1985: The flow of 7-Goodman

I wrote in my journal on my second day at National Jewish that "the only thing that makes this place seem like a hospital are that the nurses and doctors wear stethoscopes over their shoulders."  The seemed to have gone out of their way to make our stay at the asthma hospital as much like home as possible.  

Our day was highly structured, and I'm confident the reason for this was to keep us busy so we didn't get homesick and so we didn't get into trouble.  I remember being homesick quite a bit the first week, but there was so much to do there was little time to think about it.  And before you knew it, you were so comfortable around the place, with the people, that it was as much as home as your home was.  

Most of our morning medicines were due at 6:00, and we had a half hour leeway.  That meant we had to take our medicine between 5:30 and 6:30.  The first day I woke up at 6:00 and had to wait in line for the nebulizer, and I got into trouble because I didn't get my treatment finished before the deadline.  

Plus I was a little nervous around all the kids, most of whom I didn't know yet, so I opted from then on out to get up at 5:30.  This turned out to be great, because it was just me and one other kid who got up that early.  It also allowed me time to get to know the night shift nurses, one of whom was Pat, who would later become a major asset for me.  

Then breakfast came.  There was no TV in the main lounge room of 7-Goodman, so if you wanted to watch TV you had to go into the south room.  Most of the kids didn't go into the TV room before school, and I was one of them.  As soon as I was done with breakfast I left for school.  One of the rules of 7-Goodman is any time you leave the floor you had to sign out, and we had the "buddy system" rule:  you had to go with someone.  

I had to follow this rule because I was on the bottom level, level one, of the behavioral chart, because all new patients had to start there.  Once I made my way to level four I could be a leader, and I could sign out and go places myself.  That was one of the incentives of good behavior.  Once I made my way to level four I was one of the kids sought out when one of the newer kids wanted to leave 7-Goodman.

So we went to school and traveled through the tunnels under the campus.  The Kunsburg school was in another building, but thanks to the tunnel we never had to go outside.  Although we could go outside if we wanted, so long as we didn't leave the campus.  I think it was around February it got so cold, a blizzard struck, that we were ordered not to go outside  This was because cold air is a major contributor to asthma.  

After school we had free time.  This was when we sat around the tables in the lounge and did homework.  I usually took this time to sit in my room and write in my journal.  Okay, so I used some of it to do homework, although I wasn't the most disciplined person with my homework.  However, as time went on Mr. Rose spent a lot of time working with me during school hours, and I ended up getting all As on my last report card for the year.  That was something I did only once before, and it was in the sixth grade, and only because Mr. Anderson spend a lot of time with me.  

Of course there were other things we could do.  We could watch TV in the TV room.  We could play pool.  We could socialize (something I wasn't good at and still am still not).  Or we could scuffle, something that didn't elude me.  

Around 5:00 p.m. it was dinner time.  I remember sitting around some evenings starving and waiting for dinner to arrive.  And most of the meals were pretty good. Earlier in the week the nurses usually sat down with us and let us pick what we wanted for each meal during the weak.  Sometimes I didn't like any of the choices, but most of the time it was pretty good.  

Oh, and of course we had to remember when our medicine was due and go to the nurses station.  I supposed the nurses station was the only other thing in here that made the place look like a hospital.  Yet the nurses were very friendly, so that kind of offset the setting.  

Most of the patients didn't like Lee, but I really liked her. She was a nurse who was really strict, although she loved to give hugs.  I think I liked that she was strict, and I really enjoyed her as my nurse.  I guess I just needed that.  And boy did I love her hugs.  I remember the three biggest hugs she ever gave were when I was lonely after my mom left, when I was supposed to go to 2-May, and when I was going home.  Of all the nurses I thought I'd miss, Lee was one of them.  

My nurse was Kathy.  She's the one who sat down with me to make a list of my medicine and added the new ones and crossed off the old ones.  She created a list of all these and what times they are due.  It was her job to make sure I took my medicine.  It was her job to make sure I understood all my medicine.  She created a variety of note cards, and on each one she listed: the medicine, brand name, generic name, side effects, action, doses, frequency, and why I was taking it.  It was my job to memorize all of them.  My incentive was a trip to Dairy Queen, compliments of her.  

After dinner we had free time again until about 6:30 or 7:00 when we had to go back to the school and to either the gym or the pool.  In the gym we started with stretches, and then 20 minutes of aerobics.  We were encouraged to keep our legs moving, no matter what activity we did, whether it was basketball, volley ball, kick ball, or whatever else we did.  After aerobics were played a game of something, if that game wasn't incorporated into the aerobics session.  

On other days we went to the pool and had a vigorous workout.  We were told that pools were the ideal place for asthmatics to exercise because you could get a workout just my trudging through the water.  I remember one of the activities we did for aerobics was race back and forth, and I always lost because I was among the smallest kids.  Although I was always worn out by the end.  

At first my asthma would act up during aerobic activities, although as my asthma got under better control I was able to participate more freely.  Although I was encouraged to pace myself, I was scolded if I didn't work hard enough.  They pushed you to the limits regardless of how bad your asthma was, and excuses were never excepted.  However, they also made sure you took a time out when your asthma was acting up.  

We walked down the tunnels back to 7-Goodman, usually too worn out and tired to complain.  Back on 7-Goodman we took our nighttime medicines and then we had free time until bedtime.  I think bedtime was 9 or 9:30 unless you were on the higher levels, than I think it was 10:00.  This was a time that we participated in various activities, which included playing games with the nurses.  They would take time out from their busy schedule to play games.  One common one we played was spoons.  I can't remember how to play this game, but I know it sure was fun.  

Another thing the nurses did was stage activities for us.  I remember some of the kids participated in an talent contest, and the girls sang, "Girls just wanna have fun."  They were good, and I had no choice but to vote for them even though I was cheering for the guys.  The nurses also held an occasional meeting where officers were chosen.  I remember one time I ran for president, and lost in a close election.  Because I lost I have no idea what the role of officers was, beside representing us kids when rules and discipline was made.  

Then it was time for either studying, TV or bed.  I remember sitting in the TV room with Tim.  He was my best friend while I was on 7-Goodman.  He was 18, and he loved science fiction.  One of the shows we watched most often were old episodes of Dr. Who, or any old TV show.  He knew all the old actors, and perhaps it was him who got me interested in movies and such.  We also sat around and played chess, and he beat me nearly every game.  He was pretty smart  

I don't know what ever came of him.  I remember on the way to an out of town adventure, on the bus, I sat next to him, and listened to him tell of his dreams for his life.  He said that he was working on the fourth Star Wars movie.  He had the story all worked out in his head.  Plus there as another movie had made up in his head that he told me about.  I'll have to look it up and write it down here.  I Googled that movie recently, and never found it.  I also looked in the credits of the fourth episode of Star Wars to see if I could find his name.  I never found it.  

The first two weeks on seven Goodman were the busiest, as this was when you had to go for all the testing, and meet your social worker, psychologist, and all the other people who do all the tests. Of course you also had to meet all the nurses, PE instructors, nurses assistants (like Pat on nights) and all the asthmatic kids.  After that you started to feel more comfortable, and the place started to feel more like home.  Tests were less often, and you could be a normal kid doing normal things.  

I remember I would leave 7-Goodman at times to go walking around with my friend Dean.  We were both good Christians, so we looked for a church.  We were told there was one somewhere on campus.  We also looked for a workout room, considering we were on steroids we might as well work out.  

At some point I had to sell tickets for something.  Later on in life, and perhaps before 7-Goodman, this was something I'd hate to do.  But at the asthma hospital it allowed me an excuse to get away.  It gave me something to do.  I don't remember what the tickets were for, but I remember one of the places I made my way to was the adult section of the hospital.  I remember spending time with the nurses there, and they made me feel really comfortable.  So later on I would make special trips just to visit them.  Sometimes, if they were slow, we would play games.

There were a couple patients there, both on oxygen.  As I look back I think they were COPD patients, the same type of patient I take care of today.  I got to know them really well, and I would often travel down to (was it 7-Goodman or 3-Goodman) visit them.  I remember that every time I'd walk into their rooms they would smile.  They loved to see me.  Whenever I was feeling sad I would go to visit them and every time I'd leave in a better mood.  

References:

1. Frea, Rick, "My Stay at National Jewish Hospital, "1985, Denver, Colorado

20 years later I realize my dad was right about asthma dyspnea

When I was about 18 I became very winded after playing a game of basketball.  I sat down on a chair next to my dad, leaned forward with my palms resting on my knees to keep my shoulders high to breathe, and I said, "I'm out of shape."  My dad, being the sound and reasonable man he is, said, "You are not out of shape; you have asthma."

"Dad," I said, once I caught my breath.  "I'm this way because I haven't exercised in a while."

He said, "I never exercise, and I don't get that winded.  You're that way because you have asthma."

Now, let's fast forward to 2012.  I'm really out of shape now, and I feel like a fat, bloated pig sometimes.  When I get this way I almost always feel dyspneic to some degree.  I, therefore, blamed my asthma on being out of shape.  In other words, I completely forgot what my dad had said.

Last weekend, however, my asthma got really bad, and I needed to be placed on systemic steroids.  Now that they have kicked in and I am still on a high dose, I am still out of shape, and I do not feel dyspneic all the time.  It was sitting around thinking of this that I remembered what my dad said: "You are not out of shape; you have asthma."

It took over 20 years for what my dad said 20 years ago to sink in.  All these years I've been exercising just so I could breathe better.  When I was in good shape, I breathed good.  When I was not in good shape, my breathing got bad. But my dad's point was that I shouldn't have to exercise just to breathe normal; your breathing should always be normal. 

Talking to a great asthmatic friend (Mr. (Dr.)Stephen Gaudet, he reminded me that the reason that I'm probably a little short of breath all the time is because I have bronchospasm and air trapping in the smallest air passages probably all the time.  For this reason, my steroid inhalers can't get that deep to help get rid of this inflammation.  For this reason, my peak flows, even my PFTs, can be relatively normal even when I feel mildly short of breath.

The reason I'm thinking of this now is that I'm just as out of shape today as I was last week when I started getting sick.  I am not dyspniec with any bit of exertion, thinking I'm that way due to being out of shape.  Instead, I just feel normal.  Now, surely I still get short of breath every few hours and require my rescue medicine, but I do not, at present, feel out of shape out of breath (have I lost you yet?)

Now, even though I have not done one iota of exercise the past week, I do not feel out of shape dyspnea, even to a light degree, with exertion.  I go up and down stairs, and I feel fine.  I run a short distance, and I feel fine.  My asthma might act up a bit at times, but I don't feel that out of shape dyspnea. 

So was my dad right?  I'm thinking that he was.  He's not even a medical person, and he figured that out way over 20 years ago.  I guess the reason I denied his brilliant idea was because I have never lived a day in my life with normal lungs, in shape or out of shape, and my dad has.  My dad is one of those lucky guys who has smoked his entire life, and has managed to breathe easy his entire life.  Great man he is.

I'm not worried about my dad's ego going up a notch because he's ego free as I am. 

1689-1970: The slow death of a killer called Consumption

By 1880 a few physicians suspected tuberculosis to be contagious, but the idea was not rock solid in the medical community.  In fact, the idea had been brought up many times, perhaps the first time as bar back as the ancient Greeks (1, page 16), and once again in 1020 by Avicenna.

Avicenna discovered the disease could spread through soil and water, and created quarantines to prevent the spread of the disease.  Yet despite this early success, progress as far as the disease tuberculosis was concerned was slow.  The disease continued to scare people until well into the 20th century.

The following are some of the major advancements that helped end the tuberculosis scare:

1. 1689 Dr. Richard Morton determined the pulmonary form was associated with tubercles in the lungs
2. 1696 Giorgio Baglivi observed the tuberculosis patients got better after a sword wound to the chest.  This was the first observation that a pneumothorax (collapsed lung) might benefit the progress of the disease and induce healing.
3. 1834:  F.H. Ramadge performed the first successful surgery where the lungs of a patient with TB were intentionally collapsed.  Ramadge did extensive research on TB, and even invented an inhaling pipe to treat the disease.
4. 1839 J.L. Schonlein, noting the tubercle, identified tuberculosis as a single disease
5. 1854 the first tuberculosis sanatorium was opened in Gorbersdorf, Germany (now in Poland) by Hermann Brehmer.
6. 1882 Robert Koch identified Mycobacterium tuberculosis.  He thought his glycerinie extract of the tubercle bacilli would be a remedy, but it wasn't.  However, it was later adapted as a test for TB.
7. In 1895 William Rontgen discovered the x-ray, and this allowed physicians to detect the disease early and monitor its progression
8. 1906 lbert Calmette and Camille Guérin in 1906 had success immunizing against a strain of tuberculosis.  They invented what they called the BCG vaccination and used it first in France.
9. 1930s Plombage Technique was trialed to remove infected part of lung.  The part of lung was forced to collapse, and was thought to heal quicker.  Some of these patients had their chest stuffed with ping pong balls or similar objects to prevent their chest from caving in.  There actually was success between the 30s and 50s until the antibiotic was proven to be more successful
10. 1944 Streptomycin discovered as an effective treatment for tuberculosis
11. 1952 Isoniazid invented as the first effective oral drug to treat TB
12. 1967 Rifampin was another antibiotic discovered to treat the disease, it was introduced to the market in the 1970s

All of these discoveries and inventions helped with the treatment of the disease, although it was studies of tuberculosis patients at sanatoriums like National Jewish Health in Denver, Colorado, that truly helped prove the disease was spread most by places associated with poor hygiene.  

Initial studies showed a high incidence of TB among sweat shops in New York and Chicago and similar occupations where there were crowds of people in places associated with poor hygiene.  Efforts were made to educate people of important positions, and laws were passed by cities, especially the New York legislature, forcing improved hygienic practices in public work places.

Major campaigns were begun to discourage people from spitting in public places.  Hand washing was encouraged.  People were encouraged wash and bathe often.  People were educated about the disease, and this, perhaps even more so than the TB test and the vaccine that was later invented, lead to the demise of the disease.

Another significant improvement was the sanatoriums that opened up all over the United States and Europe.  These allowed for the patients to get state of the art treatment, yet it also provided an opportunity to educate them that their disease is communicable, and easily spread to others.  They were educated to not spit in handkerchiefs that sat around.  Plus these sanatoriums kept the TB patients isolated from society, and this also helped prevent the spread of the disease.

All of this helped decrease the number of tuberculosis patients, and tuberculosis deaths, yet what was the true triumph was the discovery in 1946 of the antibiotic streptomycin.  Now there was an effective cure, or at least treatment, for the disease.  Yet still, to prevent the spread, a focus must remain on good hygiene.  This effort continues to this day. 

And the breath came back, with a little euphoria

As my readers know, I was back in the ER for asthma after 16 years of avoiding that place (as a patient). For about 24 hours that visit seemed to be doing the trick, when Sunday night came. My asthma got worse, to the point I was sitting up at 2 a.m. on Sunday night taking back to back to back ventolin treatments. I decided I had to go back to the ER. I decided I had to call work in the morning and call in sick for Tuesday. Yes, the decision was made. But....

... it was 2 a.m. My wife had been up with me the night before (because I was telling her I was getting worse), and she traveled all day with the kids to get shoes and clothes for school. She was beat, and sleeping sound. I, your humble RT, did not want to bother her. Hmmm, kind of reminds me when I was a kid and was kind to my parents during just about any of my nocturnal asthma attacks. But...

...'tis how I was made, caring more for others, even in my dyspneic state, than myself. So here I am, trying to sleep, body lifted up slightly by my right arm, under three pillows... yeah, if you've been there, you know what I'm talking about. I'm lying there, rolling over more than once, and am thinking that maybe I should sleep (not sleep) on the couch so I don't wake up my wife. My mind keeps wandering to what I'm going to tell my doctor when I see him for yet another unscheduled visit this year (asthma, blood pressure, sore feet, old age...). Yes, too bad my xanax has been used up. But...

... you know, sometimes miracles happen. Yes, it's kind of neat how that preasure barrier works on breathing. Was very sob Sunday about 2 a.m. thinking about going back to the ER -- knowing I HAD to go back to the ER, when somehow, miraculously, I became so exhausted (struggling mightely to get half a breath, that I fell asleep. I even dreamed an asthmatic dream. Then I woke up...

... it was around 3:30 a.m. A cool, refreshing pressure free breeze blew threw the window, and it was like... ahhhhhhhhh, I can breathe. It brings upon one of those post asthmatic attack euphoric moments. It's the most wonderful feeling in the world.

So, now I'm feeling just as bad as I felt the night I went to the ER, only now it feels so good, because it's better than how I was at 2 a.m. this Sunday morning. I certainly don't feel normal, although I did go to work today, Tuesday. I figured I'd take the easy assignment...

yeah, right! ER was swamped for my coworker, and I had four ventilators. However, when you work with great coworkers as I do, it's easy to work with asthma, taking the occasional breathing treatment in the RT supply room. Thankfully, however, those treatments were now only required every four hours (although I certainly was ready for them as they were inhaled). So, 'tis the life of your humble RT asthmatic. Later.

1932: The first use of the term 'Aerosol' x

Many asthmatics participate in what is sometimes referred to as Aerosol Therapy.  When you take a breathing treatment you are basically aerosolizing medicine so it can be inhaled.  While aerosols are present through history, the term wasn't used until the 1930s.

It was first used i 1932 by R. Whitlaw and and E. Gray Patterson.  The term is derived in the following manner (1, page 173):

• Aer = air
• sol = solution

In subsequent years various generic terms have also been used, which include the following (1, page 173, (2 page 5):

• Mist
• Micromist
• Fog
• Fume
• Spray
• Haze
• Smog

The term aerosol basically refers to "the suspension of a liquid or solid particle in a gaseous medium. The term originated as the gas phase analogue to hydrosols (meaning 'water particle' in Greek) and refers to suspension of particles in a liquid." (2, page 3)  Most "theories describing aerosol behavior assume the particles are spherical." (2, page 6)

Aerosolized particles generally average in size from barely larger than a molecule to as large as 100 micrograms.  Although for the purpose of aerosolized particles to reach the respiratory tract, the following is necessary (3):

1. Greater than 10 um deposits in the nose
2. Greater than 5 um deposits in the mouth
3. 5-10 um deposits in the first six generations of bronchi (large airways)
4. 1-5 um deposits in the last 5-6 generations 
5. 0.8-2 um are optimal for alveolar deposition

Particles smaller than 10 micrograms generally hold their contents well, so the medicine is not likely to be lost upon aeroslization.  (2, page 9)  It's for this reason respiratory medicine can be mixed together in the same solution.

References:

1. Korting, Monika Schafer, editor, "Drug Delivery," 2010, Germany, Springer-Verlag Berlin Heidelberg.  The reference used for this information is Aiche, 1990)  Although a more specific reference would be Whitlaw-Gray, R, and Patterson, H.S., in "Smoke: A Study of Aerial Disperse Systems," (Arnold, London, 1932), 192 pages
2. Kulkarni, Pramod, Paul A. Baron, Klaus Willeke, editors, "Aerosol Measurement: Principles, Techniques and Applications," 3rd edition, 2011, Wiley
3. Elliot, Deborah, Patrick Dunne, "A Guide to Aerosolized Drug Delivery," American Association of Respiratory Care, page 9.  I wrote about this at RT Cave as you can see here. 

Asthma update: 2 days after first ER visit in 16 years

So my wife woke up around 2 p.m., her late arousal due to her working 3rd shift last night, and she pokes her head into the garage where I'm sitting in a chair, watching both the Tigers on TV and my little tykes bounce in the bounce house, and play in the kiddie pool. 

She says, "So, how's your asthma?"

Me says, with a smile, "The same."

"Are you still taking Q1 hour treatments?"

"Yep." 

"So you're the asthma expert.  If you were giving yourself advice, what advice would you give?"

"Go back to the ER."

"So are you gonna?"

"Nope."

"Nope, hey?"

" I don't want to have to explain how my asthma isn't normal again, only to get lectured about how I shouldn't use my ventolin so often.  No thanks. Besides, I'm already on steroids, so what else can they do for me.  I'll just wait until Tuesday when (my Internist) will be in his office, and hope I can get in."

"So what are you gonna do?"

"Well, as you can see, I still cleaned the house and the garage."

"Yeah, looks nice."

"Thanks."

"Chez," she says, and closes the door.  

So that's my asthma update.  

The best part of my ER visit...

... was my respiratory therapist.  I knew Jenny was busy.  I saw her on my way back to fast track giving a treatment to a kid.  Turns out the kid was really sic.  Turns out she also had a trauma she had to get off in the ambulance.  Yet even as she explained this to me, noting that she was swamped, she did so with a smile, and she sat with me while she gave the treatment.  Her beeper went off several times during the treatment, and each time she grimace and groaned, although she did so with a smile.  As she left the room she jokingly offered me a sucker.  Perhaps this is a bias on my part, but I think my RT gave me better customer service, and with a smile, than any of the other people who took care of me that day.  Even though she was obviously busy, and rushed, she was cheerful and did a great job caring for me.