What is emphysema?

Emphysema causes alveoli to become overdistended

 Your question:  What is emphysema?

My humble answer:  According to the Mayo Clinic, Emphysema is a condition where your lung tissue is slowly destroyed, and this results in you becoming more short of breath over time.

In your lungs you have air passages that branch off into smaller and smaller passages like the branches of a tree.  The larger passages are called bronchi, and the smallest are called bronchioles.  At the end of the smallest passages there are several tiny balloon like structures called alveoli.

Air travels down this bronchiole tree to the alveoli, and this is where oxygen you inhale can get into the blood, and carbon dioxide in the blood can move into the lungs to be exhaled.  This process is called respiration.

The Mayo Clinic writes that emphysema causes the elastic tissue that keeps the air passages open to break apart.  When this happens the alveoli beyond region collapse.  This causes air that makes its way into these alveoli to become trapped in the lungs.

Likewise, according to the Mayo Clinic, this condition also breaks the tissue lining the alveoli, and results in them becoming "large, irregular pockets with gaping holes in their inner walls. This reduces the surface area of the lungs and, in turn, the amount of oxygen that reaches your bloodstream."

As this disease progresses, and more and more of the lungs breaks down like this, more air gets trapped into the lungs.  It may feel like you can't get air in, yet the truth is you can't get air out. 

Your question:  What causes emphysema?

My humble answer:  Lung tissue destruction caused by emphysema is mainly the result of chemicals you inhale.  The most commin source of such chemicals is cigarette smoke from both first and second hand smoking.  Other things you inhale that can cause it are air pollution, coal, silica, grain, wood, and fumes.  Another common cause is a genetic malformation called alpha 1 antytripson deficiency.  It's also a normal process that results from aging.  In a sense, inhaling certain chemicals speeds up this natural aging process.

Your question:  What is a barrel chest?  What causes it? 

My humble answer:  This is caused due to air trapped in your chest due to chronic tissue damage.  It's called "barrel chest" because your chest becomes rounded, like a barrel.  This is a common feature of emphysema in the later stages as many alveoli are chronically overinflated with air.  The rib cage is expanded as though the person was taking in a deep breath all the time.  The shoulders are generally high.  On an x-ray the lungs are generaly pressed against a flat diaphragm.  Dr. Edward C. Rosenow at the Mayo Clinic provides a more thorough explaination here. 

Your question:  Is emphysema and asthma the same thing?

My humble answer:  Asthma can also cause air trapping and a barrel chest, yet asthma causes air trapping due to an obstruction of the air passages that is completely reversible with time or medicine.  An asthmatic barrel chest is only temporary, while an emphysemic barrel chest is permanant. 

Your question:  What is a bleb?

My humble answer:  This is when an entire section of the lung becomes an air filled space.  Air exchange in this area is not possible due to destruction of lung tissue.  These blebs can pop and cause a collapsed lung.  This is why it is especially important to use low pressures on these patients when using mechanical ventilation. 

Your question:  Is there a cure for emphysema?

My humble answer:  No.  Once you have lung damage it's usually permanant.  However, there are some things you can do to

Your question:  Is there treatment for emphysema?

My humble answer:  The following will help treat emphysema:

• Smoking cessation is essential:  This will prevent further destruction.  Remove youself from whatever is causing your lung tissue destruction and this will prevent further progression of the disease.  This disease is often associated with airway constriction due to the muscles lining your air passages spasming (like what occurs in asthma). 
•  Bronchodilators:   like Albuterol and Xopenex may help open up these air passages making breathing a little easier. 
• Oxygen therapy:  Oxygen will help with any oxygenation issues.  Often these patients require 2-3 lpm of oxygen either round the clock or while sleeping. 
• Corticosteroids:  May help reduce inflammed air passages and help improve lung function. 
• Antibiotics:  These will prevent and treat lung infections mainly due to sputum being trapped in the lungs (due to chronic bronchitis, see below). 
• Pulmonary rehabilitation:  Exercise can help strenthen your heart and lungs making you more tolerant to dyspnea
• Proper nutrition:  You should eat small meals to prevent your stomach from pressing against your lungs.  Pop and Beer can cause blotation that can make breathing harder.  Pop and Beer can also increase CO2 in your blood making breathing more difficult.  Proper nutrition is essential.
• Weight loss: Losing weight can help the lungs and heart by making it so they don't have to work as hard.  It also helps prevent dyspnea associated with exertion.
• Surgery:  Lung volume reduction is sometimes beneficial to remove blebs to allow other lung tissue room to expand.  This results in better respirations and better air exchange.

Your question:  What are the symptoms of emphysema?

My humble answer:  Common symptoms are:

• Gradually worsening shortness of breath
• Diminished lung sounds (due to air tapping)
• Crackles in bases (due to alveoli reopening with inspiration)

Your question:  What are signs of a worsening or end stage emphysema?

• Blue lips and finger tips (acrocyanosis) due to poor oxygenation
• Increased heart rate due to your bodies natural response to push more blood through your system to collect more oxygen molecules.
• Increased RBCs (polycythemia):  Your body naturally creates more RBCs in an attempt to collect more oxygen molecules. 
• Enlarged right heart: Cause because your right heart has to work extra hard to push blood through destroyed lung tissue. 
• Changing heart rhythm:  The most common is atrial fibrilation due to enlarged worn out heart. 

Your question:  Are there other diseases associated with emphysema?

My humble answer:  Yes.  It's usually associated with chronic bronchitis.  This is a condiion where the mechanisms that help you bring up secretions from your lungs are destroyed, mainly due to chemicals you inhale (such as cigarette smoke).  This causes the person to have a chronic cough.  Emphysema and Chronic bronchitis are generally referred to as Chronic Obstructive Pulmonary Disease.

Your question:  What is a pink puffer?

My humble answer:  Quite often a pink puffer is used to describe an emphysema patient.  Usually these patients oxygenate fine but are short of braeth.  They tend to be thin, have barrel chests, are short of breath, and have pink skin.  This is incontrast to your blue bloater, which refers to chonic bronchitis patients who tend to have oxygenation problems and often have blue lips and fingertips.
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Is it better to get a bonus or a raise?

Your humble question:  Is it better to get a large bonus or a small raise in pay?

My humble answer:  It often amazes me when my coworkers get excited when we get a large bonus instead of a raise.  The other day over lunch we learned we were going to get a big bonus this year, and my coworkers were all excited.  Yet I had to reign in the party by saying, "You know, you'd be better off getting a raise than a bonus, don't you?"  My friend chanted, "Oh, I'd much rather get a bonus.  I like getting the check so I can go out and purchase something."

I explained to them that if you do the math you will see that you will get more money if you get a raise.  Surely you'll get it in small sums in each paycheck so you'll hardly notice, but at the end of the year the extra money you make will be way more than the lump sum.  Plus you will get paid based on the hours you work as opposed to paid based on your budgeted hours.  And Lord knows most of us work more than our budgeted hours.

Most people just see that large lump sum of money and they see that as a good thing. It certainly is a good thing, but it would be better to get a raise.  That way you get a raise this year, and you get a raise next year that's accumulative over last years raise. Overall, you will get way more money with a raise than with a lump sum check.

Yet since my friends don't see the money they earn with a raise, and they do see the large sum in the form of a direct check in their name, they tend to think they are making out like bandits.  Yet the truth to the matter is, that's exactly what your bosses want you to think.  They want you to be excited about the bonus.

I'm not.  I took economics 101.  I know when I'm getting ripped off.  You should too.

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Respiratory therapists are the best RTs

A doctor is a doctor, a nurse is a nurse, and a respiratory therapist is a respiratory therapist.  In the same way we can say a dad is a dad, a mom a mom, a child a child, a teen a teen, and a newborn a newborn.  You cannot expect one to comprehend the world as the other as each has a limited scope of wisdom from experience and observation.

You cannot expect a child to understand the hypoxic drive theory even if there was an interesting book on the subject.  You cannot expect a newborn to babysit a child, but you can expect that a teen can do it.  An adult can do it, but not another child.

In the same way, you cannot expect the doctor to be as good at nursing a patient than a nurse.  You cannot expect a respiratory therapist to be good at changing diapers any more than a physician would be good at it.  Surely a respiratory therapist can start IVs, but he won't be as good as a nurse.

Each person has abilities based on empirical data obtained during the course of life; based on our experience; observation; education.  It is for this reason we must, as a medical industry, allow folks of each profession to perform the duties they are trained in.  Nurses do nurse duties to the best of their ability, doctors do doctors, and RTs do RTs.

Now surely a physicist can write a poem, and a poet can do physics.  Yet never will the poet be as good of a physicist as the physicist.  And never will the physicist write as good of poetry as the poet. Surely there are rare feats, but good poets are rare as good physicists are rare.  Yet good poets are even more rare than good physicists.

So my point is that we must do what we are best at and let the people who are best at something else do it to the best of their ability.  In this way we make better progress.  If, hence, the doctor changes the diaper of a 90 year old patient, he may make a bigger mess of it.  I know if I did the same I wouldn't be so good.  A nurse, however, and the nurses assistant are so trained.

This is why I believe physicians, however brilliant in what they are, do not know respiratory therapy.  It is, as Egan noted, beyond the scope of a physicians knowledge.  It is, however, in the scope of the RT's wisdom.  RTs know RT.  RTs therefore should be allowed to do RT without the physician stepping on his shoes.  RTs should be given more autonomy in order to benefit the patient.

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An interesting thought

We had a patient with 3rd degree heart block come in.  The doctor said to me, "You know, there really is nothing else we can do for this patient.  We're going to ship her to....."

I wanted to joke with him and say, "Well, we could do a breathing treatment."

Yet it's funny, because the reason I didn't was because I was afraid he'd take me seriously.  Isn't that bad? 

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Things RT bosses can do to keep you happy

Studies have overwhelmingly showed that the more satisfied workers are the more satisfied their customers will be.  This provides bosses with an added incentive to keep workers happy.

That in mind, here are some ways your boss may try to keep you happy:

• Parties
• Birthday cards
• Bonuses
• Good benefits
• Annual raises
• Involving you in tasks (writing protocols, teaching nurses, teaching BLS, writing policy, etc.)
• Involve you in departmental decision making
• Creating protocols
• Listening to you
• Giving praise

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Supporting Kinship Care Foster Placements

I have recently become interested in the process of supporting relative foster parents and helping the placements to endure.

In the REPORT TO THE CONGRESS ON KINSHIP FOSTER CARE U.S. Department of Health and Human Services, completed by the Administration on Children, Youth and Families Children’s Bureau, it is stated  that “Because States' data are scarce, it is difficult to estimate how fast public kinship care has increased-but available evidence suggests that it increased substantially during the late 1980s and early 1990s. In the 25 States that do have data, the proportion of children in public kinship care increased from 18 to 31 percent between 1986 and 1990."

I was struck when a foster care leader in our state system described relative foster parents as “the most under-resourced families in the system.” It seems as though there is an un-examined assumption that because relative foster parents are well, relatives, love will carry the day and they will not need help. Foster parenting is a hard job for anyone who does it. And there are some aspects of kinship care that make it uniquely difficult.

Ambiguity of choice presents a significant stressor. Unrelated foster parents choose to be foster parents, decide that this is a good time in their lives, and have to go through an elaborate screening before even hearing the name of a child. Relative foster parents are presented with a child who is a member of their family and who is in distress. They may or may not know this child, and this may or may not be a good time in their lives. But they have to choose between taking the child or having the child go into the child welfare system. Even those who feel deeply that this is more than they can handle also feel a moral obligation to care for the child. The Report to Congress further states that: “Unlike non-kin foster parents, kinship caregivers usually receive little, if any, advance preparation for their role. In all States, non-kin foster parents are required to complete a rigorous training program before the State will license them. Such training helps future foster parents understand the needs of abused or neglected children and emphasizes strategies for meeting these needs effectively. Non-kin foster parents also have time to prepare mentally for their new roles and to adjust their living space to make it appropriate for children of a particular age. In sharp contrast, kinship caregivers often become involved in a crisis situation with little or no notice.”

Accompanying family history and dynamics are always present in the placement. The related child comes with an entire history and many attached feelings. This aspect of relative foster care seems to be rarely discussed in the literature, but is a powerful factor in the outcome of the placement. For example, if a grandmother is caring for a grandchild, that child inevitably connects to a history of pain and distress with this mother’s own child. Perhaps the child’s mother is addicted to drugs. Inevitably her mother, the child’s grandmother, has suffered a lot of pain around this. She may have taken her daughter to treatment progress without success. She has often been deeply hurt by her daughter’s betrayal, such as if her daughter has stolen from her. She has experienced many episodes of hope when her daughter was in rehab or appeared to be turning her life around, followed by despair when the drugs took control again. Furthermore, she may have had experiences with the child’s father, perhaps bad ones. Maybe the child’s father was abusive to her daughter. All of this hurts a mother’s heart and leaves deep impressions. And in fact her daughter is often still in the area, drifting in and out of the family’s life.

How does this all effect the grandmother’s relationship with the child? She loves the child. She wants to do the best for him and raise him right. She wants to protect him from all harm. Yet who does the child look like? How hopeful does she feel towards the child’s future? How resentful does she feel about having this added responsibility in her life at this time?

All these factors are also influenced by the relative caregiver’s health, his/her financial and social situation, and many other aspects of their life.

Often the caregiver has no one to talk to about this, no one to validate their complex feelings and to help them separate the present with the child from the past with the child’s parents. So, the child and the caregiver are both being profoundly influenced by the unexamined past.

Then,  to continue to quote the report, “Unlike trained non-kin foster parents, kinship caregivers often receive little formal training and may have a limited understanding of the child welfare system, what is expected of them, and the resources available to assist them. Kinship caregivers, however, generally have greater knowledge of the family history and dynamics that have created the need for a child to be placed outside the home. Not only are public kinship caregivers less likely than non-kin foster parents to receive services, their needs are more often overlooked. Public kinship caregivers are referred for, offered, and actually receive fewer services for themselves and for the children in their care public kinship caregivers are less likely to request or receive educational or mental health assessments, individual or group counseling, or tutoring for the children in their care.”

Specifically, the kinship care providers often receive little training about trauma, how it affects children, and how they can heal. The main advantage of having such knowledge is that it enables parents to define the child’s behavior differently. When the child won’t eat with them, or refuses to talk, or questions their directives, or has a meltdown in a store, or is aggressive with other children in the home, or won’t go to sleep at night, the parent sees this as rejection, defiance, and a behavior to be eliminated. If the parent is given training that really helps them understand behavior differently, they instead can define the behavior as fear, emotional over load, and problems with trust. This change of definition leads to a complete change of reaction. The kinship care parent is less likely to take the behavior personally, less likely to respond with punishment and more likely to respond with support. This training is essential for kinship care parents. And it must be available in many flexible delivery modes, including a trained person who can offer the parent training in their home individually. Support groups can be both helpful and powerful, but for some parents the thought of having to schedule attendance at a group is such a stressor that any benefit is undermined. A flexible delivery system allows each parent to utilize the help that fits where they are at the moment.

Another essential component of supporting kinship care is to pay attention to the experience of the parent themselves. How is being a kinship caregiver affecting the parent themselves? At a recent training one foster mother stated that she had been a foster mother for sixteen years and no one had ever asked her how the work was affecting her. Caring for children with trauma histories produces vicarious traumatization in foster and kinship care parents as it does in treatment workers. Foster and kinship parents have the additional stress of being largely alone when crisis occur; of possible getting pressure from extended family; of losing friends and family because of being unable to leave the child; of worrying about the effect of the foster child on their biological children; and other issues. For kinship foster parents managing the relationship with the child’s biological parents may be another source of stress.

The kinship care parents need a safe place to discuss all this and to receive validation. This can be individual or in a group. A group, when it is possible for a parent, has the strong benefit of helping the parent that they are not alone. But the parent needs to be educated on the inevitability of vicarious traumatization, how to care for oneself to combat it, and how to maximize the transformative power of providing foster care.

The limited information we have about relative foster care does show that despite the lack of education and support services, relative placements tend to last longer than non-relative placements. We desperately need to create stability for these children that have been hurt through no fault of their own. All the other healing they need and deserve can only take place when they feel safe, cared for and that they belong somewhere. It seems that one way that we could increase that safety would be to provide more and earlier support for kinship care families.

What are your thoughts on this? Have you done any work in this area? Do you know of anything written about supporting kinship care families? Please click on “comment” and let me know. Thank you.

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The ongoing search for natural truths

We must assert that the medical field is an art based on a science.  That means we use science and adjust it according to the assumed needs of the individual.  As we learn better it is assumed that we will do better.  That has been the existence of the medical industry since the beginning of science during the Renaissance when science began.

How well does the medical industry use science?  The answer until the 1950s was not very well.  Since then, however, the medical industry has blossomed.  To use asthma as an example, this was the decade the inhaler was invented that incrementally improved life for asthmatics.

So are we now therefore at the zenith of our scientific wisdom.  The answer is no.  We are still in a quest for the natural truth.  Prior to expounding this conversation allow for a few definitions compliments of Plinio Prioreschi in his book, "A History of Medicine": (1)

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Sense data:  Information that confirms the truth; that confirms reality

Natural truth:  What really occurs in nature.  The reality of the universe.

Reality:  What we know; how we perceive the universe

Scientist:  A person who performs research in a quest to learn natural truths, in search for a perfect correspondence between sense-data and reality and assume there is a natural truth they are striving to discover

Science:  The ongoing quest to discover natural truths. The quest brings us closer and closer to our goal even though we usually are not quite there
Scientific explanation:  How scientists perceive the truth today.  It should be noted here that any accepted scientific explanation is considered a temporary hypothesis ready to be replaced by another that is closer to the truth.

Knowledge:  What we know; wisdom

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Many of us are not aware that science comes from the Latin word scire, which means to know.  So the original definition of science is knowledge. Science is wisdom. In its original form science is philosophy.  Our original scientists were philosophers.  Such knowledge was empirical, or learned by observation and experience.

I can give many examples.  One such philosopher was a physician I did extensive research on recently called Dr. Henry Hyde Salter.  He was a physician in the 19th century, an asthmatic, and he wrote a book based on his asthma wisdom.  His book was the best selling asthma book of the second half of the 19th century.

As I read the book I think:  "He made this crap up.  It's poppycock."  Yet it wasn't poppycock in 1850 when the book was written.  The wisdom Salter obtained about asthma was siphoned into his mind through his own experiments and observations.

He was an asthmatic, he took care of asthamatics, he read, he did autopsies, and he learned a lot about asthma.  What he learned was to him the reality, the sense data the he drew from his natural surrounding.  What he learned became the scientific wisdom of his day.  It was the scientific theory of his day.  It was his fact.

During the scientific revolution, as mathematics and geometry came to be seen as instruments capable of explaining the universe, science became knowledge of the physical world, that is of physical reality.

In this way, philosophers turned scientists like Locke, Berkeley and Hume learned that science was more than knowledge to be picked up by empirical means.  They learned science could not be assumed.  They learned science was ideal not real.  Philosophy is real; it's what exists.  Science is ideal: it's what is.

Think about this.  It's easy to see what is real.  It's hard to see what is.  What is, therefore, is the natural truth.  It is this difficulty to see what is, the natural truth, that makes the medical industry real and not ideal.  It holds back knowledge.  The main culprit here is ignorance and dogma (stubbornness).

These philosophers took the position that reality is the position of the mind, it's the real existence that we live in.  What we are in search of is idealism, ideal knowledge, or the natural truth.  It is this that we yearn for in the medical industry.  Yet what we believe, what we know, what we live by, is realism.

What we see, therefore, blinds us.  It makes it difficult to come up with new theories and even to accept new theories as we come up with them.  And it must be noted here that while new scientific theories are written and accepted, they will replace the old theories.  It doesn't mean the old theory is wrong, it just means the old theory is less true.

So, the more willing or capable we are to learn and accept new wisdom, the better our medicine will be; the better doctors and respiratory therapists we will be.  The better off the patient will be.  The less money we will waste on frivolous therapies.

Oblivious to the natural truth, doctors in general continue their work with what they know; with what they believe is the natural truth.  In fact, scientists and doctors in general ignore the philosophical arguments casting doubt on the knowability of the external world, no matter how strong and convincing they are.

Scientists and doctors, in other words, are normal; they are dogmatic.  It is for this reason that medicine is slow to grow.  It is for this reason doctors have a hard time letting go of such theories such as the hypoxic drive theory and that Albuterol cures everything except stupidity.

Of course, this indifference to philosophy on the part of scientists and doctors is not due to intellectual dullness.  Most doctors and scientists we know, or read about, are among the most intelligent people in the world.  They have trouble seeing beyond what is real.  They "assume" what they know is the natural truth.

Yet what we learn today is that what we call science is the ongoing quest for the absolute truth; natural truth.  It is the ongoing process of discovering truths.  The process brings us closer and closer to the goal even if, it is assumed, never quite up to it.

For this reason, any accepted scientific explanation is considered a temporary hypothesis ready to be replaced by another that is closer to the truth.  This, of course, is what we call scientific progress.  It entails that we keep an open mind and are willing to sometimes accept we don't know all.  We must not be arrogant.

References:

1. Prioreschi, Plinio, "A History of medicine," Volume 1:  Primitive and Ancient Medicine," 1991, Edwin Mellen Press, New York, page XI-XIV

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