontaneous dicision to fake the diagnosis to get the patient to shut up.  (Doctor #1 says:  "How did you come up with the diagnosis?"  Dr. #2 says:  "I faux't it."  See F-it.

Faux it:  A less bedecking way of saying Faux't it or F-it.  It's faking the diagnosis to suit the needs of the doctor and to satiate the persistent and pressing patient.   

F-it:  An abbreviated way of saying, "Faux't it."  Faking the diagnosis.  Not to be confused with Fu#$ it. "Rather than think, the doctor F'd it."


Faux Nosocomial Diseases: See trashcan diagnosis.  Are generally fake (pseudo, faux), disorders that one develops at the convenience of the physician, institution, insurance company, and Centers for Medicare and Medicaide Services in an attempt to lower government and insurance costs and ensure hospital reimbursement.

Trashcan diagnosis:  See Fake diagnosis and Faux Nosocomial disease. A made up diagnosis for idiopathic disorders. 

Fake diagnosis:  Trashcan diagnosis, faux diagnosis, faux nosocomial disease.  May result from any of the following:  1)  The patient pressing the doctor because "something must be wrong with me."  2)  The doctor is tired dealing with it and just wants to be done.  3)  Any attempt to name vague symptoms (i.e. the patient is short of breath is must be asthma).  4)  to meet admission criteria.  5)  To meet reimbursement criteria.

Faux diagnosis:  See fake diagnosis, trashcan diagnosis, Faux nosocomial disease

Faux Pneumonia:  Most common fake diagnosis of any patient admitted to the hospital.  It assures reimbursement criteria will be met so long as breathing treatments are ordered.  As you look at the chart you'll see no indications of pneumonia (no increased wbc count, normal x-ray, etc.).

Aspiration pneumonia:  Most common fake diagnosis of any nursing home, bed ridden, stroke patient in order to assure the patient meets admission and reimbursement criteria.  Any time the patient, or mother of a child perhaps, indicates water, swimming in a lake, or anything like that this is a good diagnosis in order to throw investigators off your track if they see pneumonia ordered too much

Faux obstructive lung disease:  This is nosocomial COPD.  It's degeneration of the lung tissue caused out of the convenience of the physician who wants to assure reimursement criteria and cover his bases.  The patient will deny short of breath, any respiratory history, and benefit from treatment.  Any patient with a history of smoking -- even just one cigarette -- must require breathing treatments.  See cigarbuterol.

Elective induction:  What the OB doctor orders when he doesn't want to be bothered over the weekend, has to go on vacation, or the mom is tired of being pregnant.  Any of the following may be the diagnosis:  faux diabetes, STOP syndrome, Impending macrosonia, pre eclampsia.


Faux Diabetes:  Most common Fake diagnosis for pregnant mothers with large or small fetus's who have to participate in a variety of testing only reimbursed under the diagnosis of diabetes.  As you look at the chart the patient shows no real history of diabetes.

Stop Syndrome (sick and tired of being pregnant):  Faux disorder when mom is complaining of symptoms of being pregnant and is ready for elective induction.

Imprending macrosonia:  Creatively lie that you think the baby is large so reimbursement criteria will be met for elective induction of labor for STOP syndrome.

Pre-eclampsia:  Mom never had a high blood pressure but mom tired of being pregnant, so to meet criteria the doctor just faux's a diagnosis.

Exaggeration of Asthma:  The patient fakes asthma so as to get a break from family, freinds, stress.

Nosocomial COPD:  See Faux obstructive lung disease.  The patient miraculously catches lung disease during admission to hospital.

Adrenal fatigue:  You have any of the following symptoms:  tired often, hate getting up in morning, exhausted on Mondays, need coffee and Coke to function, feeling run down, feeling stress.  If you have any of these otherwise normal symptoms you must have a disease, and we'll give it the faux name Adrenal fatigue. For more on this syndrome, click here.

Faux Bronchiolitis:  A meet criteria diagnosis for kids.  You have a kid in the ER who doesn't look quite right, or the mom is pressing you to admit the patient, or the patient has crummy parents and you question the parents are giving adequate care.  Symptoms may include cold or cough, annoying lung sounds.  Should alternate this diagnosis with faux pneumonitis

Faux pneumonitis:  Same as Faux bronchiolitis.  Again, you will find no evidence on x-ray.

Post election depression:  You're pissed because your guy lost.

Stomach flu:  The patient is nauseated and/ or vomiting and has symptoms of gastroenteritis and the patient is convinced he has the flu, so the doctor just goes with it.  There is no such thing as the stomach flu.

Pseudogout:  The patient complains of general pain (joint, shoulder, hip, back) and the doctor has run a gazillion tests that show up nothing.  The patient insists he has something, so the doctor gives in with this faux diagnosis just to shut the f-ing patient up.

Faux croup:  Usually diagnosed on adults with sleep apnea whereas the snoring or grunting is mistaken by nurses and/ or doctor as stridor.  This is a common post operative diagnosis when the patient with sleep apnea doesn't wake up right away from anesthesia and suffers from apnea episodes.

Faux bronchospasm:  The patient presents with annoying lung sounds that the nurse thinks are wheezes but are really stridor, rhonchi, rhales, crickets or snoring. So instead of thinking the nurse calls respiratory therapy for a breathing treatment.

Fulmonating Pulmonary Edema:  Sudden effuse onset of pink idiopathic pulmonary edema resulting in pink, frothy secretions

Cardiac asthma:  It's generally diagnosed as asthma sans the cardiac part because many nurses and doctors have no clue that all that wheezes is not asthma.  It's a wheeze caused by right or left heart failure that results in increased pulmonary pressure and pulmonary edema squeezing the bronchial tubes large and small resulting in a wheeze.  If the wheeze is audible it's cardiac asthma, yet on paper we'll just call it asthma (simpler that way) and order breathing Q4ever Albuterol. 

ABGbies:  A condition where an RT will become incesantly irritable when viewing a frivolous ABG order.

Fulmonating pulmonary edema:  A better word for heart failure causing pink frothy secretions.

Flash pulmonary edema:  Rapid onset heart failure causing fulmonary pulmonary edema.  It's a cover-your-ass-diagnosis for doctors to explain heart failure due to medical incompitence.  No patient suddenly goes into heart failure without showing signs.  If the doctor or nurse misses the signs, this is the default diagnosis.  It works well in courts.

Plamonia:  (n) A faux diagnosis of pneumonia for a patient admitted to the hospital awaiting placement to a nursing home; pneumonia for pacement

Koff-monia:  Faux Pneumonia diagnosis because the patient had a cough and wasn't sick enough for a real diagnosis.
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What's the dumbest doctor order?

Your humble question:  What's the dumbest doctor order ever?  Do you get a lot of stupid doctor orders.

My humble answer:  I think the dumbest order I can think of was when we were informed a short of breath patient was coming in by ambulance and the doctor ordered a continuous breathing treatment as soon as the patient arrived.  The patient arrived and, based on my assessment, the patient did not present with bronchospasm.  Air movement was good except over one region of the lungs, and the patient had a history of pneumos. I asked the doctor if she still wanted a continuous, and he said, "I ordered it, didn't I?  So here I spent an hour doing a treatment on a person because she had a collapsed lung.  And the doctor ordered it before even assessing the patient. 

Another patient came in with all the signs of heart failure.  She had dyspnea and cardiac wheeze.  The doctor ordered back to back breathing treatments and then Q1 after that.  So before she even assessed the patient to determine if a bronchodilator was effective she's decided the patient still needs one every hour after that.  My philosophy is that if a patient is still short of breath two hours after being admitted with CHF the doctor should be fired.  Yet no one ever questions doctor orders, and I didn't want to be the first. (Although I did recently question a disrespectful physician here).

You can pretty much click on the humor tab above to get a plethora of examples of stupid doctor orders. 
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The RT/ doctor relationship

I have learned in my years as a respiratory therapist that the reliance of most physicians on my and my fellow RTs understanding of equipment used on patients, many times to keep the patient alive and to buy the physician time of which to fix the patient's underlying disease process, has formed a strong bond between me and many of these physicians.

Many times I have called a physician in the middle of the night to propose an idea or a concern I have, and many times the physician has listened to me knowing I wouldn't call in the middle of the night just to chit chat.  Sometimes the physician agrees with me, and others he or she acknowledges disagreement and chooses to do things his or her way.  Yet through all our discussions the benefit of the patient has always been at heart.

Many times I have had a question about the course of a patient's disease, perhaps a question about what the physician thinks, or what is on an x-ray, and almost every time the physician has taken the time to share his knowledge and expertise.  Many times a physician has come to me with a question about equipment.  In this way I have formed a good relationship with most doctors I've worked with.  Many times our discussions have evolved further than the patient to discussions about politics, family, and even personal matters.

Many of these physicians rely on us to analyze labs, blood gases and even EKGs and make decisions on our own without calling them, and to the benefit of everyone (patient, physician, RT).  They rely on us to determine who needs breathing treatments, and to recommend who should and shouldn't continue on such a regime.  They rely on us to increase and decrease oxygen in the middle of the night as appropriate without always calling them.  Yet they trust that we will call if the patient's condition deteriorates, or we suspect such is occurring.  Thus, the bond between physician and RT is strong.

Yet there still exist a few physicians who believe they know everything and have no reason to communicate with a respiratory therapist other than to direct orders.  They do not trust us to know what a normal EKG is, and insist we hunt them down with all EKGs.  They do not trust RTs to know when oxygen is needed, and insist we call them instead.  They do not trust our scope of knowledge, and question our skills and abilities when things don't go as planned.

Such is what happened to me recently.  The BiPAP was set up and the patient got worse not better.  His CO2 rose from 60 to 100.  I informed this doctor on several occasions that the patient was bucking the BiPAP and if sedated I think the BiPAP would work better.  Yet she chose to ignore me.  She even questioned that I set the BiPAP up correctly.  She even questioned that I listened to the patient.  She said, "You are a tech, it's your job to listen to your patient."

I've had many run ins with this doctor in the past, and so have my coworkers.  On the first day I met her she pulled me aside and said, "Look!  I'm the doctor and you're the tech.  You do EKGs and I read them.  You're not trained or qualified as I am in reading EKGs and even ABGS.  So when you do them I want you to bring them to me no matter where I am.  Understand?"

In the days since there have been many times I have approached her and said things like, "So, what do you think?" Many times I've asked this of a physician and it's lead to a discussion of the patient.  Many ideas have come forward, and many patients have benefited with shared wisdom.  Yet this bad doctor simply looks at me like I'm an ignorant cuss and she rolls her eyes and says, "So, do you have any bright ideas?"  In other words, I'm wasting her time.

So what do you do when you have an arrogant and condescending doctor?  In most cases I would recommend what I normally do, and simply walk away.  Yet this physician has had many such run-ins with what she calls "here respiratory therapists."  Or, rather, "her techs."  She thinks of us as ancillary  staff meant to do a job, as opposed to professional members of the team.  I decided it was time to step up and face this doctor -- mano-a-mano.

I calmly said:  "I am not a tech, I'm a respiratory therapist.  I have two years of school in respiratory therapy, and I am registered and licensed.  I know what I'm doing.  I think it's time you start respecting my skills and knowledge as other doctors do, and I think it's time you start respecting my fellow RTs who work here too.  I respect you.  You respect me.  The patient benefits."

I turned and walked away.  It was at this time the adrenaline started flowing, and I was shaking like a leaf in a hurricane.  I could no longer function.  I wanted to call my boss, but my voice was so shaky I decided better of it.  I completed my other tasks, yet not without difficulty.  As soon as my boss arrived I told her what happened to make sure I stayed a step ahead of this doctor, and kept this doctor on defense.

My boss and all my coworkers were actually impressed at what I said to her.  Some didn't believe I did it, considering this was totally out of character for me.  Yet I had witnesses.  Yet something had to be done.  I did not question this doctor's skills, because she is an excellent doctor.  What I did was question her respect for a respectable group of professionals.  What I did was deflate her big, fat, bloated, egotistical head.

I discussed this with another physician of whom I have a good bond with, and I asked, "Was I wrong?  Should I have just walked away yet again and said nothing? Should I stop sharing ideas with her?"  He said, "Rick, you did the right thing.  I would recommend you not change anything."

So I won't change a thing.  I also doubt I'll be confronting any more egotistical and condescending doctors in the near future either.  I also wonder what my relationship with this doctor will be from here on out.  Imagine nothing will change, because ignorant people rarely learn.

I will leave you today with a quote from Donald F. Egan, MD, et al, "Egans Fundamentals of Respiratory Care," 1982, 4th ed., page 678:
"The techniques that have evolved for the treatment of these patients required the supervision of highly educated and skilled professionals whose degree of specialization is beyond the scope of the average attending physician or nurse."
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