WEANING FROM A VENTILATOR:MAJOR CHALLENGE

The purpose of this article is to assist loved ones, caregivers and ventilator patients themselves to understand the complexities of trying to wean off a ventilator. In order to accomplish this understanding we must first understand a few basic ideas.First let's start with the word ventilator. Many people refer to a ventilator as a respirator. In medicine we understand when people refer to the ventilator as a respirator. The difference is simply in the technical definition. A ventilator moves air from one place to another a respirator exchanges gases; such as the oxygen and carbon dioxide we exhale.People find themselves on ventilators for various reasons, but many utilize this intervention because of lung disease. In certain lung diseases the ability to exchange these gases is significantly altered. Because of this alteration the ventilator can assist the patients breathing but not reverse the lung disease process. Therefore gas exchange cannot be guaranteed; hence a ventilator and not a respirator.It is sometimes difficult to understand why when it seemed so easy to initiate the ventilator can it be so difficult to remove it. There are many components to returning a patient to their own spontaneous breathing and each individual is just that “an individual”, so weaning programs should be tailored for the individual need.We must understand in the recovery and rehabilitation of a ventilator dependent patient removal of the ventilator is often the last phase of the process. So lets start at the beginning and work through the understanding of this process.A ventilator patient is deemed ready to wean. This determination is usually made when the primary reason for the initiation of the ventilator has been reversed or stabilized. It is important to remember there are as many ways to wean a patient, as there are reasons to place them on the ventilator. This concept works in favor of the weaning patient because it allows for the individualization of each patients program.A key component that is often overlooked in a weaning program is the patient’s nutritional status. The patient may have been supported for days on intravenous fluids that provide hydration but little nutrition. Often when a patient is deemed ready to wean their serum albumin and total protein levels in the blood reveal malnutrition. It is this writer’s belief that until significant gain in correcting this malnutrition has been achieved no weaning should be initiated. It is like asking a marathon runner to not eat for a weak and then run a 26-mile race. I am sure they wouldn’t get very far or finish.A dietician will work closely with the physician to provide the caloric intake and nutritional values that the patient needs to support the weaning process. The dietician has many factors to consider when determining the correct nutritional recipe for the patient.Patients often have many diagnoses that have to be considered in the nutritional formula. A patient with kidney disease will have difficulty with protein, a diabetic with glucose, and the lung disease patient may have significant issues with volume, an obese patient needs nutrition in a reduced number of calories.Another factor that must be considered, especially for those patients who eat by mouth is food simply has little or no taste. The reason for this is the tracheostomy tube. When a patient has a tracheostomy tube breathing through the nose and mouth no longer occurs. It is the nose that helps us smell and taste food. The tracheostomy patient no longer or has little ability to smell and taste like most people. This may cause decreased appetite. Encouragement and utilization of devices referred to as speaking valves often help with this issue.Once the recipe or nutritional formula has been determined and the patient is tolerating it and nutrition is improving its time to look at the next area that can and often does complicate the weaning process.Medications are like a double-edged sword; they have significant benefit in treating disease and their symptoms but never without consequence. In medicine the physician weighs the “risk-benefit” of medications carefully. The need for certain medications such as pain and anti-anxiety medications can complicate the weaning process as well as enhance it.Lets start with pain medications. If a patient has pain they are unable to participate in their rehabilitation process to the maximum potential. Many pain medications such as those in the opiods family (morphine) can suppress a patients breathing. Many of the anti-anxiety medications can cause the patient to be sleepy again reducing the ability to participate. Some medications can even cause confusion making it even harder for the patient to participate. The physician must look to relieve the pain and anxiety without over sedating the patient. If the level of medication required to relieve these symptoms cause the undesired side effects it may be necessary to postpone weaning attempts until these issues have been resolved.Now that the patient has improved nutritional status and has pain and anxiety well controlled we can proceed to the active rehabilitation of the ventilator dependent patient.Occupational, Physical and Speech therapists may begin to work with the patient one by one or as a team. It is imperative to remember a patient must be able to follow simple commands and participate in order for active therapy to occur.The therapists are an integral part of the weaning process. The major component of breathing requires muscle use, the diaphragm as well as muscles in the neck and chest.Just like the marathon runner it takes time and training to reach the goal. No one decides to run a marathon and succeeds the same day. Daily participation in therapies is essential to achieving the ultimate goal of weaning off the ventilator.During the rehabilitation phase the Respiratory therapists will work closely with the physician to determine a weaning program that will best suit the individual patient. Remember no matter how much we want someone to wean it takes all or most of the components to be successful as well as time.It is sometimes difficult to understand why patients are hesitant to come off the ventilator but if we look carefully we can comprehend the fear and anxiety that is associated with this process for the patient. Imagine if you will that you couldn’t breath and now you have a machine that helped you, makes your work of breathing easier. Now suddenly everyone wants to take that away from you. Patients wonder, what if I get short of breath, what if I get tired, what if I go to sleep and these are just a few of the “what ifs” that weigh heavily on their mind.Together the medical team and families can help allay the patients fear. Families can give the medical team insight to the personality and coping skills the patient had prior to their illness. These valuable insights can help the medical team develop a successful plan towards weaning. As family members your support in the process is essential. If you are fearful of the process so will the patient.Asking questions of the medical team will help you understand the plan. Trust is the essential ingredient for the patient. They must have the trust and confidence in their medical team to keep them safe and breathing easy.Very often the medical team will see the patients and their families focusing on “numbers”. They hear questions such as what is my pulse oximetry? Yesterday the number on the machine was 10 now its 12, why? This phenomenon is very understandable; people want to make sense out of all this technical information. The numbers are familiar, they flash on the ventilator screen and across the pulse oximeter routinely. Yet the question begs to be asked, what do the numbers mean?The numbers are used by the medical team to assess and trend information and monitor the patient’s progress. People often forget to look at the patient. Is the patient comfortable, not sweating; has good pink color, able to perform their required therapies?These are all good indicators that the patient is doing well. The medical team will evaluate all the “numbers” and adjust the plan of care accordingly.It is important to remember that just like in the laws of physics the patient is the sum of all its parts. Many factors and chronic conditions must be considered when initiating a plan of care for weaning. Age, chronic conditions, anxiety, depression, previous level of function as well as setting realistic goals are part of the planning process. It is very important that every member of the team; which includes the patient and their family, agrees with and understands the plan. Together, as a team with dedication and hard work the reward of being free from mechanical ventilation awaits you.

BILLY GRAHAM AND HIS MISSION

Billy Graham preaching sermon at Madison Square Garden in New York
Billy GrahamTranscending doctrine and denomination, he served as the nation's spiritual counselor and made America safe for public testimonies of faithBy HAROLD BLOOM Dubious Influences: Century's Villains and Antiheroes Five Captivating Romances: When Love Was the Adventure
Monday, June 14, 1999William Franklin Graham Jr., known to all the world as Billy, is now 80 years old, and has been our leading religious revivalist for almost exactly 50 years, ever since his eight-week triumph in Los Angeles in the autumn of 1949. Indeed, for at least 40 years, Graham has been the Pope of Protestant America (if Protestant is still the right word). Graham's finest moment may have been when he appeared at President Bush's side, Bible in hand, as we commenced our war against Iraq in 1991. The great revivalist's presence symbolized that the Gulf crusade was, if not Christian, at least biblical. Bush was not unique among our Presidents in displaying Graham. Eisenhower and Kennedy began the tradition of consulting the evangelist, but Johnson, Nixon and Ford intensified the fashion that concluded with Bush's naming him "America's pastor." President Clinton has increasingly preferred the Rev. Jesse Jackson, but the aura of apostle still hovers around Billy Graham. Harry Truman unkindly proclaimed Graham a "counterfeit," a mere publicity monger, but while I still remain a Truman Democrat, I think our last really good President oversimplified the Graham phenomenon.

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No one has accused Graham of intellectualism, profound spirituality or social compassion, but he is free of any association with the Christian right of Pat Robertson, Ralph Reed and all the other advocates of a God whose prime concerns are abolishing the graduated income tax and a woman's right to choose abortion (which Graham also opposes). And there have been no scandals, financial or sexual, to darken Graham's mission. His sincerity, transparent and convincing, cannot be denied. He is an icon essential to a country in which, for two centuries now, religion has been not the opiate but the poetry of the people. In the U.S., 96 percent of us believe in God, 90 percent pray, and 90 percent believe God loves them, according to Gallup polls. Graham is totally representative of American religious universalism. You don't run for office among us by proclaiming your skepticism or by deprecating Billy Graham.

DEMS WANT OBAMA TO HURRY UP AND FIX THE ECONOMY

WASHINGTON Some Democrats are increasingly concerned about President Obama's $787 billion financial fix for the ailing economy, and are demanding greater transparency on further spending.

Rep. Earl Pomeroy, D-North Dakota, says there are big concerns over talk about a second stimulus package.

With the White House seemingly comparing the nation's economy to a house on fire, some congressional Democrats are asking, where's the fire truck?
One New Hampshire congresswoman said as much to Treasury Secretary Tim Geithner on Capitol Hill recently.
"I said, hurry, please hurry, because people are waiting and they are hurting, and they need the help now," Rep. Carol Shea-Porter, D-New Hampshire, said.
She's one of a growing number of nervous Democrats on edge or at odds with some of the Obama's administration's plans on the economy. Some are taking aim at the president's budget proposals that would curb popular tax deductions for wealthier Americans. Watch more on why some Democrats are nervous »
"I don't think ultimately the criticism is surprising. That certainly happens and is all part of the process," said White House Press Secretary Robert Gibbs.
As a nod to moderate concerns, Obama took steps to make his budget more transparent. He included items former President George W. Bush passed separately in recent years to obscure the true operating cost of the government, such as the money for the wars in Iraq and Afghanistan, an annual multibillion-dollar fix of the fees Medicare pays physicians and Alternative Minimum Tax relief for the middle class.
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Sen. Evan Bayh, D-Indiana, who along with Nebraska Democrat Ben Nelson and Connecticut Independent Joe Lieberman is one of the so-called Gang of 15 -- a coalition of moderate Democratic senators -- says it's all about the messaging.
"Like getting health care costs under control is important to the economy and getting the deficit down," he said. "Sustainable sources of energy at reasonable prices is also important to the economy. Dealing with the financial crisis is obviously important to the economy."
Bayh added: "So what needs to be done is, Obama's got to move on all these fronts but also integrate them back to the same theme of always strengthening the economy, getting people to work, growing businesses, improving our standard of living." Watch more of Obama's solutions for the economy »
Rep. John Tanner, D-Tennessee, is a member of the "Blue Dog" group of 47 fiscally conservative Democrats in the House -- six of whom voted against Obama's stimulus plan. He said Obama at least is being honest about the dire condition of the economy.
"At least the budget that the Obama administration presented, even though it's huge and it's a huge deficit -- and that enables the other team to beat up on it -- the truth is that it's honest and truthful," he said.
Democratic media consultant Steve Murphy, who represents several moderate Democrats, said that Blue Dogs are all "deficit hawks," so they're "nervous about spending."
"They're against giving more money to the banks without any accountability, they want to zero in on wasteful spending and they strongly believe the shrinking deficit and eventual balanced budget was the underpinning of our economic success in the '90's," he said.
Murphy added that these Democrats do, however, realize that more money is going to be needed.
"So I expect them to be about greater accountability and fairness for the taxpayer. They won't join [GOP House Minority Whip Eric] Cantor's 'Hell No' chorus."
And that is something resonating with House Speaker Nancy Pelosi who said top economists told her a second stimulus package may be necessary.
"You have to keep the door open to see how this goes," she said.
House Democrats, CNN has learned, heard that message in a meeting with top economists, who predicted the president's stimulus plan will fall short of saving or creating three to four million jobs, as he promised.
"Over the first two years about 2 1/2 million jobs saved and created," said economist Allen Sinai. "A little less than the administration and perhaps Speaker Pelosi has said ... the jobs created may be a little disappointing."
Sinai said that over time, the economy may produce the jobs president Obama promised, but that people should try to be patient.
But budget hawks in the party don't like the sound of that.
"I mean, if we were to take a vote this afternoon, the stimulus package would probably fail," said Rep. Earl Pomeroy, D-North Dakota. "If they want substantial, more public funds committed, they're going to have to go out there and explain precisely how this is going to work."
Shea-Porter said she's simply on the message she's getting at town meetings back home, a message that's also aimed at some in the media.
"It's terrifying people. Before, people were very optimistic and the leaders were optimistic. Then we hit a spell here where we're hearing a lot of media ... people who are frightening without necessarily giving both sides," she added.
For now, the White House says it has no plans for another stimulus, arguing its plan needs time to work.

'Power of Pitt' Drains Congressional Offices of Female Employees

WASHINGTON — First of all, no, Brad Pitt is not short. Yes, he's handsome enough to stand out in any crowd. And, sorry, Angie wasn't with him.
From the moment he stepped into the Capitol on Thursday, sunglassed and goateed, Pitt's star power transformed congressional business-as-usual in a way any lawmaker or new president might envy.
Pitt's superpowers are such that he and President Obama pulled off an improbably secret meeting on the same topic earlier in the day, White House spokesman Thomas F. Vietor confirmed.
House Speaker Nancy Pelosi was not immune to his charms. Praising Pitt for his work to rebuild New Orleans' hurricane-ravaged 9th Ward, she even allowed that meeting him affords her "bragging rights to my children and my grandchildren — a real treat for me as well."
And during a closed meeting earlier, Senate Majority Leader Harry Reid confided to Pitt that he was envious that his lieutenant, Majority Whip Dick Durbin, got to meet soccer star Mia Hamm a day earlier, according to one person who was present and spoke on condition of anonymity.
Well, Pitt replied, he'll bring along co-parent Angelina Jolie next time to help Reid make Durbin jealous, this person said.
Later, a Durbin aide sniffed: "Durbin's already met Angelina Jolie."
These officials demanded anonymity because the meeting was private and they did not want to be caught gossiping about a movie star.
The Power of Pitt drained entire congressional offices of their female employees and quite a few male aides as well, all of whom could be picked out by the way they suddenly appeared in the Senate's doorways and halls, nonchalantly cupping cell phones and cameras at their sides and hanging around waiting news crews.
Finally, around 1:30 p.m., Pitt, four aides and assorted security guards climbed out of a darkened SUV at the Capitol's north gate and strolled across the sun-dappled plaza.
As he approached the building, all nonchalance inside disappeared. Was he coming in the carriage entrance? No! He was coming through the North Door.
And so he did, entering through the famous Brumidi corridor, whose ornate and historic paintings he probably couldn't see through his sunglasses. Reporters, photographers and giggling staffers shuffled after him, up a flight of stairs and around a corner toward Reid's office. As Pitt entered the parlor, he took off his shades. An aide closed the door behind him.
Inside with Reid, Pitt made an earnest case for nationalizing his "Make It Right" campaign, in partnership with Congress, according to a second knowledgeable aide who spoke on condition that he not be named because the meeting was private.
Afterward, this official said, Reid and Pitt posed for pictures, the senator cracking, "How will people tell us apart?"
Outside the door, grinning Capitol Police officers put up ropes to keep the hordes out of the path Pitt was expected to take toward his next meeting, with Sen. Patty Murray, D-Wash., in a building across the street.
Sen. Patrick Leahy, D-Vt., the Judiciary Committee chairman who has appeared as himself in several "Batman" movies and even had a speaking line in "The Dark Knight," stumbled across the crowd gathered outside Reid's door.
Told who was inside, Leahy issued a giddy, "Gosh!" and kept walking.
In the end, Pitt and his entourage slipped out a side door and took an elevator to the basement subway.

LEGENDARY NEWS PIONEER PAUL HARVEY DIES

CHICAGO – Paul Harvey, the news commentator and talk-radio pioneer whose staccato style made him one of the nation's most familiar voices, died Saturday in Arizona, according to ABC Radio Networks. He was 90.
Harvey died surrounded by family at a hospital in Phoenix, where he had a winter home, said Louis Adams, a spokesman for ABC Radio Networks, where Harvey worked for more than 50 years. No cause of death was immediately available.
Harvey had been forced off the air for several months in 2001 because of a virus that weakened a vocal cord. But he returned to work in Chicago and was still active as he passed his 90th birthday. His death comes less than a year after that of his wife and longtime producer, Lynne.
"My father and mother created from thin air what one day became radio and television news," Paul Harvey Jr. said in a statement. "So in the past year, an industry has lost its godparents and today millions have lost a friend."
Known for his resonant voice and trademark delivery of "The Rest of the Story," Harvey had been heard nationally since 1951, when he began his "News and Comment" for ABC Radio Networks.
He became a heartland icon, delivering news and commentary with a distinctive Midwestern flavor. "Stand by for news!" he told his listeners. He was credited with inventing or popularizing terms such as "skyjacker," "Reaganomics" and "guesstimate."
"Paul Harvey was one of the most gifted and beloved broadcasters in our nation's history," ABC Radio Networks President Jim Robinson said in a statement. "We will miss our dear friend tremendously and are grateful for the many years we were so fortunate to have known him."
In 2005, Harvey was one of 14 notables chosen as recipients of the presidential Medal of Freedom. He also was an inductee in the Radio Hall of Fame, as was Lynne.
Former President George W. Bush remembered Harvey as a "friendly and familiar voice in the lives of millions of Americans."
"His commentary entertained, enlightened, and informed," Bush said in a statement. "Laura and I are pleased to have known this fine man, and our thoughts and prayers are with his family."
Harvey composed his twice-daily news commentaries from a downtown Chicago office near Lake Michigan.
Rising at 3:30 each morning, he ate a bowl of oatmeal, then combed the news wires and spoke with editors across the country in search of succinct tales of American life for his program.
At the peak of his career, Harvey reached more than 24 million listeners on more than 1,200 radio stations and charged $30,000 to give a speech. His syndicated column was carried by 300 newspapers.
His fans identified with his plainspoken political commentary, but critics called him an out-of-touch conservative. He was an early supporter of the late Sen. Joseph McCarthy and a longtime backer of the Vietnam War.
Perhaps Harvey's most famous broadcast came in 1970, when he abandoned that stance, announcing his opposition to President Nixon's expansion of the war and urging him to get out completely.
"Mr. President, I love you ... but you're wrong," Harvey said, shocking his faithful listeners and drawing a barrage of letters and phone calls, including one from the White House.
In 1976, Harvey began broadcasting his anecdotal descriptions of the lives of famous people. "The Rest of the Story" started chronologically, with the person's identity revealed at the end. The stories were an attempt to capture "the heartbeats behind the headlines." Much of the research and writing was done by his son, Paul Jr.
Harvey also blended news with advertising, a line he said he crossed only for products he trusted.
In 2000, at age 82, he signed a new 10-year contract with ABC Radio Networks.
Harvey was born Paul Harvey Aurandt in Tulsa, Okla. His father, a police officer, was killed when he was a toddler. A high school teacher took note of his distinctive voice and launched him on a broadcast career.
While working at St. Louis radio station KXOK, he met Washington University graduate student Lynne Cooper. He proposed on their first date (she said "no") and always called her "Angel." They were married in 1940 and had a son, Paul Jr.
They worked closely together on his shows, and he often credited his success to her influence. She was inducted into the Radio Hall of Fame in 1997, seven years after her husband was. She died in May 2008.

OBAMA'S TAX PLAN WORRIES SOME DEMOCRATS

One of the most controversial provisions in President Obama's proposed budget might have a short shelf life on Capitol Hill.
To pay for half of his $634 billion health reform fund, Obama has proposed limiting deductions for high-income taxpayers starting in 2011.
Instead of using their top income tax rate to calculate the value of a deduction, single filers making more than $200,000 and joint filers making more than $250,000 wouldn't be allowed to reduce their bill by any more than 28% of a given deduction. That's below what the top two tax rates would be in 2011.
That means the value of some of the most popular deductions -- such as mortgage interest and charitable contributions -- would be reduced for high-income filers.
But the provision, which is likely to be debated at a health care summit the president has set for Thursday, has already met resistance from some leading Senate Democrats including Finance Chairman Max Baucus and committee member Ron Wyden, D-Ore.
At a hearing Wednesday, Baucus told Treasury Secretary Tim Geithner that he questioned the "viability" of the itemized deduction proposal and suggested the administration find another way to help pay for its health reform fund.
"There are other tax provisions that have a lot to do with health care, but that one does not. I'd just urge the administration to dig down deeper to try to find viable savings and concentrate on savings within health care reform," Baucus said.
One main criticism of Obama's proposal is that it would harm charitable giving.
In response, Geithner said the provision would only affect 1.2% of taxpayers and have only "modest effects" on how much people donate.
"The most important thing you can do for overall charitable giving is to get the economy strong," Geithner said.
One expert agrees that giving is closely tied to the fate of the economy.
"If GDP is down, there's going to be a decline in giving," said Daniel Borochoff, president of the American Institute of Philanthropy.
Len Burman, director of the Tax Policy Center, estimates that the provision would reduce annual giving by roughly 2%, or $9 billion, in 2011.
Congressional push-back on the plan to curb deductions could force the administration to find another way to generate the billions it needs to fund its signature health care plan.
Senator offers another approach
Baucus pointed to one possible alternative. He asked Geithner whether the administration would consider generating new revenue by curbing or eliminating the tax break offered to employees when they buy health insurance policies through their companies.
Currently, the portion of their premiums paid by the employer is treated as tax free income to employees, meaning they pay no income tax on that subsidy, nor do they pay Social Security or Medicare tax on it.
The health insurance exclusion is the federal government's single biggest tax expenditure, worth $246 billion in forgone revenue in 2007, according to the Joint Committee on Taxation.
Calls to change the tax exclusion have been made before both because the subsidy does not discourage workers from being more cost-conscious in their health care decisions and because it favors only those who get insurance through an employer, not those who buy policies on their own.
During last year's campaign, Obama said that while he wanted to reform health care, he would not seek to overturn the tax-free subsidy for those who get their insurance from their jobs.
Without committing to Baucus' suggestion in particular, Geithner seemed to indicate that the administration might be willing to reconsider its deduction proposal.
"We recognize there [are] more paths to [paying for health reform] than what we laid out in the budget," he told the Finance Committee. "But we wanted to put it on the table to prove the credibility of our commitment to do this, concrete proposals that would achieve that."
First Published: March 4, 2009: 6:27 PM ET

THE ECONOMY AND THE JOB MARKET

It's no secret that the job market is bad.
The Labor Department will release its latest jobs report Friday. Economists surveyed by Briefing.com forecast that the unemployment rate rose to 7.9% in February and that 650,000 jobs were lost.
Still, as bad as those numbers are, some have argued that this jobs downturn is not as bad as the early 1980s. The unemployment rate peaked at 10.8% in late 1982.
But several experts say it would be a mistake to come to that conclusion. They argue that unemployment rate only hints at why this jobs downturn is worse than any since the Great Depression.
Steep decline
If the job loss forecasts for February turn out to be accurate, it would be the worst monthly drop since 1949.
It would also bring total job losses over the last six months to 3.1 million, the largest six-month job loss since the end of World War II.
Even adjusting for the large growth in the nation's job base in recent decades, this would be the biggest six-month job loss since 1975.
Economists say the steepness of this decline will make it tougher for the job market to improve any time soon. The increasing job losses create a downward spiral in which businesses, faced with lower demand because people can't afford to buy their products, lay off even more people.
0:00 /1:59Surviving an economic downturn

"The dramatic hemorrhaging of jobs means we're in this for the long-haul," said Heidi Shierholz, economist with Economic Policy Institute, a Washington think tank supported by foundations and labor unions.
Another reason why this downturn is more painful is because the layoffs have come from companies in virtually all parts of the economy.
"There's no place to hide in terms of job losses," said Lakshman Achuthan, managing director of Economic Cycle Research Institute. "And when measuring the impact of job losses, it's very important how pervasive the losses are. That's what makes this the worst since the Great Depression."
Achuthan points to something called the diffusion index of employment change, which showed that three out of four business sectors cut jobs in January.