Respiratory Therapy Education ForumDavid R. Gibson BS RRT RCP

Most Important - Burn Calories

2011-08-07T17:10:00.000-07:00

Article #4 in a series: "Simple Equation that's not so simple"

Why is the failure rate with diets so high? Diet alone usually fails. I know why: You must make your body do something it doesn't want to do that is:

burn more calories during lean times!

When you are on a diet-and that means less energy-and believe me, your body knows it! The body automatically ramps down your metabolism to maintain homeostasis (it's a lot more complicated than this, but for all practical purposes, think of it this way).

How do you keep your metabolism up there? Do something! Remember the Nike ad: "Just Do It"? That's what you do. Find something you like to do and do it a couple a hours a week to start. For me it was biking, I love bike riding, and it's just not a chore, like some exercise can be. Make that change for a month or so and stick with it.

Caution: Another sure way to fail is to over-commit to some rigorous exercise program and beat yourself up both physically and mentally. You'll realize right away that it's too much and you'll decide you "just can't do this"....followed by: end of effort, end of diet, stay fat.

Once you have proven to yourself that you can stick to a routine of more physical activity for a month, it's time to upgrade your calorie burning engine. You've been burning your energy (carbs, fats, and protein) with a four cylinder engine. You need to upgrade to a high horsepower V8, something that really burns a lot of fuel!

There's only one way to get your calorie burning engine upgraded, and that by building muscle! If you don't have a friend that knows their way around the gym, get a trainer....it will be the best money you ever spent.

You must go to the gym, and you must lift weights.

Trust me, you have to work out with weights to build muscle. No diet is any good without this important step of muscle building. This is so important that you must do this before you cut down on any calories. I would recommend going to the gym one day a week for a month before you even try to diet. Be sure you get lots of protein (20 grams) before and after each work out....there's lots of stuff available....for example pick up a "muscle milk" at the convenience store.

If you can get into this routine:

one to two days a week of some kind of exercise that gets you heart pumping for 30-45 minutes (cardio),
and one hour a week of weight training.

It's time to add another hour in the week.
If you can work up to two 45 minute sessions of cardio, and two 1 hour session of weights a week, you are doing great!

The next step is focusing on your diet.

Diets/supplements

2011-08-06T08:17:00.000-07:00

Article #3 in a series: "Simple Equation that's not so simple"

When trying to change your body:

Dieting alone is likely to fail.

That said, some diets and/or supplements are ok, some are crazy (no real science supports it), and some are potentially dangerous. Let's place the current "fad diet/supplement", HCG in that last category....remember Fen-Phen?

Fenfluramine/phentermine was the "miracle" weight loss drug of the 90's later to be linked to a host of adverse effects including heart damage. What we should have learned from this (but apparently didn't) was that "you can't fool mother nature" and/or that's there's no short cuts.

HCG (Human chorionic gonadotropin) is the new, potentially dangerous, diet du jour. From Wikipedia: "...warnings by the Journal of the American Medical Association and the American Journal of Clinical Nutrition^[15] [is] that hCG is neither safe, nor effective as a weight-loss aid." Wow, strong words by experts. Why are so many jumping on board?

Because our desire to believe outweighs our common sense?

Other diets/supplements, such as "homeopathic", acai berries, etc... remedies, rely solely on the placebo effect, and the only adverse effect is a lighter wallet. Oh, they also fail (failure meaning you don't keep the weight off). Think critically, do your homework on the Internet before you decide on anything!

Any diet you decide on must meet the following criteria:

Must provide adequate calories for energy - if you cut yourself too short, your body reacts by dropping you metabolism, this works against you!
Must be a complete source of nutrition including vitamins and minerals.
Must contain adequate protein (discussed later)

I decided on Weight Watchers for a good, complete diet with a scientifically proven track record, but only after I had established an exercise program. Diet (calories consumed) is only half the equation. You must deal with the calories burned part of the equation carefully, or the diet part will affect the calories burned part in a counterproductive and unplanned way! This is because your body can react negatively to dieting unless you work to address this.

Are you sure you want to do this?

2011-08-05T09:38:00.000-07:00

Article #2 in a series: "Simple Equation that's Not So Simple"

Some of us are lucky. Eat what you want stay the same size. The body auto regulates intake and output to maintain the correct balance. For others of us, it's a constant struggle. I'm in that latter category. I've learned a lot on my journey to better health, and I don't mind sharing what I've learned (after all, I'm a teacher at heart!).

As with any problem, you can't solve it unless you: a) recognize that there is a problem, and b) you are realistic about the impact of that problem. As it was with me. I realized that I was overweight, but didn't fully appreciate the how bad it was, as I was keeping my ideal body self image from my slim college days! (Just the opposite from people that suffer from body dysmorphic disorder)

I was forced to see myself through others eyes, though, when I joined an online dating site "Plenty of Fish". (I'm no longer a member) Sites like this are brutal in that, other than a quick description, a person's physical appearance (most often in amateur photographs) is the method by which you are judged. Physical attractiveness for any age group can be summed up in three letters: BMI.

Body Mass Index (basically a height/weight proportionality number) is directly correlated with physical attractiveness as well as overall health...but guess which one I was worried about! Yes, at a BMI of 31, I wasn't getting any "bites" on my Plenty of Fish profile. According to wikipedia, I was "Class I" obesity (Table below). At my fattest, I had a BMI of 36! (Before my divorce). Optimum BMI for physical attractiveness rating seems to be around 20 give or take a few points either way. The data is in a bell shaped curve with extremely underweight and extremely overweight having the same degree of unattractiveness.

Table from Wikipedia classifying BMI

Severely underweight	less than 16.0	less than 0.66	less than 53.5 kilograms (8.42 st; 118 lb)
Underweight	from 16.0 to 18.5	from 0.66 to 0.73	between 53.5 and 59.9 kilograms (8.42 and 9.43 st; 118 and 132 lb)
Normal	from 18.5 to 25	from 0.74 to 0.99	between 60 and 80.9 kilograms (9.4 and 12.74 st; 130 and 178 lb)
Overweight	from 25 to 30	from 1.0 to 1.19	between 81 and 96.9 kilograms (12.8 and 15.26 st; 180 and 214 lb)
Obese Class I	from 30 to 35	from 1.2 to 1.39	between 97 and 112.9 kilograms (15.3 and 17.78 st; 210 and 249 lb)
Obese Class II	from 35 to 40	from 1.4 to 1.59	between 113 and 129.9 kilograms (17.8 and 20.46 st; 250 and 286 lb)
Obese Class III	over 40	over 1.6	from 130 kilograms (20 st; 290 lb)

My health was clearly at risk, but it took being alone to give me the motivation that I needed to start on a path change.

What's your motivation? Is it strong enough to get on the right path and stay on it? I'll bet that it is. If I can do it, I know that you can.

Update: If you are building muscle, BMI becomes less important since muscle is about 18% more dense than fat. Another way of looking at this is that a muscular person will have about a 20% higher BMI as a similar framed non-muscular person.

The Simple Equation That's Not So Simple

2011-08-05T06:18:00.000-07:00

Article #1, first in the series

My appearance is changed a lot in the last 6 months, and I'm constantly asked the same questions:

"What did you do? How did you do it?".

I found a formula that works, I'm excited about it, and I'd like to share this information with anyone that wants to know.

As you know, obesity is the major health crisis facing Americans today. Tons of well documented information links a sedentary lifestyle and associated obesity with enormous health costs....both monetarily and in quality of life.

From my standpoint as a respiratory therapist, there is a strong link between lung pathology and obesity as well. For example, obesity is linked with asthma severity in several studies (American Journal of Respiratory and Critical Care Medicine, January 2004). It stands to reason that losing weight can help reverse many health problems including asthma.

OK, so we all know that weight control/maintenance are important to good health, but how do you do it? Here's the "simple" equation mention in the title of this article:

Calories Consumed - Calories burned = BMI (body mass index)

Sounds simple right? If so, then why is obesity such a major problem? Is it apathy? Lack of will power? or is it some other issue? The answer is Yes and No. Those things mentioned are a factor, but also, the "formula" and all it's modifiers must be understood completely. A complete understanding takes knowledge, but you must also understand your own body as well.

Over the next several articles, I will share my "secret". I'll start by writing about motivation, and nutrition, but the most important topic will be about burning calories. Follow this guide, and you might see a difference too!

2011-03-14T07:58:00.000-07:00

Once, while checking a student off on an extubation procedure, the just-extubated patient suffered sustained ventricular tachycardia. A "Code Blue" was called and this post-operative heart patient, in addition to ACLS, had his chest reopened in the room. The outcome was bad.

This tragedy was years ago, and many hospitals away...but what I remember best is the reaction of the student....backed up against the wall with eyes as big as half dollars. Surely this student must have thought, after seeing it happen for himself, that this is a common complication associated with the procedure. Fortunately it's not, but I bet he approaches extubation very cautiously, even years later.

The point of the story is that an experience of something unusual or traumatic, may lead to believe that the event is more common than it really is. Case in point: my experience with life-threatening artificial airway obstruction due to mucus plugging. While the chances of mucus plugging are real, in an era of good practices and techniques, routine respiratory therapy reduces this risk considerably. Care of trachesotomies are a good example, respiratory practices have evolved that maintain a safe airway, although one of these practices may itself pose a life-threatening (although rare) problem.

Heat moisture exchangers (HMEs) have found to be a reasonable alternative to the heated humidity needed to maintain airway patentcy, for without humidity, airway secretions casting/plugging can become a concern. Frequent cleaning, suctioning, and careful assessment are all parts of a plan to maintain a healthy tracheostomy. But what happens if the HME, through which all the breath is directed, becomes completely clogged with secretions? This is that rare occurrence that I've personally seen happen--and these occurrences would have been life threatening too, had I not been there to correct the problem. Also, in support of myself, I remember hearing about a lawsuit (although I'm having trouble finding reference to it online) about a trach patient that died from just such an occurrence. In this case I remember hearing that the Respiratory Therapist was held liable for that dreadful outcome.

My experience being what it is, I would expect to see the Internet littered with references to this HME plugging hazard (stories/incidents). To my surprise, though, very little is mentioned about this potential complication. Some of the best online respiratory references mention, only in passing, that "sputum plugging" is a potential complication, but most references don't mention anything about this possibility.

So what should you know? HMEs are used to help prevent drying of secretions that lead to plugging and airway obstruction, but, partial or complete sputum plugging is also hazard when using an HME. Also, recent studies have confirmed that HMEs can be used long term. Below is a list of considerations when using an HME:

Is the patient continuously monitored (Heart rate, blood pressure, SpO2)?

Is the patient on a mechanical ventilator that has monitored alarms?

What is the neurologic status of the patient? Can they remove the HME if there's a problem.

What is the nature of the patient's secretions? (thickness and amount)

Does the surface area of the HME and set-up allow for some small amount of sputum without significant compromise?

Keeping in mind these considerations, one might be able to avoid the nightmare scenario where the unmonitored neurologically impaired patient with thick tenacious secretions coughs a large plug of sputum into their HME and dies of airway obstruction. Sound rare? Maybe, but a frank discussion of the risk/benefit is necessary to maintain a safe situation for the patient.

Keep in mind that unusual and rare occurrences do happen. Remember Murphy's Law? Don't wait for a horrible outcome to keep yourself educated and prepared.

2010-11-10T03:08:00.000-08:00

"As it's fundamentally flawed core, the aim of almost any learning program is to help us become who we are not."

-Tom Rath

Launched back in August, my project, "WorkForce Education", will be written, in part, from a series of thoughts from this blog...and I'm hoping that this might help keep the content moving along.

Don't be fooled by the fake cover to the left....the book is in production with "Workforce Education as working title. The goal is to formulate a system of workforce education that can be incorporated into any business.

The interesting quote above came from the best selling "Strength Finder", and helps explain why the task of workforce education is so difficult. Even more difficult is to teach people to overcome this obstacle and motivate others to achieve what is necessary to be effective and safe in the workforce. The aim of this book is to do just that, help us become better educators.

2010-11-10T02:59:00.000-08:00

AARC Launches it's Drive4COPD campaign. That's Danica Patrick being interviewed on WFAA (ABC)'s "Good Morning Texas" That chubby guy on the end is me!

Respiratory Care Week Happenings

2010-10-22T12:36:00.000-07:00

"New Dimensions in Respiratory Care", a symposium at Medical City Dallas Hospital will be next week, and will provide 6 CEUs.

Seats are filling up fast, so reserve your space by visiting http://www.rtconnection.org/

Forrest Bird coming!

2010-10-22T12:32:00.001-07:00

Dr. Forrest Bird will be visiting Medical City Dallas Hospital / Medical City Children’s Hospital November 12th and 15th 2010. Dr. Bird will be giving a 3 hour lecture each of the two days at Medical City Dallas Hospital City Hall.
Dr. Bird has won multiple awards presented by current and past US Presidents including, the "2008 US Presidential Citizens Medal" by President Bush and recently the "2009 US Presidential Technology and Innovation Medal" by President Obama.
Many have requested the opportunity to meet Dr. Bird. We have dedicated the lecture on Friday, November, 12th at 1300 to be open to all of Medical City and the community.

Launching "Workforce Education"

2010-08-11T04:53:00.000-07:00

Improperly trained employees cost employers untold millions of dollars, result in poor customer satisfaction, and in the worse case, can be deadly.

On the flip side, as any manager will tell you, orientation of new employees costs considerable money and resources.

The question, then, is how do you introduce new people into your organization safely, effectively, and with the least cost?

Supervisors that deal with problems and crises every day will tell you that they wish the employee education was done better, and wish there was a resource to help guide the process.

Introducing the launch of "Workforce Education" (working title) a resource for managers, supervisors, educators, and preceptors.

This project will utilize, and is open to, the talents of interested individuals with he goal is that a book on workforce education be developed from the information.

This blog will be used to facilitate the project launch, or you may contact David Gibson at the email on the sidebar.

My Article in AARC Times

2010-08-01T08:10:00.000-07:00

My article "RT's role in the Treatment and Prevention of MRSA" is in the August 2010 issue of the AARC times, available online for now for members. (I haven't received my copy in the mail yet. Appreciate any feedback, you can email me or use to comments below.

Nebulizer during mechanical ventilation...

2009-12-08T10:07:00.000-08:00

First, can you do MDI instead? Studies suggest they are just as effective at bronchodilator delivery, although perhaps not as good at bronchial hygiene (nebulized saline that accompanies the nebulizer might provide more effective bronchial hygiene).

I had a chance to discuss nebulizer placement with some experts in the exhibit hall, and you get varying opinions. I believe that the nebulizer should be placed on the inpiratory limb--closer to the machine (I realize that this is counter-intuitive but the study I likes confirms this) to take advantage of the the "inspiratory limb as a reservior" model, you must run the device continuously. Doing this you can clearly see a lot of nebulized mist mixing with the inspiratory flow from the ventilator. Whether the particle size remains effective is unknown, though. For this method, a HME bypass (see picture above) is necessary. I would not recommend breaking the circuit and removing the HME for infection control reasons.

Placing the nebulizer in front of the HME and running the neb inermittantly is cheaper but may be less effective (the ventilator peak flow of 60 L/m only contains 6-8 L/m of nebulized mist). Be sure to use a spring loaded "T" to avoid breaking the circuit.

PEEP or not to PEEP

2009-12-07T09:49:00.001-08:00

Atelctasis during mechanical ventilation
11:10 dec 7

Con opinion
Neil MacIntyre MD

Is cyclical opening and closing alveoli during MV harmful? May be, but as you will see, it might be better to leave it closed.

It is easy to over distended some units trying to recruit others. How do you balance protection from over distention with recruitment and better gas exchange? That's the issue.
Part of the answer is to get the plateau press as low as possible, although there will more atelectasis there are better outcomes.

The take home message: be very careful not to correct atelectasis if it's going to kill the patient; live with the poor gas exchange. Use PEEP to get PaO2 above 55, but not more than 80 (PEEP-FIO2 tables)
Studies support the practice of keeping plateau less than 30, use Vt 4-8 ml/kg, outcomes don't support high PEEP.

Pro opinion:
(that you should recruit the lung)
Also: Neil MacIntyre MD

Neil believes that statistics may suggest a morality benefit from higher PEEP. Atelectasis is a risk factor for pneumonia, and therefore worse outcomes. Agrees that the plateau should be kept less than 30 however.

Sent from my iPhone

The Future and the RT

2009-12-07T08:53:00.001-08:00

Speaker: Bill Dubbs
10:30 dec 7

Bill talks about the "2015 Project Creating a Vision...", which you can read about here:

http://www.aarc.org/education/meetings/summer_forum_09/summer_forum.cfm

Good summary.

Sent from my iPhone

Chest xray

2009-12-07T08:19:00.001-08:00

Interpreting the Plain Chest Film
James K. Stoller MD,MS
9:30am dec 7

One of my favorite topics to cover, so this is a big post.

About quality: Proper exposure...really penetration (kV)...is achieved if vetebral bodies are just seen above the diaphragm. Tracheal air column should be in line with spine or rotation is present.

Scan the film systematically using whatever method you choose. Of course noting quality, position of lines and tubes, bones and soft tissues, heart, pleural space, and lung parenchyma. Also important to understand the bronhopulmonary semental anatomy to apperciate the segments of the parenchyma.

Absence of expected shadows is a sign that fluid may be adjacent to that structure such as with a the heart border which is anterior and therefore the anerior consolidation will hide that border.

Kerley B lines is the lymphatic system distention such as seen in heart failure and associated effusion.

Note whether structures are pushed away, or pulled as in atelectasis. Absence of lung parenchmal markings in a dark area may be a pneumothorax. Air bronchogram sign is consolidated lung surrounding a bronchus. "Sail sign" is the presence of atelectasis.

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Let's get critical

2009-12-07T06:09:00.000-08:00

As a follow-up to yesterday's post, "It's not there yet!", I would add that Blogs should function in a way that organizations can't or won't: that is, by taking a critical look.

Individuals with no affiliation with organizations are free to engage in criticism--an important aspect of a free thought/expression. Companies are afraid of this, of course, but valid criticism has the potential to improve patient care.

The down side is that a blogger, with an ax to grid, might be unfair or downright inaccurate.

As blogging develops, participants should agree on a basic set of rules such as disclosing any financial interest or relationship that may conflict with their ability to remain objective. Bloggers that refuse to agree or violate these rules, links should be removed from participating bloggers...and of course blogs and bloggers can and should be criticized as well.

Someone want to help me draft a bloggers creed?

David Gibson

Congress Gazette

2009-12-07T06:02:00.000-08:00

Added to the links...I didn't know that the AARC provides a section called the "Congress Gazette" to give a wrap up of the days events.

Bruce Rubin MD

2009-12-06T14:48:00.001-08:00

Bruce Rubin MD
Originally uploaded by drifter120

Here's a picture of Dr. Rubin from his lecture earlier today. My understanding is the Dr. Rubin (a pediatrician) likes to do sleight of hand magic and performed a rope trick as he spoke.

Why arent' you here?

2009-12-06T14:07:00.000-08:00

This representative picture is not from an actual event

Top reasons to attend the Congress that have nothing to do with the lectures/meetings...

CareFusion's Welcome Party
Exciting Sputum Bowl Competition
Meet your future employer (ALL the important people are here)
Vendor arena is like "RT Disneyland" and is packed with interesting stuff (takes days see it all)
Renew relationships, form new professional relationships
Music, dancing, dining, and fun after the lectures (and sometimes during the events).

Update:

Covidien's Sputum bowl finals

Massimo does it again

2009-12-06T14:05:00.001-08:00

Massimo
Originally uploaded by drifter120

Massimo has done it again with it's newly FDA approved system of monitoring breathing sounds. This unit is able to "hear" breathing-- even if the patient is talking.

As a caregiver, I appreciate Masimo's commitment to innovation. Finally, a way to reliably and easily monitor breathing sounds on my floor patients--particularly those individuals on narcotics/patient controlled anesthesia.

From what i've seen, the device seems to be inexpensive and easy use with its disposable probe. The monitor (see next to the patient with the cable attached) reads SpO2 (Massimo's technology for SpO2 is superior), heart rate, and breathing.

David Gibson

Lung boy

2009-12-06T13:51:00.001-08:00

Lung boy
Originally uploaded by drifter120

He may be hideous, but he gets the girls.

Simulation

2009-12-06T12:46:00.001-08:00

Simulations
Julianne S. Parretta MSEd, RRT-NPS
Johns Hopkins Medical Center

When writing objectives for clinical simulations (multiple obectives should support a single goal) objectives should have four elements: A-audience, B-behaviour (action verb), C-conditions, D-[to what] degree.

Sent from my iPhone

EnVe Vent

2009-12-06T09:54:00.001-08:00

Posted to www.rcmeeting.blogspot.com

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Sputum Bowl Update

2009-12-06T09:44:00.001-08:00

We (Texas) lost to Colorado. A second loss (which we suffered yesterday with Minnesota) means we are out of the competition. Good luck to the remaining teams!

Sent from my iPhone

It's not there yet!

2009-12-06T08:59:00.001-08:00

This idea of "live blogging" an event, where very well developed at political conventions, is nearly non-existent at the respiratory congress...but it's coming.

My vision for the future is that several independent bloggers will add content to their own blogs that will be linked to each other. At the beginning of the convention the bloggers will meet at a predetermined area...perhaps designated (and supported by) the AARC. We would cooperate as to what to cover and provide links to each other.

Obviously one person can't cover much....and as far as I know, I'm the only ony trying to do this (at this event). One things for certain: live blogging (or whatever you call a public communication forum on the internet) will grow and within a few years will be commonplace.

David Gibson

Sent from my iPhone

Bruce Rubin MD speaks

2009-12-06T08:20:00.000-08:00

Donald Egan Memorial Lecture, Dr. Rubin is talking about the variety of things that can be nebulized: morphine, certian anti-microbials, insulin, nicotene, gene transfer ( for treatment of CF), migraine meds.

He also reviews data showing MDI, used appropriately, is just as effective as nebulizer treatment. He reminds us of the importance of our job as educators.

Orally administered corticosteroids reduces deaths from asthma, but patients must use a device that they like.

Sent from my iPhone

Sputum Bowl

2009-12-05T09:55:00.000-08:00

One of the reasons we come to the Congress is to compete in "Sputum Bowl", a quiz bowl of respiratory therapy knowledge. Both Texas teams, the "practitioner" team (myself, David Barton and Sue Young) and the student team (Tarrant County College) made it through to the next round. Our competitor, Arizona, failed to show and we won by default. Tarrant County College had a solid victory over Oklahoma 11-4.

Musical interlude

2009-12-05T06:28:00.001-08:00

Nice mariachi band performing at 8am near the registration area. It
seems kind of early for this much excitment!

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Countdown to San Antonio...

2009-12-04T16:00:00.000-08:00

55th International Respiratory Congress
San Antonio, TX
Dec 5-8

Program Here

I'll be (unofficially) live blogging from the Congress like last year. I'm hoping to link to other bloggers that are doing the same.

If you are a subscriber of my YouTube videos (see link to the left) and plan to attend the meeting, please email me.

Join the AARC!

Off Topic: Gas Station Food

2009-12-04T14:32:00.001-08:00

photo.jpg
Originally uploaded by drifter120

On the Road to Respiratory Congress in San Antonio:

I'm thinking about doing a blog on [good] gas station food. Check out the "Czech Stop" in West, TX. (in the Shell station). Great bakery items and sandwiches. 5 stars.

Earthquake in Sichuan

2009-12-04T07:55:00.000-08:00

Interesting coincidence...As a follow-up to the post about Jean's visit from China: the May 2008 7.9 magnitude earthquake in Sichuan Province, China, (site of the only RT school in China) was used as a backdrop for a study about ARDS. Link Here

RT in China

2009-12-04T07:31:00.000-08:00

Ever wonder what Respiratory Therapy was like back in the 1960's?

According to Yua-hua Yuan (who goes by "Jean") Respiratory Care in China is currently similar to the beginnings of Respiratory Therapy in the USA. Jean, Director of Respiratory Care at Sir Run Run Shaw Hospital
is visiting America to learn more about respiratory services in several US hospitals courtesy of the AARC's international fellowship program.

Some facts:

There are only about 100 respiratory therapists in China
One Respiratory School in Sichuan Province graduates 10 students per year.
Enormous growth potential exists for RT in China and is expected continue to expand
Loma Linda University Medical Center helped create the RT department at Jean's Hospital.

Picture: Yua-hua (Jean), and Chad Martin, Manager of Respiratory Care, Medical City Dallas Hospital. Standing in front of a display at the AARC headquarters.

Davida

2009-12-02T08:59:00.001-08:00

Davida
Originally uploaded by drifter120

Test Post: Davida Nelson, Manager of Information

Test photo 3

2009-12-01T13:35:00.001-08:00

Test photo 3
Originally uploaded by drifter120

David Barton - Education Coordinator

Test video

2009-12-01T11:56:00.000-08:00

Sent from my iPhone

Preparation for live blogging in San Antonio...

2009-11-30T14:46:00.000-08:00

As I did last year, I'll try to report on events at the 55th International Respiratory Congress as it happens using the latest available technology.

Unfortunately, last year I was limited in my ability to add multimedia content with the older 2g I-phone. I think with the 3gs phone that I am using now, things will be much easier, especially getting video from phone to blog.

In the next 72 hours, I will be testing my ability to quickly add text, pictures, and video using primarily the iPhone 3gs. Any readers that can make helpful suggestions will be appreciated.

I have not yet, but shortly I will add a YouTube video to alert my almost 500 subscribers to the existence of this resource.

Cheers, and Join the AARC

Today's Word: Critical Thinking

2009-07-08T08:45:00.000-07:00

It is generally accepted that good critical thinking plays an important role in every profession, particularly Respiratory Therapy. Employees are valued on the basis of their perceived ability to critically think; so much so, that enormous emphasis is placed on this ability both in the workplace, and academic settings. That critical thinking is important is certain, what's not certain, however is whether or not critical thinking can be taught.

More directly, is critical thinking a learned or innate skill?

OK, I realize that it's probably not completely one or the other, but to what degree can critical thinking be learned?

Unfortunately research shows that most universities are ineffective in
fostering critical thinking. For example, in a three year study of 68 public and
private colleges in California, though the overwhelming majority (89%) claimed critical thinking to be a primary objective of their instruction, only a small minority (19%) could give a clear explanation of what critical thinking is. Furthermore, though the overwhelming majority (78%) claimed that their students lacked appropriate intellectual standards (to use in assessing their thinking), and 73% considered that students learning to assess their own work was of primary importance, only a very small minority (8%) could enumerate any intellectual criteria or standards they required of students or could give an intelligible explanation of what those criteria and standards were. (Wikipedia)

If critical thinking can be learned to any degree (and I suspect that it can) how do you teach it, and how do you measure the effectiveness of the teaching?

If you ask "What is critical thinking", you're sure to get a variety of similar (yet somewhat vague) answers...although there are certain phrases that tend to come up frequently. One of these is the "application of logic".

Logic, no doubt, plays an important role in critical thinking, but might be (I suspect), the hardest to teach. It occurs to me that teaching critical thinking, requires critical thinking, and where teaching the application of logic may be difficult, it is central to the act of critical thinking and therefore worthy of any energy expended on its behalf.

To this end, I will attempt to find any exercise in logic, and make them available to my students and perhaps come up with a way to measure their success.

Watch this blog for my progress.

Should I make teaching materials for the 840?

2009-07-06T16:27:00.000-07:00

My goal for making educational videos and other materials was primarily to educate the staff and students in the facility in which I am the "Clinical Education Supervisor" (Note: I am not, however, the RT educator. This is David R. Barton BA RRT RCP).

I like the way I teach, and rather than go over important concepts again and again I created useful materials to help teach. My hospital won't allow video websites but YouTube hosts the videos for free. I'm glad that others find the materials useful.

Yesterday I had a request by email to create something for the 840, and this is not the first request of this kind. In order to do this, however, I'll need a source of funding to compensate me for my time, (since this does not benefit my current staff or students I can't do it while I'm at work).

How do I get paid? Do I make materials for sale on a web site to subscribers, or, better yet, receive a grant and make it "Open Source" and available to everyone.

I'd rather do the latter, and so I'll make some inquiries about possible grant money.

Wednesday thru Thrusday at TSRC

2009-07-06T16:08:00.000-07:00

Why so late blogging information about the TSRC? See below for excuses:

I was busy being the Audio/Visual volunteer during the Conference; and I learned you can't do two jobs at once (it was difficult to do ONE job when there's four rooms to worry about!)
I failed in my quest to blog directly from my I-phone....text worked, but not pics. Being a visual person I felt the posts would be to bland without images.
The holiday kept me busy until now.

What can I remember about the TSRC conference? Other than the usual excellent speakers...

The "Sputum Bowl" (quiz bowl competition for RT) winners were: Tarrant County Junior College for the 2nd year in a row (although a different team). The winning practitioner team (by default...no other practitioner teams competed?!) was from Medical City Dallas Hospital: David Barton, Sue Young, & David Gibson (yes, me). Now it's on to San Antonio for the National Competition in December.

Texas Sleep Conference

2009-06-30T11:16:00.001-07:00

The first day of the TSRC Convention is the "Texas Sleep Conference".

There has been a change in the speaker line-up:

First, Tammy Hardin RRT spoke on "CVD/BiLevel PAP Titration".

Now, Dr. Alfred Maksoud is speaking...
More to come including pics.

Update:

One of the scheduled speakers, Dr. Moss, was not able to make it, so Dr. Maksoud was kind enough to stay and give another lecture. He's an excellent speaker so the audience is not upset with the change.

One more lecture to go, then it's off to the dealers exhibit room. I'll post something from there later.

One last thing, if you would like to add content to this blog, email it to me...the link to my email is to the right.

2009-06-26T13:09:00.000-07:00

next week:
Texas Society for Respiratory Care's Annual Meeting
and convention.

I'll be unofficially live blogging from the convention. Come back to this web site to see all the action.

Official link:
http://www.tsrc.org/annual_meeting.asp

I'm back on Facebook but a warning...

2009-06-26T05:23:00.000-07:00

Anyone new to Facebook should know this: don't supply your personal email password if you don't want Facebook to spam your entire contact list with the message: "[Your Name] wants you to join Facebook".

Some people will hate you for this!

Here's the screen capture:

I've Abandoned my Facebook Account

2009-06-24T11:27:00.000-07:00

First it was the useless fad: "Twitter". Deleted!

Now Facebook's turn. Not that I didn't find some functions usefull...staying in touch with family that's out-of-town, for example.

What I didn't like though, is the way they trick you into giving Facebook access to your email account. Then...like a virus.... Facebook sends all your contacts "invitations" to join Facebook as if YOU sent it to them.

Some people, like my boss, hates this.

I think I'll join again, but this time, with what I now know, be very careful to:
1) Use an alias, but that is familar to my family and close friends.
2) Deselect/Block all the annoying stuff.
3) Use Greasemonkey's add on for Mozilla to protect my privacy and block ads.
4) Avoid the Noid.

Get your life back from Facebook

2009-06-15T14:35:00.001-07:00

Ok, I've been on Facebook a month and It's time to carefully analyze whether it's is worth my time. To sort through my impressions, I wrote this article: "Get your life back from Facebook."

Yes, I have acquired a somewhat negative feeling about Facebook, and it's not just because Facebook posted to my blog without permission with follwing message: "David wants you to join Facebook", complete with a Facebook graphical interface and links.

Apperently, in order to have Facebook stop doing this, I need to "unsubscribe" from something or some function I had no idea even existed.

In spite of my irritation, Yes there's a possibility Facebook can be useful...but not the way we're doing it. Here's what you need to do to get your life back:

1) Leave the past where it is. For certain past events, and people of which we are/were fond, we have an idealized notion. Unfortunately, Facebook sometimes destroys this fondness...for example the friend who you now can't stomach because of his rabid political views. Also, I would like to be remembered as that "Greek God" (yea right!) and not the aging, balding, fat, opininated guy we have now.

2) Am I really friends with ninety people? How many of those friends want me to call 'em up and see how it's going? Maybe some, not ninety.

Now here comes the advice section: Don't be afraid to prune this wild tree! Maybe the criteria for exclusion should be this: if the Facebook friend would think think it odd that you called them up on the telephone, then, perhaps you don't need to know their most private (Facebook) feelings...."gosh, work was tiring today, I think I'll have a couple dozen frozen margaritas!"

3) Facebook is pretty invasive of your privacy, sending invitations to take part in ridiculous time wasters to your "friends", even though you may not be aware that it is doing so..."Does my elderly aunt Martha really want to join her gang in 'Mafia Wars'. (Note: I may be wrong about facebook misrepresenting itself as if it was you, but I don't think so, say so in the comments if you think this is or is not happening).

4) Finally, Facebook is a good tool for family and close friends, but when you include aquantinces, and co-workers (even though you may like them a lot) it becomes too much.

Simplify your life.

Give 'em your non-facebook information they'll email or call if something important happens!

Thank you wasting your time by reading to the end of my rant!

David

This Blog is changing again...

2009-06-01T14:32:00.000-07:00

Now that the event is over, this blog will change to a forum for Respiratory Therapy Educational materials of interest to RT's and RT students.

David

2009-04-13T11:47:00.000-07:00

RRT Focused Workshop
Saturday May 30, 2009 9am-5pm

$20 HCA Employees, CCCCD students, ATI students
$60 All others

Location: "City Hall", 2nd Floor "E" Bldg.

Selected Topics:

Advanced Oxygenation
Reading the CXR
Hemodynamics
Attacking the Clinical Simulation
Pleural Drainage systems: Chest Tubes

June 1, 2009 UPDATE: The Seminar is over and it was a complete success: many CEUs were awared, candidates were helped with materials for the RRT exam, and funds were raised for the March of Dimes. If you participated, Thanks! If you didn't, hope to see you at the next event!

Save the date: The location and date has been decided...

2009-04-06T11:06:00.001-07:00

Preliminary:

What: Respiratory Care Education Workshop
When: Sat. May 30, 2009 9:00AM to 4:00PM (time subject to change)
Who: Given by staff educators at MCDH. Target audience: Students and staff.
Why: To educate students and others interested in taking the RRT Exam
How: Multimedia presentation covering a wide variety of respiratory topics (TBA).
Also: The charge for this presentation will be a donation to the March of Dimes.

Cost: $75.00 for non members

This presentation is targeted to individuals interested in taking the NBRC's RRT written exam and clinical simulation. Unlike a comprehensive review (like Kettering Seminars), we are offering indepth examination on a variety of hard-to-understand topics like PFT's or Hemodynamics. In fact, the topics offered are those that YOU want to know about!

Keep track with the planning of this seminar as it develops through this blog.

This Blog has changed....

2009-04-06T11:03:00.001-07:00

This blog has been transformed from "Live Blogging from the 54th Annual Respiratory Congress" to "Respiratory Care Education Workshop" in preparation for the upcoming event.

Details to follow.

You want to nebulize what?

2008-12-15T14:36:00.001-08:00

Speaker: Brian K. Walsh RRT-NPS RPFT, Boston, MA
Remember inhaled insulin? Although it offered close to if not equivocal efficacy to injection it was a failure. Why? Some reasons: not recommended for patients who have lung disease. It may have caused cancer in rats. It was finally discontinued because of of disuse.

Obviously not every substance can/will be nebulized will be accepted or be successful. What are some of the factors to consider when nebulizing a drug:

The pH of the lung is 7.8.
There is an increase not only is there a mucus viscosity and amount with more acidic lung, but also decrease mucociliary clearance, finally there is a impaired transport of albuterol with the acidic lung.

Particle size: Adults only receive 5-30% of inhaled medication even if particle size is “just right”. However, Should we have a different nebulizer for every goal?

Off label use: 60% of what we nebulized has never been approved for that use. What if the dose is wrong?

What is safe to inhale? Needs to be isotonic, sterile, and have appropriate pH. Believe or not, Albuterol pH is 3.5! This may need to change. Mucomyst has a 7 pH.

Hypertonic solutions are popular recently. It seems to improve FEV1, clearance, and exacerbations although it causes coughing, and tastes bad. Mannitol might be just as good as a hypertontic solution.

Why not raise the pH of drugs? It lowers the shelf life and also potentially raises the risk of infection.

Cost, reimbursement, and our attitudes are all factors that affect what is nebulized. To determine best practice, we need more RT researchers. Shockingly, 80% of what we do has not been proven effective despite our talk about “evidence based medicine”.

High dose albuterol: NAEPP does not recommend more than 15mg/hr of continuous Albuterol. There is some studies that support the use of high dose albuterol.

Pulmozyme vs. Mucomyst vs. Bicarb: Pulmozyme is approved as a mucolytic for CF, Mucomyst is approved as a mucolytic, HCO3 (Bicab) is still used and may reduce viscosity through aklinization of sputum. Why did HCO3 fall out of favor? 2% is probably safe and may positively affect peak flows in asthma. The speaker believes in the use of acetylcistine (Mucomyst) in treatment of thick mucus.

Recommendations: Follow good protocols, toleration is not acceptance, and old does not mean obsolete. Weigh risks and benefits as a patient advocate.

Sent from my iPhone

Asthma Therapy in 2018

2008-12-15T13:45:00.001-08:00

Speaker: Bruce K. Rubin MEngr, MD, MBA, FRCPC

Excerpts from the lecture:

New inhaled corticosteroids (ICS) are being developed for the treatment of asthma. They are longer acting, easier to take, fewer side effects. Cost, however, continues to be a concern.

Is the long acting beta-agonist safe? In a study (Smart study) there was an increase in death, particularly in the African-American population when using salmeterol. It is speculated that this may not be the fault of the drug but other factors such as compliance, availability of healthcare, availability of this [costly] drug, and appropriate follow-up of patients receiving asthma care.

About leukotriene receptor antagonists:

Good as an alternative therapy for mild asthma, not recommended in guidelines for persistent asthma or uncontrolled asthma, not as effective as ICS, poor synergy with ICS. Virally triggered asthma may follow the luekotriene pathway, and these drugs may show benefit. Some patients will do great with drugs like Singular.

Fact: people that die of asthma have severely reduced surfactant, but also an increase in neutrophils (perhaps available anti-neutorphilic agents are indicted). For further reading, see neutophilic inflammation.

Also interesting is that early exposure to antigens is associated with lower rates of asthma. Such as children that grow up with a barn attached to the house that have lower rates of asthma. There may be a drugs developed that helps prevent asthma through this mechanism.

About Xolair (Omalizumab): For patients that can not not be controlled with high dose steroids. Very expensive. May inhibit Eosinophils?

Antimicrobials such as macrolides (erythromycin) may play a significant role in treatment of asthma.

Monoclonal antibodies against TNF-a (also associated with neutrophils) may be a reasonable option in treatment of severe asthma.

Over the next 10 years several new drugs are coming to treat asthma. Such as those mentioned above.

PDE4 inhibitor “Daxas” (a phosphodiesterase inhibitor specialized to block inflammation response) has been released for treatment of COPD.

Mucus in Asthma: there is significant mucus plugging in individuals that died of asthma, and the type of mucus is unfortunately very viscous. Neurokinins, a new type of drug, may be a treatment in the future for this.

Strangely, heat delivered by bronchoscopy is being studied to reduce smooth muscle hypertrophy seen in asthma. “Bronchial Barbecue” as Dr. Rubin called it. The study is showing promise.

Lots of new medications are on the horizon. RT's are uniquely suited to keep up with and deliver eduction on these developments.

[Note from author, I will try to ask Dr. Rubin to read my blog and correct me where he feels it is appropriate, as there was a lot of complex information in a shot time period]

Sent from my iPhone

Assessing and Quantifying Lung Receitment

2008-12-15T12:31:00.001-08:00

Speaker: David A. Grooms RRT, Norfolk,VA

See Neiman Video here

Gary Neiman in NY came up with an interesting method to see lung recruitment in rat lung on video. Doing so, it is interesting to note various changes upon the visual appearance of inflation/deflation. Shown to the audience is a video of Alveolar Hyperinflation (Over stretching) compared to normal in the rat lung.

Regarding ARDS, displayed on a slide are regional difference in ventilation: Non dependent areas inflate easily, mid areas have small airway collapse, dependent areas show complete alveolar collapse. High levels of Peep did not always seem to affect collapse in dependent areas, as explained below.

There are two types of ARDS, extrapulmonary ARDS (like from trauma), and pulmonary ARDS like would happen in aspiration. Extrapulmonary ARDS responds to recruitment maneuvers by PEEP, long I-times, and other maneuvers. PEEP is generally needed around 10cmH2O or more.

In pulmonary ARDS recruitment potential is low, and there is not benefit beyond 8-10 of PEEP. But there is, however, a risk of over distension and resultant higher mortality.

Lower inflection point may be used initially to set PEEP. Recruitment will only occur if you exceed to closing pressure of the alveoli. Shown is a CT of lung recruitment during an inspiratory breath. A recruitment maneuver to brings the lung up to lung capacity (such as 40-45cmH2O held for some number of seconds). At high pressures recruitment occurs, and the PEEP would then be set at a higher level in order to maintain alveoli open.

Sent from my iPhone

Motivation - getting the most out of your staff.

2008-12-15T11:01:00.001-08:00

Speaker: Tiyonda Valentine Cook MS RRT
At Barnes Jewish hospital in St. Louis, a mentoring/motivation program was put into place that made an impact on retention, skill level, and job satisfaction.

This was done primarily by focusing on recognition, professional development, achievement, and reward.

There are 5 levels from novice to expert. "Competent" is is the middle and is considered the minimum level for clinical practice. Competent, Proficient, and Expert are the top three and are assigned RCP I, RCP II, & RCP III.

Levels I-III are compensated-
Rcp-I is considered "competent". Rcp-III "Expert" is highest compensation and requires a number of outside activities, like presenting, writing papers, involvement in projects and committees as well as community activities (like health fairs), etc...
20% of the eligible RRTs will rise to that level this year. Staff must reapply for this level each year.

Desire for professional achievement was the primary motivator for moving up. Monetary gain was the second motivator, surprisingly.

Barnes has seen increased retention, engagement and involvement, by the staff since inception of the program. The staff also felt these changes positively impacted patient care.

Another key part of the plan is for the staff to motivator each other so that it is self-propagating. Also, it is important for supervisors and management to understand and keep track of what motivates the people.

In closing, staff feel like this program is making not only individuals but the team stronger. This is a win/win for the department and the patients that they serve.

Sent from my iPhone

Mentoring - Douglas Laher.RRT, MBA

2008-12-15T10:21:00.000-08:00

I caught just the end of Laher lecture to document his seven points:

Attitude
Balance
Technique
Accuracy
Timing
Speed
Power

Mr. Lahler imparted that if you wish to speak at the AARC national convention then you should consider participating in the "RC Idol". Which is: practice a modified version of a talk that you would like to give at nationals, your presentation will be judged, and if accepted, you will be asked to speak at the national convention. A great way to "get your feet wet".

Sent from my iPhone

Finding Best PEEP

2008-12-14T14:05:00.001-08:00

Speakers: Dr. Dean Hess, Dr. Ira Cheifetz

Hess:
Studies show that low tidal volume high Peep has lower mortality than high tidal volume low peep, but, as it turns out, it's the lower tidal volume that seems to make the most difference.

Use 6 ml/kg (ideal weight).

Higher levels of Peep does not not necessarily improve mortality put possibly better lung function, and enhanced weaning - but only with certain peep strategy (French study).

When should higher peep be used? Higher peep is more likely to help with atelectasis than consolidation. Be sure not to over distend with high Vt in either case. Look for recruitability, to indicate a condition which requires higher peep.

Test "recruitability" by testing (before/after) compliance after adding peep for 30 minutes. Use dead space formula and P/F ratios help determine best peep as well.

The use of the Pressure-volume curve to set peep is not currently popular and for good reason as the machine may not accurately represent the patient.

Also, It is difficult to determine the real inflection points. May require an esophageal balloon.

A better way may be observation of pressure waveform, see: "Stress index" (don't want concavity on the pressure scalar during volume delivery--want linearity) may be better for finding best peep than ARDS net reccomendations.

8-15 peep is probably best for patients with ALI. More or less may be harmful.

Cheifetz:

The potential downside of peep is that PPV can decrease cardiac output (Q) by decreasing venous return.

PVR can be increased if peep not optimal (high or low).

PaO2 alone can not be used to determine best peep because although O2 may improve, Q may drop, and O2 delivery will drop with it.

Setting peep is no doubt a very complex issue and many factors need to be taken into account for the cost/benefit of this therapeutic option.

Sent from my iPhone

Is thirty-four Stethoscopes Better than One?

2008-12-14T12:42:00.000-08:00

GE Healthcare is promoting this new technology that uses two arrays with a thirty-four mini stethoscope to non-invasively and easily detect the distribution of ventilation of the lungs. After achieving a baseline (black and white video that almost looks like a V/Q scan) you can see inflation an deflation in real time, you can repeat after interventions like: lung recruitment, PEEP, etc... Apparently this is being studied and literature (he is going to send me) exists as to the value of this diagnostic approach. Cool.

Dealer Room

2008-12-14T12:29:00.000-08:00

My second trip through the exhibitor hall and I have some things to report:

Massimo - Must see their non-invasive monitoring. Improved pulse oximetry and Hb. I have video I can put up later. Great party they put on last night at the House of Blues.

Phillips/Respironics - new mask, I got to try it out (see picture). I'm going to try to wear it tonight with my Resmed CPAP machine. I like what I see so far, I'll try to review it later.

GE Healthcare has a cool technolgy that deserves its on post (see above).

Maquet - NAVA - Neurally adjusted ventilatory assist. Improves patient ventilator synchrony, and response time I think is the claim. The have a nice presentation on it. I'll try to learn more.

Ikaria - Now owns Inotherapeutics (Nitric Oxide) has new machines that they claim are easier to use and calibrate....I hope we get them.

That's all for now.

We now resume our our regular program...

2008-12-14T11:14:00.001-08:00

We're out, but it was fantastic.. Losing to the very capable Wisconsin team, we are done with sputum bowl for this year. We set out to have a good time--mission accomplished. Good luck to the remaining competitors!

Sent from my iPhone

Sorry, no. Video yet

2008-12-14T08:44:00.001-08:00

Video has proven to be difficult. The problem is getting the video from my IPhone to my laptop for editing.

I don't know if there is a way to upload video from IPhone to the blog. Using different equip sure, but the whole point of this experiment is to see if it could be done easily with the equipment I had.

The problem is that I would have to pay another $13/day to WiFi from my phone. The convention center charges too.

I guess the video I take will have until I get back into free WiFi range!

Sent from my iPhone

2015 Initiative - Dr. Charles Durbin

2008-12-13T16:26:00.001-08:00

What are the internal and external factors that will change the direction of Respiratory Therapy? Changes in reimbursement as well as changes in coverage. The increase in the number of individuals diagnosed with lung disease. The use of home care and improved use of informational technology. Are just some of the factors that will affect our profession.

Other questions include: what initiatives will lawmakers and a new administration take on?

It appears that new types of educational delivery to patients and practitioners will become more important (like what I am trying to take on with this blog!)

One things for sure, in the short run, at least, RT's job is more important and secure than ever! Of course, it's good time to be in healthcare with all of the economic woes.

We are certainely lucky that The AARC is at the forefront of navigating this unfamiliar white water ahead.

In summary, RT's must keep pace with all these changes (such as changes/improvements in skill sets) to come out stronger in the near future.

I believe, as you do, that a stronger RT profession is good for our (increasing) number of patients. We can, and will change--as Dr. Durbin points out, it wasn't that long ago we were " pushing oxygen tanks".

UPDATE: Dr. Durbin offered to send me his slides so that I could cover the story more completely and accurately. I'll make another post when I get these.

Sent from my iPhone

Hess Lecture

2008-12-13T15:58:00.001-08:00

Improving ventilator patient synchrony requires carefull assessment of the patient's clinical presentation. Waveform analysis is one way to examine the need for changes such as a change in mode, flow dynamics, pressure support level, and even PEEP.

One point that Dr. Hess made, and I hope that I am not inaccurately representing it, is that not only can and should auto peep be measured, but that set peep should be used to diminish the amount--take the place of--of that auto peep. I've heard this before, but it was interesting to hear Dr. Hess' explanation of why.

This topic got me thinking of the tendency of us RT's to set parameters--like flow at 60 L/M--and never change it even though a change in flow might improve patient comfort and even mean the use of less sedation. Is this laziness, inattention, lack of knowledge, or some other reason?

Whatever it is, my experience shows that more can be done, and Dr. Hess is helping by sharing his vast knowledge on the subject.

Sent from my iPhone

Fellows from Norway

2008-12-13T11:07:00.001-08:00

Dr. Sigurd Aarrestad and Heidi Markussen are international fellows sponsored by the AARC to visit Dallas/Ft. Worth, Cleveland, and now Anaheim. Respiratory Manager Chad Martin (Medical City Dallas Hospital) acted as host and tour guide while the pair was in Dallas/Ft. Worth, and saw to it that the duo enjoyed themselves--which I think they did.

I was lucky enough the accompany the trio on an outing to Ft. Worth and was fortunate enough to share ideas with a a couple of professionals from a county that boasts the highest of all countries in the human development index (wikipedia). I'm sure Chad would say that hosting fellows is an emmensely rewarding experience.

Pictured is Rick, Sigurd, Chad, & Heidi.

Opening Ceremonies

2008-12-13T10:01:00.001-08:00

Sam Giordano, CEO of the AARC, just delivered a fitting tribute to one of my favorite authors who passed away this year Barry Shapiro MD.

I fond his texts on clinical respiratory therapy to be invaluable in the bedside care of the Respiratory patient. Still as relevant now as when he wrote it years ago.

Among the many receiving awards is my friend and colleague Dr. Kathy Jones Boggs Rye for the Education Specialty Practitioner of the year! Sorry the pic didn't come out. Congratulations to Dr. Rye for her distinguished efforts.

Pictured: Sam Giordano, and a slide showing Barry Shapiro MD

We have arrived

2008-12-12T16:17:00.000-08:00

Waiting on super shuttle is me, Rick Plunk, Carolyn Turner, Sue Young, David Barton, Chad Martin. Our "sputum bowl" team is me, Sue, & David.

Sent from my iPhone

Pre-convention blogging

2008-12-11T15:05:00.000-08:00

If you've been here before, you've probaly noticed that all the test posts have been removed in preparation for "go live" tomorrow. This is a good time to explain the purpose of this forum.

Although this is called a "Live" blog, that's really a misnomer as there is no live feeds as the name implies. Rather, this is a forum to document events as soon after they unfold as possible. The name was borrowed the from the polical blogoshpere, where the interpretation of events could be discussed almost as soon as the event occured.

Ideally, there would be many "live" bloggers covering the same event. Possibly discussing, in blogosphere, the interpretation of material presented at the same lecture. Readers would be then be free to continue the discussion in a comments section added to each post. Ideally, bloggers would not only link to each other buy refer to each others posts...thus a blog community.

Sure beats the days of trying to regurgitate what I learned at the convention for the staff that couldn't go days or weeks after the event.

Now everyone can benefit.