Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 10

I got a call to go see one of my HH patients, who I am very familar with, because the family reported that her/his 02 sats were hanging in the 70's all day and even though she/he was not SOB they... Read More

  1. by   vamedic4
    Quote from emernurse
    i have to agree on the side of the medics in this, though i understand the hh nurse's frustration.

    we have awesome ems personnel in my city and their protocols are pretty solid. occassionally annoying <grin> but solid.

    i was at a baby shower once and one of the young ladies (early 20's) had an anxiety attack. this was someone i didn't know. before i even knew what was going on, the family had called 911. then came and got me. i assessed her (alway keep my steth/cuff in the car) and when ems showed up, gave 'em a quick update on situation from what i could learn, and got outta the way. they did what they had to do. girl was fine, of course, but my point here is that i got out of their way.

    in the er, on the recieving end of the ambulance ride, we assess the patient ourselves as soon as they hit our bed. if this patient had come into my er, we would have assessed him and determined ourselves, his o2 need and proceeded accordingly. given his condition, i'd have had the intubation equipment right next to him, too. the ambulance ride is governed by strong protocols which are meant to protect the patient en route, but once they hit the er, we determine what's needed. 99% of the time, the ems folks have gotten everything started in the right direction and we move on from there. sure, there are exceptions, where their protocol might not fit exactly, but ems can't go on the assumption of the exceptions - they have to follow those protocols. those exceptions are why ambulance rides are fast and er staff pounce when these types of folks come in.

    as for the family/hh folks not wanting the o2 upped, were i the ems, i'd have blamed my protocols with something along the lines of "i'm sorry but i'm required to do this for the patient while en route, but it's a short ride and the er folks will make a longer-term decision in just a few minutes." then slapped the o2 on and went.

    one comment i really feel i must make though, even though i'm now babbling: if i had to know every damn thing every other medical person knows, my head would explode. i count on ems to know badda-bing what to do with someone hanging upside down in a car so that their airway is not compromised and thier c-spine is kept intact, all the while disengaging said patient from said car. i count on med-surg nurses to take what i send them and juggle all the details of their care that i simply don't have time to do. i count on icu nurses to be so ingrained in the detail of thier patients' conditions that they catch the slightest change before it becomes a huge issue. i count on hh nurses to manage difficult disease processes (and families) outside the hospital so that, for the most part, those folks don't hav to come back unless absolutely necessary. i count on rt to shift to the left, to the right, do the hokey pokey and "see" those alveoli just by listening to the patient.

    my point? nursing (and other medical folks) are no longer interchangable. in our insanely acute healthcare world, we have to specialize simply so that there's someone available with expert knowledge for a given situation, whether that situation involves an intraaortic balloon pump, a 15-car pile up, 12 sundowners trying to nosedive out of bed, or the next acute mi busting through the door. we must show respect for each other. no patient will have an optimum outcome as they move through the continuum of care unless all of their providers respect and trust their brothers/sisters on the medical team. we're all on the same team with the same goals.
    [font="comic sans ms"]very well put...and so completely true.
  2. by   burn out
    Let's look at it from another angle then. Say the medics listened to the hhRN and left the oxygen at 2.5 l and when the patient got to the hospital and an abg was drawn and the pco2 was 152 and the po2 was 20 and the ph 7.01 what defense does the medic give for not administering more oxygen..because the HH nurse told me to. I think the jury would hang the medic up to dry.

    Once again the abg would justify the medic ignoring the patients request for not increasing the o2 because a pco2 level of 152 would automatically make him incompent no matter if he was oriented or not at my hospital.
    Last edit by burn out on Jan 31, '07 : Reason: to add to
  3. by   RunnerRN
    Quote from chip193
    Plantiff's Attorney: "Can you explain to me what hypoxia is?"
    Paramedic: "It is when there is not enough oxygen to perfuse the organs."
    Attny: "What are organs?"
    Medic: "They are the different systems that carry out the work of the body."
    Attny: "Such as?"
    Medic: "The lungs work to exchange gas, getting rid of carbon dioxide and bringing in oxygen."
    Attny: "And what happens if the lungs fail?"
    Medic: "You would stop breathing."
    Attny: "What if is wasn't that bad? What is Respitory Failure all about?"
    Medic: "That is when the lungs don't do their job and you get a build up of waste products and carbon dioxide."
    Attny: "And is that bad?"
    Medic: "Yeah, that's bad."
    Attny: "How do you treat it?"
    Medic: "Give oxygen, maybe intubate the patient and breathe for him."
    Attny: "How could you tell if a patient is in Respiratory Failure?"
    Medic: "Well, he could be acting weird, or if the sat is low?"
    Attny: "What is a sat?"
    Medic: "It's a pulse oximetry reading."
    Attny: "What does that do?"
    Medic: "It gives and idea of how much oxygen is being carried on the hemeoglobin."
    Attny: "And what's normal?"
    Medic: "Usually 92% or above."
    Attny: "And what was my client's Dad's?"
    Medic: "73%."
    Attny: "And he wasn't in Respiratory Failure and didn't need additional oxygen?"

    Game, set, match. Get out the checkbook.

    You have to prove that a patient is competant in order to let him refuse. That's why RMAs and AMAs take so long to chart.

    That's why the Paramedic was right to turn up the oxygen.

    That's why the Paramedic should have thought about intubation.
    :yeahthat:

    The above is pretty much what I think this all comes down to. We live in a very litigious society, and work in a field that is very susceptible to lawsuits. Unfortunately, a lot of what we do is to avoid becoming a party to a lawsuit (how much do you double chart to make sure it is completely evident that the patient is fine?) I think the medic in question could have been a little better in her bedside manner, explaining why she was doing what she was doing and not being so pushy, but I also think that is a side issue here.
    I have nothing but respect for home health nurses (I can't do what you do) and I also respect my paramedics. The point is that when the family made the choice to call 911 (I know the OP tried to correct herself and say that the family COULDN'T take the pt in, in the original post, the reasoning was stated that they didn't want to wait in the WR) they also transferred care to the paramedic. I also would be very interested to see the ABG results.
  4. by   morte
    Quote from chip193
    Plantiff's Attorney: "Can you explain to me what hypoxia is?"
    Paramedic: "It is when there is not enough oxygen to perfuse the organs."
    Attny: "What are organs?"
    Medic: "They are the different systems that carry out the work of the body."
    Attny: "Such as?"
    Medic: "The lungs work to exchange gas, getting rid of carbon dioxide and bringing in oxygen."
    Attny: "And what happens if the lungs fail?"
    Medic: "You would stop breathing."
    Attny: "What if is wasn't that bad? What is Respitory Failure all about?"
    Medic: "That is when the lungs don't do their job and you get a build up of waste products and carbon dioxide."
    Attny: "And is that bad?"
    Medic: "Yeah, that's bad."
    Attny: "How do you treat it?"
    Medic: "Give oxygen, maybe intubate the patient and breathe for him."
    Attny: "How could you tell if a patient is in Respiratory Failure?"
    Medic: "Well, he could be acting weird, or if the sat is low?"
    Attny: "What is a sat?"
    Medic: "It's a pulse oximetry reading."
    Attny: "What does that do?"
    Medic: "It gives and idea of how much oxygen is being carried on the hemeoglobin."
    Attny: "And what's normal?"
    Medic: "Usually 92% or above."
    Attny: "And what was my client's Dad's?"
    Medic: "73%."
    Attny: "And he wasn't in Respiratory Failure and didn't need additional oxygen?"

    Game, set, match. Get out the checkbook.

    You have to prove that a patient is competant in order to let him refuse. That's why RMAs and AMAs take so long to chart.

    That's why the Paramedic was right to turn up the oxygen.

    That's why the Paramedic should have thought about intubation.
    the testimony you quote, would have been from a very ill prepared (by their lawyer) paramedic......and no you did not miss anything, where i work has no relevance to this discussion....i am familiar with comfort care, dnr,dni
    Last edit by morte on Feb 1, '07 : Reason: added "not" to correct from positive to negative
  5. by   Noryn
    The paramedic was right in rationale but I also agree with the poster who was concerned that the pt did not want an increase in oxygen. The O2 sat reading alone is not that important. It is a nice tool that we have, but there are so many limitations hence why we get ABGs on pts. The most important thing was how was this pt tolerating the o2 sat.

    I for the life of me cannot understand how just an o2 sat reading of 73% makes you incompetent to make decisions. Now if the pt was lethargic or confused that is another story all together. So what is the cut off mark for an O2 sat? One of the posters in an interrogation stated that 92% + is normal. So if I have a chronic COPD pt their normal sat is above 92%? At what point does the low O2 sat make someone incompetent? 85% or 80%?

    If I were the paramedic, here is what I would have done. I would of course assessed the pt's mental status. Explained to the pt, family and home health nurse why she needed the extra oxygen and the risks involved of not having this. I then would have documented if the pt refused along with what the home health nurse was telling the pt. A lot of times, patients dont make what I consider the best decision but it is their body and they do have a right to refuse treatment.

    I just really have a hard time agreeing with the fact that the paramedic increased her oxygen and she was alert and did not want this to be increased.
  6. by   DutchgirlRN
    I know the OP tried to correct herself and say that the family COULDN'T take the pt in, in the original post, the reasoning was stated that they didn't want to wait in the WR.
    The family stated they WOULD NOT take the pt in their car, they refused.

    They didn't want to have him/her sit in the WR. This hospital ER has a bad reputation. Pt's with CP have waited in the WR. Pt's have coded in the WR and died. One patient called 911 from the WR to be taken to another hospital due to a ruptured appendix. All the signs were there. Triage seems to be an unknown word there. Besides the pt was just released 2 days prior with a fx shoulder in 3 places and not easily moved .

    I did not try to correct anything. I was so upset when I posted, I rushed through and didn't explain "everything", didn't know I would have to. The important matter to me was that the paramedic totally dismissed me, the family and the patient not to mention the doctors order. Never increase the 02 above 2.5 no matter what. The doctor who wrote that order is a pulmonary specialist. I was more concerned with his order, the pt's wishes and the family's wishes than the paramedics protocol. Besides her bedside manner sux'd.

    Obviously there are two sides to this issue. I have read all the posts and I have learned something from both sides. I appreciate what I have learned from both sides as this information will stick with me and will be valuable to me and my patients in the future.

    I am confident in my HH skills. If any of you think it's easy, give it a try. You won't have everything accessible to you as you do in the hospital or in the ambulance. You have to use your knowledge and critical thinking skills. We didn't even have pulse oximeters until 6 months ago. Next time you go to work use only the tools to get VS and breath sounds and then continue your job and not even be able to get a hold of the doctor or have anyone else to bounce thoughts off of. It's not as easy as you might think.

    BTW the county ambulance ride is not free. The pt (Medicare) will pay nearly $600. In a similiar situation, next time, I'll call a private ambulance. They may have the same protocols but in this case "I feel", I repeat, "I feel" that I did the best that I could for my patient. You may disagree but we've already worn that issue out.
    Last edit by DutchgirlRN on Jan 31, '07 : Reason: Spelling
  7. by   morte
    Quote from Noryn
    The paramedic was right in rationale but I also agree with the poster who was concerned that the pt did not want an increase in oxygen. The O2 sat reading alone is not that important. It is a nice tool that we have, but there are so many limitations hence why we get ABGs on pts. The most important thing was how was this pt tolerating the o2 sat.

    I for the life of me cannot understand how just an o2 sat reading of 73% makes you incompetent to make decisions. Now if the pt was lethargic or confused that is another story all together. So what is the cut off mark for an O2 sat? One of the posters in an interrogation stated that 92% + is normal. So if I have a chronic COPD pt their normal sat is above 92%? At what point does the low O2 sat make someone incompetent? 85% or 80%?

    If I were the paramedic, here is what I would have done. I would of course assessed the pt's mental status. Explained to the pt, family and home health nurse why she needed the extra oxygen and the risks involved of not having this. I then would have documented if the pt refused along with what the home health nurse was telling the pt. A lot of times, patients dont make what I consider the best decision but it is their body and they do have a right to refuse treatment.

    I just really have a hard time agreeing with the fact that the paramedic increased her oxygen and she was alert and did not want this to be increased.
    thank you
  8. by   burn out
    I agree that the drop in the sat is not as significant as the pco2 in a copd'er. The first and biggest problem for a COPD'er causing a low sat is high co2 levels normally that their bodies get used to but in resp emergencies the COPD'ers biggest and first thought is CO2 retention with accompanying low pO2 levels and is treated with increase in oxygenation until intubation and mechanical ventilation can occur. The fever should indicate probable pneumonia and what were the breath sounds like. Lets not forget that this patient only has one lung and with pneumonia is not going to perfuse well ..so increase the o2.
  9. by   Noryn
    Quote from burn out
    I agree that the drop in the sat is not as significant as the pco2 in a copd'er. The first and biggest problem for a COPD'er causing a low sat is high co2 levels normally that their bodies get used to but in resp emergencies the COPD'ers biggest and first thought is CO2 retention with accompanying low pO2 levels and is treated with increase in oxygenation until intubation and mechanical ventilation can occur. The fever should indicate probable pneumonia and what were the breath sounds like. Lets not forget that this patient only has one lung and with pneumonia is not going to perfuse well ..so increase the o2.
    I agree with everything you are saying except the last few words. I feel that most of these posters are treating numbers and disease process but they are not treating this patient. The patient was alert and did NOT want the O2 increased. So why are you forcing treatment on her especially if she if competent?
  10. by   jnette
    Quote from burn out
    I agree that the drop in the sat is not as significant as the pco2 in a copd'er. The first and biggest problem for a COPD'er causing a low sat is high co2 levels normally that their bodies get used to but in resp emergencies the COPD'ers biggest and first thought is CO2 retention with accompanying low pO2 levels and is treated with increase in oxygenation until intubation and mechanical ventilation can occur. The fever should indicate probable pneumonia and what were the breath sounds like. Lets not forget that this patient only has one lung and with pneumonia is not going to perfuse well ..so increase the o2.
    Agree wholeheartedly.

    Whew ! Just read this ENTIRE thread BECAUSE........... I recently came across a very similar situation in which I was the HH nurse and I was called to teh pt's home because patient stated she was not able to get her breath, was not able to breathe well. She is CPOD with long hx. of pnx.

    Get there and find that she had just been released from the hospital the noc before..for double pnx. This patient had both lungs, however. Check her VS, temp of 101.7, HR 136, lung sounds adventitious as all get out and no steth was needed to know that she was in serious trouble. 02 sat was 80. Mentation was ok still, but she was visibly struggling to breathe.

    I took it upon myself to increase her usual 2L NC to 4L, and called 911.


    My agerncy owner later questioned me about increasing her 02 "without an order" and while she was supportive, and didn't ream me out for it, she did say that this could have cost her HER license as well as mine, and shut down the agency.

    So.... MY question in all this is this... where does NURSING JUDGEMENT come into play, or is it all a myth???

    I will defend my decision to increase her 02 regardless. But I need to know WHEN we can do what we feel is right for the patient without an MD order.

    So many of you have said you all would have done the same, or HAVE done the same.. but I've not heard many or any of you say that you first obtained an MD order to increase a pt's 02 in an emergency situation, be it in the hospital setting or out in the field.

    I could really use some clarification on that end of it. Thanx!
  11. by   rnin02
    Quote from jnette
    Agree wholeheartedly.

    Whew ! Just read this ENTIRE thread BECAUSE........... I recently came across a very similar situation in which I was the HH nurse and I was called to teh pt's home because patient stated she was not able to get her breath, was not able to breathe well. She is CPOD with long hx. of pnx.

    Get there and find that she had just been released from the hospital the noc before..for double pnx. This patient had both lungs, however. Check her VS, temp of 101.7, HR 136, lung sounds adventitious as all get out and no steth was needed to know that she was in serious trouble. 02 sat was 80. Mentation was ok still, but she was visibly struggling to breathe.

    I took it upon myself to increase her usual 2L NC to 4L, and called 911.


    My agerncy owner later questioned me about increasing her 02 "without an order" and while she was supportive, and didn't ream me out for it, she did say that this could have cost her HER license as well as mine, and shut down the agency.

    So.... MY question in all this is this... where does NURSING JUDGEMENT come into play, or is it all a myth???

    I will defend my decision to increase her 02 regardless. But I need to know WHEN we can do what we feel is right for the patient without an MD order.

    So many of you have said you all would have done the same, or HAVE done the same.. but I've not heard many or any of you say that you first obtained an MD order to increase a pt's 02 in an emergency situation, be it in the hospital setting or out in the field.

    I could really use some clarification on that end of it. Thanx!
    I've only worked in the hospital setting, so that's where my emergencies have been. At any rate, for most of my patients in that situation I would have increased the O2. The exception to the rule,well, there are a few exceptions, but the biggest one, is who the MD is for the patient and whois on-call. There is one MD I work with who is not tolerate of nurses doing anything without his OK. And then when you do get him on the phone he's a sarcastic jerk most of the time. So his patients we get an order for everything. This MD has little to no respect for nursing judgement. And I have to say my hospital's fairly small, so for the most part the MDs do get to know which nurses they can trust and which they can't, but it makes no difference to this guy. Anyway, I guess the point I'm trying to get out is there's no clear cut answer for you...just knowing your patient and your MD. And I guess your director feels its best to have an order for everything. I'm not sure how HHN works, do you guys have "orders"? If so, do you have "standing orders" for certain DX? If you do, maybe they should add prn O2 2-4 lpm for SOB? We have that in my hospital for certain DX.
  12. by   jnette
    Quote from rnin02
    I've only worked in the hospital setting, so that's where my emergencies have been. At any rate, for most of my patients in that situation I would have increased the O2. The exception to the rule,well, there are a few exceptions, but the biggest one, is who the MD is for the patient and whois on-call. There is one MD I work with who is not tolerate of nurses doing anything without his OK. And then when you do get him on the phone he's a sarcastic jerk most of the time. So his patients we get an order for everything. This MD has little to no respect for nursing judgement. And I have to say my hospital's fairly small, so for the most part the MDs do get to know which nurses they can trust and which they can't, but it makes no difference to this guy. Anyway, I guess the point I'm trying to get out is there's no clear cut answer for you...just knowing your patient and your MD. And I guess your director feels its best to have an order for everything. I'm not sure how HHN works, do you guys have "orders"? If so, do you have "standing orders" for certain DX? If you do, maybe they should add prn O2 2-4 lpm for SOB? We have that in my hospital for certain DX.
    That's my point.. do you call a doc and get an order FIRST before you turn up the 02? How have most of you done this.. orders first or 02 first?

    I asked our owner if we did nont have any "standing orders" for EMERGENCY situations such as these. Evidently not. I think there should be some. Of course that would entail a LOT of docs, right? She said she would inquire of the BON about this.

    Either way, I know I did the right thing and would do so again. I guess I could always call the ED and request to speak to a doc, ANY doc, and get an ok. Just seems like such a waste of time, and makes our own nursing judgement null and void. :stone
  13. by   smk1
    Quote from Noryn
    The paramedic was right in rationale but I also agree with the poster who was concerned that the pt did not want an increase in oxygen. The O2 sat reading alone is not that important. It is a nice tool that we have, but there are so many limitations hence why we get ABGs on pts. The most important thing was how was this pt tolerating the o2 sat.

    I for the life of me cannot understand how just an o2 sat reading of 73% makes you incompetent to make decisions. Now if the pt was lethargic or confused that is another story all together. So what is the cut off mark for an O2 sat? One of the posters in an interrogation stated that 92% + is normal. So if I have a chronic COPD pt their normal sat is above 92%? At what point does the low O2 sat make someone incompetent? 85% or 80%?

    If I were the paramedic, here is what I would have done. I would of course assessed the pt's mental status. Explained to the pt, family and home health nurse why she needed the extra oxygen and the risks involved of not having this. I then would have documented if the pt refused along with what the home health nurse was telling the pt. A lot of times, patients dont make what I consider the best decision but it is their body and they do have a right to refuse treatment.

    I just really have a hard time agreeing with the fact that the paramedic increased her oxygen and she was alert and did not want this to be increased.
    I am just a student so I can't chime in on the care aspects of this, but I have to say that this poster hit my thoughts square on. I would have thought that a mental exam and A+O questions would take care of the issue of mentation. If deemed competent then the patients wishes should be honored. (At least this is what i have been taught so far) Then if things started to go down hill on the ride, change the O2 etc... I just assumed that this was how it would work.

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