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

Nurses General Nursing

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  1. Chronic COPD'er, 1 lung, 02 @ 6L, What would you do?

    • 222
      I think the Paramedic was right to increase the 02 to 6L. I am a Nurse.
    • 16
      I think the Paramedic was right to increase the 02 to 6L. I am a Paramedic or EMT.
    • 180
      I think ultimately the patients wished should have been honored. I am a Nurse.
    • 6
      I think ultimately the patients wishes should have been honored. I am a Paramedic or EMT.
    • 122
      I think the Paramedic should be reported to her agency for ignoring everyone. I am a Nurse.
    • 8
      I think the Paramedic should be reported to her agency for ignoring everyone. Paramedic/EMT.
    • 79
      I think this was a true emergency situation. I am a Nurse.
    • 9
      I think this was a true emergency situation. I am a Paramedic or EMT
    • 13
      I don't know, it's all too confusing
    • 7
      Leave me out of it. I don't want to participate.

148 members have participated

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 felt it should be coming up after breathing treatments and wanted to call before it got too late in the evening.

She/he is a chronic COPD'er, who has only one lung, who functions well with 02 sats in the low 80's. She/he has 02 BNC @ 2.5L/min. When I got there she/he was sitting up talking to me. She/he said she/he didn't feel in the least SOB, 02 sat was 73%, Temp 102 and her/his one lung was full of wheezes. I felt as though she/he should go to the hospital but that it was not an emergency situation. The family fully agreed. They said she/he preferred to go by ambulance so she/he wouldn't have to sit in the ER. I agreed. We called 911.

An EMT got there and asked what was going on. I told him. A few minutes later the ambulance got there and a paramedic came in. She saw me but asked the EMT what was going on. "Oh my God a sat of 73% crank her up to 6L/min. I said no. I explained why. She said "well we have to get her 02 sat up because she's not perfusing 02 to her brain. I said she's talking to you. Please do not turn her up to 6L/min you'll do more harm. She did it anyway. The daughter said "the last time you guys did this she/he ended up with a CO2 of 134 and ended up on a ventilator". The patient said please don't do this to me. The paramedic ignored everyone. The EMT turned it back down to 2L/min the paramedic saw it and turned it back up to 6L/min. She told the patient she would put her/him on a non-rebreather once they got her/him in the ambulance!

I was told that once the paramedics arrive they are in charge and what they do is their responsibility but how ignorant to not listen to the nurse, the family and the patient?

I will make sure this paramedic gets reported. I wonder what you guys thoughts are?

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

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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.

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Specializes in OB, M/S, HH, Medical Imaging RN.
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.

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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

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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.

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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?

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Specializes in Hemodialysis, Home Health.
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! :)

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Specializes in Telemetry, Nursery, Post-Partum.
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.

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Specializes in Hemodialysis, Home Health.
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

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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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Specializes in Lie detection.
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

i would say definitely have standing prn orders. i'm going to run it by my supvr also. but as with everything else, they usually make the policies after something happens...

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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%?

This is an excellent point. I don't think anyone has talked much about O2 sat errors either. Setting aside the ABG's and the fact that the patient was vented in this particular case, just for the sake of discussion ...

What about errors in O2 sat readings? I've personally seen variances of 6 points just by using different machines. I know RT's who have complained about this problem also.

So, hypothetically, if the baseline is 80 but that baseline comes from one machine, and another machine says 74 but ... that could simply be a six point equipment variation ...

Do we say that patient is incompetent and ignore their wishes? Especially with no mentation changes?

:typing

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