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Today I heard on CBC radio that patients are refusing blood transfusions because they don't want to be exposed to the COVID vaccines. My patience for these uniformed people is limited. How can medical professionals combat this kind of ignorance? 

There is a part of me that blames the medical community for the way it handled the pandemic. There were so many confusing guidelines and conflicting information that many people just lost any level of trust or respect for the "experts". 

The pandemic and the reactions of so many people so vigorously campaigning against the vaccine and the public health measures demonstrates the incredible distrust that many people have of science and government. I'm wonder if this may be a global example of how existential fear results in individus grasping to simplistic and conspiracy theory causes of all the problems in the world. Most of us need answers that we can understand and fit our view of the world.

So I am trying to understand these antivaxers and ultraright nationalist but its very difficult when these individuals feel no obligation to consider anyone else's views. In fact they resent me more because my trying to understand them suggests, correctly,  that I think they are either uniformed, idiots, or just simply self serving assholes. Which of course I do.

Al

The Mysteries of Mindmapping Revealed

The term mindmapping is maybe not very helpful as it invokes visions of large machines probing  into our heads trying to find out our innermost naked thoughts. In a way there is some truth to this view, less the machines, and the probing is more self directed but other than that there some obtuse similarities.

Mindmapping or creative capture is simply a way to quickly capture ideas or random thoughts in a way that allows you to grasp, organize, or visualize large complex problems. The traditional way to do this is on paper. A central concept is written in the middle and spiraling ideas or related elements are written randomly around the edges. The desired trends or ideas are then organized to give clarity and direction. This method works well with groups or individuals, with everything from developing advertising promotions to research methodology.

Now what I like is that computers can help us do this. There is a variety of software programs that run on regular computers and all the modern mobile devices. My personal favorites for a desktop / laptop computer is "X Mind" and "Freemind".  Both of these software products are powerful, quick to learn, extremely useful, and best of all, totally free! The tools that I have tried for mobiles have been much less satisfying but there is hope in products like "Big Fat Canvas"  which starts to mimic the pleasure and power of handwriting for mind mapping by offering unlimited zooming and area to freely explore a concept. This is a much different concept than the other computer based models but it offers an insight to where the technology may take us.

Mind mapping software can be a very effective way to manage large complex projects and come to grips with complex tasks. As a writer, teacher, and sometimes manager these tools have worked well for me. I can only suggest that as a computer user you should look into your brain and unleash your total creative capacity by mindmapping your next project or idea. Check them out, it costs you nothing.

Attitudes Matter

Maybe after all these years of teaching I am a little sensitive to the concept of attitudes as I have one as a teacher and so do students.

I tried a little experiment the other day. I asked the class to divide themselves into two groups. The first group I explained were experts in respiratory therapy and were teaching a student about PEEP and how to do PEEP studies on a patient. They were very busy but took the time to demonstrate the procedure, explain it to the student, and show them were the policy and procedure manual was for the procedure so they could study it.

The second group were also RT experts but they were now with the student the very next day and were going to discuss their learning and how help the student understand PEEP studies.

I, as the instructor, was the "student".

So I set it up that the second group were meeting me, the student, and they correctly were trying to determine what I needed to know and what they could help me with. They asked appropriate questions such as; What did you learn yesterday? What is your understanding of PEEP? Can you describe the steps to performing a PEEP study?

To all of these questions I stated that I did not know. That I didn't learn anything from my preceptor. I have no idea how to do or what a PEEP study is.

This is where it gets interesting. The second group, who are taking over the teaching, were quick to point out that the first instructor / preceptors must be a very poor teacher. It was almost unanimous in the group that the Preceptor needed more training and needed to learn how to be a more effective instructor.

I let this play out in a class as a discussion. As an instructor and preceptor I know this type of scenario often happens.  The class basically went on to describe how preceptors need more training. What I would like to put forward for consideration is were is the responsibility of the learner in this scenario. Why did the students not consider that the student who spent hours with a preceptor reviewing a procedure not be responsible for anything. How can they just state "They didn't teach me anything". Where is the personal responsibility for learning? Also I suspect that if I had been the preceptor spending time with the student and learned how they can offload the responsibility and basically blaming the instructor for their lack of involvement I think I, as their teacher, might be very insulted.

Attitudes matter and I suggest students consider taking responsibility and even if they don't understand or can't recall everything demonstrate a positive attitude by using comments like; I know we reviewed this yesterday but I'm still unclear of how to do the procedure. I'd like to review the policy and procedure again to refresh my mind and learn the procedure better know that I've seen it. Or even try: I know we went over this yesterday but I need more time to learn all the details, can you help me by demonstrating and explaining this again.

This sets up a positive learning environment where preceptors are supported and the needs of the student can be met. I have personally heard many time in the hospital students report to preceptors: They never taught us that! This blames the school and their teachers. Good preceptors know this is not true but you would be surprised at how often we get complaints from preceptors asking us why we don't teach effectively and the student's don't know anything. Informed preceptors know the student is just passing the buck. They now have a poor opinion of that student.

I suggest student demonstrate more responsible and positive attitudes.

Al

My 59th Year

And so I am once again confronted with my yearly reminder of mortality. Death draws closer and I notice the age of those in the obituaries and who's death make the news and I compare my age to theirs. Like all those before me I wonder the eternal questions, how much time do I have? Have I contributed anything to the world? Will anyone notice my passing? Have I been a good man?

On good days I have positive feelings about some elements of my life. On many days I feel that my efforts as an educator have been wasted. Students prefer the more sociable and socially capable members of our Faculty. My idiosyncrasies, over enthusiasm, and insecurities build a subtle but definite barrier between myself and effectiveness.

My true love of the outdoors and exploring the world around me seems selfish and indulgent when I look at so many others who struggle for the basics of life. I feel like a rich spoiled child. Okay maybe not rich.

I love my photographs. They speak to me but they are only my treasure, no one shares my joy of these images. It is like this blog, useful in it's reflective therapeutic exercise. Working my images is like working these words. It lets me pause and gain some perspective and the luxury of remembering.

It is with a true but harsh perspective that I see myself as the selfish, sometimes foolish, man who has been give two great gifts, a wonderful wife and a wonderful daughter. My only contribution to the world should be to help them and love them as best I can. If I can truly love that is enough.

And yet, that said, if I can get in a few more hikes, some sailing, and maybe drink a few more bottles of whisky that would be good too.

I guess there is still more living to do before I die. The glass is after all, half full, and I realize I'm still thirsty.

Al

Arterial Blood Gases

We as respiratory therapists are experts in arterial blood gas procurement and interpretation. This places a burden on students of the profession as their preceptors and instructors expect a high level of understanding and performance with regards to arterial blood gases (ABGs).

An approach that may get a novice started is to work on the initial classification system. To help with this there are many tools but the tradition of using HCO3, bicarbonate, as a basis of interpretation is often problematic in my opinion. An alternative is to focus on the base excess (BE) to guide the classification. Here is a link to my website where these free tools are offered, check out the "Resources for  Clinicians" (http://respiratory-education.usefedora.com/). I have also created a Google Play application that also guides you through the classification and also provides some insight into the pathology or patient conditions that would be potentially consistent with an ABG classification.

This leads me to the next level of ABG interpretation. A practitioner should be aware of how the ABG results aid to the understanding of the patient's condition and treatment plan. Clearly this takes time to develop this level of understanding and students will gain experience by studying cases, a patient's history and clinical situations.

So as a student where does this leave us? Well using the tools and becoming an expert in the mechanics of classification and relating that to pathologies is a good start. My suggestion would be then to work on the application of this knowledge and using one of the most fundamental rules that I believe should always be applied.

Never interpret an ABG without knowledge of the patient's condition and history at the time of the ABG.

I can highlight the critical nature of this with a simple example, a patient has an ABG with a PaO2 of 85, SO2 of 98%, PaCO2 of 40, pH of 7.40, HCO3 of 24, BE of 0. Often when presented with these ABG values a student will suggest the patient has no immediate problems, then when confronted with the facts that the patient is on a non-rebreathing mask and a respiratory rate of 28 b/min the view of the ABG changes.

Another aspect of an ABG that is often overlooked is an assessment of oxygenation. Examination of the PaO2 and SO2 is only part of the equation, oxygen delivery is the other critical component so hemoglobin and cardiac output are critical and leads to my next rule of ABG assessment.

Never interpret an ABG or the oxygenation status of a patient without knowledge of the hemoglobin and cardiac status of the patient.

With these two simple rules in mind and in practice a novice practitioner of the respiratory arts is well on their way to being an expert. An important aspect of the application of these rules is to always ask for the patient information and provide the critical information when discussing ABGs.

Introduction to Mechanical Ventilation

I have been an instructor of respiratory therapy for many years and the topic of mechanical ventilation is an absolute passion of mine for it is the one area of medicine where we as respiratory therapists should be the absolute experts. This fuels my passion and frustration.

My fortune is that I'm gifted with teaching the course RESP 266 Interventions 1 which includes the introduction of mechanical ventilation along with many other course elements. Thus my first concern is that we have diluted the topic and time we as students spend on the subject. A challenge and an obstacle. In years of teaching I've never heard of a instructor who would not proclaim that the time allotted to his subject is insufficient to do it justice. My goal is to see that justice is done! Regardless of the time.

Okay so what advice would I give to students embarking on this introduction? The answer is to play. Play with the ventilators and the tools supplied for the simple pleasure of discovery. Spend the time to discover the ventilator control interactions in both the lab and at home on your computers. The tools are there, ventilator calculators, examples of control interactions, lab time with ventilators and case studies. Play with all of these with enthusiasm and vigor and you will be rewarded with understanding and insight.

In my view lecture time is wasted time. Hearing about it is one thing experiencing it is the real thing.

My zeal for this topic has driven me to create some learning tools that I hope students will find useful. Years ago it was Virtual Ventilators, now I have distilled the essence of that experience and my teaching to offer videos and a synthesis of control interactions on my website; http://respiratory-education.usefedora.com/. I have to charge for the course "Control Interactions" to recover some of my expenses in development but I believe it is a valuable resource for students.

I guess we will see.

Opinions of Common Humans

Does the common human have anything relevant to say?

In a world where we are constantly exposed to instant information, though I suspect often erroneous or misleading, can the average person have anything but an ill informed opinion? I ask this because I suspect that most of us do not have the time or ability to collate the facts.

Maybe some of us can be knowledgeable about a few areas within our expertise of work or special interests but really how are we to have viable opinions on things like gun control or pipeline construction? Who and where do we turn to for reliable information?

As a common human I feel I can only ask these questions and be skeptical of all the proclaimed experts. My personal experience of financial and political experts is that their analysis is only correct after the facts. How many times have I heard on CBC Radio the financial expert explaining to me that I was paying over $1 / L for gas because of high demand and low supply? Then the next week the price of oil goes down and the price at the pump goes up.

As beacons of hope I take solace in the writings of authors like Malcolm Gladwell and Carl Sagan who seem to grasp the need to focus their genius and give us a glimmer of insight. My problem is I'm not sure how their works alter the course of the world or if anyone of influence is even listening.

Another situation that troubles me is that I seem to be surrounded by individuals who tout that they are entitled to their opinions and that their opinions are as valid as anyone's. Even if it's their believe in an obscure god or that global warming is a myth. No longer does it seem that there needs to be any supporting facts or critical analysis. It now seems like it's enough to just have the opinion? It is often touted, in my little world, that everyone's opinion deserves as much attention and respect as others. Thus the dilemma we face when zealots indignantly demand equal education on creation as evolution because they are both equally valid opinions.

Now I have just as many ill informed opinions as anyone but I would like to believe that I'm not so foolish as to believe I'm correct. The problem in my view is how is an average human suppose to vote or give input into majorly important issues? How can we build trust in our news and other media sources to give us the information we need? Who can we trust? Is it time for us to give up on the notion that the common human is entitled to contribute to the decision making process of important issues like global warming or the economy? Are politicians even capable of making these decisions?

I doubt that they are, but that's only my opinion.