Rules for dealing with night shifters

The following is a sign that hangs on wall of RT Cave:

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Rules for dealing with night shifters:

1. Don't call him before 4 p.m.
2. Don't lecture him about his faults at 4 a.m.
3. Don't call him after he leaves work to tell him he's a screw up.  All this will do is piss him off so he can't sleep, and he'll be even less effective the next night
4. Remember that one error doesn't constitute a crisis
5. Don't tell him he looks or sounds tired, because he is and he does

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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.

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Two ways to hire doctors: Part 2

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

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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.  

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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. 

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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.”

 

 

 

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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.

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