Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 12

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   LuvWounds
    I didn't say all emt/medic arrive on scene like this, I said I have freinds and former classmate who feel nurses don't know anything. I too have worked as an EMT for a private ambulance company and i have worked with many paramedics also. We do receive different trainning, what I learned as an EMT I did not learn in LPN school. I understand that but you would not be substaining life but for so long with that copd pt because the excess o2 would overload her because she can't make the exchange of CO, and I did learn that as an EMT and I know that he/she learned that as a Medic. Thats all I'm saying, no argrument intended here.
  2. by   Sheri257
    But do those protocols override the patient's right to refuse treatment when mentation is intact?

    Overall, I don't have a problem with what the medic did in this case but, I don't see how they can ignore a patient's request when the patient is alert and oriented.

    :typing
    Last edit by Sheri257 on Feb 1, '07
  3. by   NeosynephRN
    Quote from lizz
    But do those protocols override the patient's right to refuse treatment when mentation is intact?

    Overall, I don't have a problem with what the medic did in this case but, I don't see how they can ignore a patient's request when the patient is alert and oriented.

    :typing
    In the case that is being discussed I have no idea I was not there...I cannot tell you how the patient was acting...but in general here is my take..if you arrive on scene to a patient that has an O2 sat of 72%...they may be talking ok...but I have no idea what there baseline is...I do not know if the way they are acting is normal for them...and families are not always that big of a help...so I would say you have to err on the side that the majority of people that have O2 in the 70's, their brain is probably not perfusing properly, and they may not be able to make an informed decision at that point. If the patient was "with it" and was refusing treatment...then the family should have stepped up and driven them to the hospital...but since they felt it was an "emergency" I think they should take the emergency treatment...I am not saying that it was handled completley correctly...but I am just giving my opinion..which does not count for much..since I am not a nurse and am just an EMT-B. Hopefully some medic's will come back and give you a more "professional" opinion.
  4. by   wtbcrna
    Quote from lizz
    Question for the paramedics:

    Does the act of calling 911 and low O2 sats which, may or may not be reliable, override the patient's rights to refuse treatment if mentation is intact?

    From reading some of the posts, it seems that some of the paramedics think it does but, I was wondering if they could clarify their position and why.

    Does anyone know what the law says in this situation?

    :typing
    Without trying to fuel this fire anymore than it already is... I would like try answer this ( I am critical nurse/ICU/ER/LTC/clinic and prison nursing background). Unless the paramedic has a direct order from their medical director they need to act based on the scene situation. A patient that has chronic hypoxia/COPD and presents with O2 sat in the 70's cannot be deemed, without further testing, to be able to make appropriate judgements. I read where the family and the HH nurse requested to not turn up their O2, but this is normal procedure for the paramedic to turn up the O2. To break with that normal procedure is to put that paramedics' license/certification at risk. This is not being macho it is just normal procedure. I would have done the same thing in ER/ICU with the same presentation until I could get the physician to exam the patient.
    I truly don't see how turning up the O2 caused this patient to be intubated. This patient is going to be intubated over and over and over again until they either sign a DNI/DNR, can no longer tolerate being extubated/become a long term vent patient, or their body goes into multi-system failure.

    I think the big differences in opinions I am seeing is that the people who think that the O2 should be turned up are the people who are used to dealing with COPD patients in their acute excerbation phases, and the other group is used to dealing with them ,mostly outside the hospital, on a day to day basis.
  5. by   SEOBowhntr
    Quote from dutchgirlrn
    sorry, i disagree. i just called to check on the patient who is now in icu on a vent. co2 level of 152.
    ...........

    the pt could not wait in the waiting room in the condition in which she was in. people have died in waiting rooms.
    dutchgirl,
    i know your heart is in the right place, but if she's on a vent, and her co2 is 150, then she got to the hospital too late!!!! sat's that are in the low 70's, even in an unsymptomatic patient are a problem, as the brain may tolerate that just fine, but the other organs of the body are not going to for long. frequently, we see patients who come to the hospital with low sat's like this patient, who have elevated troponins. then some nit-wit doc, ignoring the fact that the patient was hypoxic with a sat in the high 70's, wants to get a cardiology consult. and too often, we send these people to the cath lab to find that they have clean coronaries. it was their decompensated lungs that caused cardiac ischemia (hypoxia) not occluded coronaries. in her situation, i actually would believe she was semi-emergent, if not emergent. i would also question why she's out of the hospital and back, in only a few days. obviously, someone may have discharged her when she really wasn't ready to discharge. giving her additional o2 didn't get her to that co2 of 150 and cause her to end up on a ventilator, a severe respiratory and metabolic disorder, such as a septic pneumonia did.

    keep in mind, these medics are trained with abc training, and "if the sat's are 73%, then the patient has an ineffective breathing pattern" is their thought process, and i'd honestly tend to agree. now give me sats in the mid 80's, i'm not nearly as concerned, unless the patient is complaining of dyspnea and is full of rales.

    again, as was previously stated, let this be a learning experience, not a vendetta. the medic did what he "was trained to do," and his actions honestly weren't the "causing harm."

    additionally, after i read the whole thread, i see that the patient apparently had a wbc of 1.7??? if so, was the patient a cancer patient undergoing treatment??? if not, and if she wasn't known to be severely neutropenic, the she was/is in moderate to severe sepsis.
    Last edit by SEOBowhntr on Feb 1, '07 : Reason: After reading a bit more
  6. by   chip193
    Quote from newatthis
    i didn't say all emt/medic arrive on scene like this, i said i have freinds and former classmate who feel nurses don't know anything. i too have worked as an emt for a private ambulance company and i have worked with many paramedics also. we do receive different trainning, what i learned as an emt i did not learn in lpn school. i understand that but you would not be substaining life but for so long with that copd pt because the excess o2 would overload her because she can't make the exchange of co, and i did learn that as an emt and i know that he/she learned that as a medic. thats all i'm saying, no argrument intended here.
    it seems that you were taught erroneous information or perhaps interpreted it incorrectly.

    you never withhold oxygen from a hypoxic patient. another poster did a wonderful job explaining the problems with nrbs, privacy, assessments, and copd patients. please look at that again.[font='arial unicode ms']

    the oxygen that you state is excess is actually not excess. the problem, in theory, is that the copd patient has lost the usual breathing trigger (hypercarbia) and now has breathing triggered by the back-up system (hypoxia). the theory is that if the patient does not become hypoxic, breathing will cease.

    the reality is that the relatively short transfer time that ems operates in (usually under 30 minutes from contact to er in urban and suburban settings), hypoxic drive is not knocked out. there is not enough oxygen bound to the hemoglobin and dissolved into the plasma to cause apnea.

    where things get tricky is when the copd patient is intubated and placed on oxygen. most of these folks are in a chronic respiratory acidosis, usually compensated by the kidneys with retention of bicarbonate. when respiratory failure ensues, the hypercarbia worsens, the acidosis worsens, and the kidneys are unable to compensate (hence, uncompensated respiratory acidosis). if untreated, end organ failure is imminent. when intubated, the oxygen settings are usually titrated to achieve a normal abg, but the "normal" abg is quite abnormal for these patients.

    with the attempt to wean the patient from the ett and reduce the amount of oxygen, the patient does not quickly re-compensate for the acidosis. hence, the problem actually isn't so much supplemental oxygen delivered for 30 minutes, it is the supplemental oxygen delivered for days to weeks that is forced by a ventilator into the lungs. it is these patients that are "trached and peged".

    so why doesn't the bicarbonate go up again? well, it took months to years to get the bicarbonate to that level and the body is unable to quickly compensate for it. even adding bicarbonate by iv push or drip is ineffective as it is quickly removed by the kidneys, which are back to performing in a normal manner.

    i hope that this helps.
  7. by   morte
    as i have said, at least twice, i am not arguing the medical, only the legal.....we are trained that NO IS NO....
  8. by   chip193
    Quote from lizz
    But do those protocols override the patient's right to refuse treatment when mentation is intact?

    Overall, I don't have a problem with what the medic did in this case but, I don't see how they can ignore a patient's request when the patient is alert and oriented.

    :typing
    Lizz,

    It comes down to this. This is a chronic COPD patient who EMS has responded to for hypoxia. I am sure that the patient's presentation was not of a pink, warm, and dry patient with easy respirations and a wacko sat of 73%.

    I am sure that the patient had at least some peripheral cyanosis, was probably in some sort of respiratory distress (perhaps at his baseline respiratory distress, but in some none the less), and was probably tachypneic and tachycardic.

    Given the presentation of someone who looks sick (but may be a the baseline appearance – but EMS has never seen the patient before) and has a crummy sat, the ability of permitting the patient to refuse oxygen is a huge can of worms that opened. In both the ambulance and the ER, I would have increased the oxygen.

    Chip

    Another thought: as you watch your friends that you see every day get a little older, maybe a little grayer, or even a little fatter, do you notice it? If you consciously think about what someone looked like a year ago verses today, you can point out the changes in that person. But can you do it day to day?

    The same thing applies to the patient that you've been watching for weeks to months. Can you pick up a gradual decline - or does the decline need to be an acute change to grab your attention?
    Last edit by chip193 on Feb 1, '07 : Reason: Added "another thought"
  9. by   Sheri257
    So ... this is what I gather from reading the responses:

    Since the patient, more than likely, will be confused regardless of their current mental state, that overrides any right to refuse treatment.

    And, obviously from a practical standpoint, it's probably better to have the patient alive rather than dead with their refusal rights intact.

    Ok ... I get it. But, it still seems kind of dicey. That's why I was also wondering what the law says in matters such as this. Does anybody know?

    :typing
    Last edit by Sheri257 on Feb 1, '07
  10. by   morte
    Quote from lizz
    So ... this is what I gather from reading the responses:

    Since the patient, more than likely, will be confused regardless of their current mental state, that overrides any right to refuse treatment.

    And, obviously from a practical standpoint, it's probably better to have the patient alive rather than dead with their refusal rights intact.

    Ok ... I get it. But, it still seems kind of dicey. That's why I was also wondering what the law says in matter such as this. Does anybody know?

    :typing
    hi lizz...i asked that question a couple of days ago, no one has been forth coming, only an oblique mention of law suits.....
  11. by   cardiacRN2006
    Sorry, but if I were on-scene, the mere act of calling 911 is a consent to basic treatment such as oxygen.

    I will never find myself in a courtroom defending my 'failure to intervene' in a situation like this. I may be defending treatments, based on protocols, standing orders, and personal history and experiences. Also, I would be held to a standard called the 'reasonably prudent person' standard. I would be vindicated.

    And I would know I did the right thing. If I did nothing and the pt died, I would feel horrible. If I did everything that I am trained for, and expected to do, and the pt died, then I did everything right.


    Again, it's been said a bazillion times. 911 was called. This means the pt thought that this was an emergency. The sats were critically low. The paramedic doesn't have time to trust that these sats are "ok" for the pt.


    The mere act of calling 911 with those sats constitutes implied consent.
  12. by   chip193
    Quote from morte
    as i have said, at least twice, i am not arguing the medical, only the legal.....we are trained that NO IS NO....
    "No is no" is only in play if the patient is competent to make that decision.

    Given the hypoxia and hypercarbia, that is a very gray area. In the ER, the doc would have the "how far do you want us to go" talk. In the field, it's not that easy, especially since the DNR cannot be given by medical control (it must be pre-planned).

    And remember, as I often say, I went to "short school" and the doc went to "long school". He can make that decision. I can't.

    Therefore, implied consent kicks in and the patient is treated to his/her best interest, which is increasing the oxygen.
  13. by   Sheri257
    Quote from cardiacRN2006
    The mere act of calling 911 with those sats constitutes implied consent.
    Well, that was my other question. Does the patient forfeit rights to refuse treatment after they call 911? Because I thought consent could be withdrawn at any time, even with emergencies. But, of course, I could be wrong which is why I am asking.

    :typing

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