Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 15
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
Feb 1, '07chronic copd'er, 1 lung, 02 @ 6l/min. what would you do?
you asked for it and here it is. it will be interesting to see how it pans out.
there are answers for nurses and for paramedics. you can choose more than one answer.
for those of you who have no clue: i am a hh nurse. i had a patient who is a chronic copd'er, smoked 3 packs a day (45+ years). normal 02 sat in the low 80's. has 02 bnc @ 2l/min. has a doctor's order to never increase the 02 above 2.5l/min. when i arrived at the patient's home, 02 sat was 73% and had been in the low 70's for the entire day. pt was alert & oriented, said they had no sob, was sitting up playing cards with the daughter when i arrived. the one lung was full of wheezes. i wanted this pt to go to the er more because of the wheezing and temp of 102 than because of the 02 sat. the patient reluctantly agreed to go. the family agreed. they refused to take her in the car because they felt the pt would have to sit in the waiting room because pt didn't appear sick or in any distress. also refused because the pt had just been released from the hosp two days prior with a shoulder broken in 3 places and surgery could not be done due to severe osteoporosis and fragile respiratory status. we decided to call 911.
paramedic arrived. heard the stats "oh my god a sat of 73%, turn the 02 up to 6l". i asked the paramedic not to do that. i advised her of the doctors order. the daughter stated "my mom's co2 went to 134 the last time she was transported with 6l of oxygen, please do not turn it up that high". the patient said to the paramedic. "please don't do that to me". i had been unable to reach the doctor due to a faulty answering service, all i could get was a fax tone. i called the hospital to confirm i had the correct contact number and it was confirmed. i wanted to ask the doctor if this pt could be a direct admit. i was out of luck. the family was refusing to transport so 911 was the choice i made. we were all calm and relaxed in making these decisions, no anxiety was involved. once the paramedic arrived, the anxiety level went sky high, things happened very quickly and the patient was on the way. my issue was that the paramedic totally ignored me, the doctors order, the grown daughter who is dpoa, and the pt's wishes. at the time i believed the increase in o2 would harm the patient. that factored in with my anxiety as well. i think everyone is curious as what this poll will show. remember you can choose more than one answer.
steroid induced acute hemorrhagic pancreatitis.
who would have thought? even with all the available tests/tools available in the hospital only her respiratory status and infectious status were looked at and treated. i did create a poll regarding this matter in case you are interested. i have learned alot, from both sides. i thank you all for that. it has been hard to lose this patient that i had become very fond of.Last edit by NRSKarenRN on Feb 3, '07 : Reason: highlighted points
Feb 1, '07Kudos to DutchGirl for coming into this debate all fired up and leaving it having learned something. I think we can all take your example and run with it. Yes, we get emotional and we get involved in what we do. But one of the great things about these boards is that they give us a place to step back, take a breath, hear some opinions and learn from one another.
DutchGirl, I'm so sorry to hear that your patient passed away. It's rough to lose someone you've become close to.
Feb 2, '07Quote from DutchgirlRNI'm sorry if you misunderstood my post. I was referring to the many posts on this thread which have talked about how a patient can deceptively appear to be mentating when they're really not.I will say this "one last time" her sats had been in the low 70's all day. She had breakfast, lunch, and dinner. Shopped on e-bay, Watched a movie and was sitting up playing cards with her daughter when I arrived. Mentating. Yes she definately was!
Feb 2, '07Quote from dutchgirlrni'm sorry to hear about your pt. thank you for sharing this case with us, i too learned something as well.steroid induced acute hemorrhagic pancreatitis.
who would have thought? even with all the available tests/tools available in the hospital only her respiratory status and infectious status were looked at and treated. i did create a poll regarding this matter in case you are interested. i have learned alot, from both sides. i thank you all for that. it has been hard to lose this patient that i had become very fond of.
Feb 2, '07DutchGirl...I am sorry for the loss of your patient! I too learned alot from this thread, and I am sure many others did as well. Once again I am sorry for the loss.
Feb 2, '07Wow. I don't think I would have ever come up with that one. I also would like to commend you - many OPs run away and never return to their posts once things start to get a little hairy. I too feel like I've learned something....a good review of acid base balance in COPD for starters. And this was definitely a thread that got us thinking for sure!
Wishing you peace and a relaxing weekend. PS - I'm very glad there are people like you to do HHN. I can't do it!
Feb 2, '07I'll echo what other have said: sorry to hear about your patient, DutchGirl, but WOW, has this thread been an education!
Did it take an autopsy to discover the pancreatitis?
Shows that even doctors can really, really blow it now and then. But given the WBC count, yeah, I certainly would have thought some sort of sepsis.
Feb 3, '07Quote from wtbcrnaYour wish is my command.......http://allnurses.com/forums/f118/chr...do-204677.htmlIs there a way to turn this debate into a poll to see where the majority of people fall? It would also be interesting if we could tie in the response to what area of nursing you worked in also...Just a thought
Feb 5, '07We just had a schizophrenic patient in our vent unit in resp distress refuse to go to the hospital. Full code. The paramedics refused to take her. A psych consult was pending to determine competancy. Meanwhile, has no guardian or POA either. I"m curious what everyone thinks about that situation? Right thing to do? Sats in the 70's -80's still apply, don't they, regarding her ability to still be competant? Don't know the outcome, yet. (Not my unit) I know that when I had a similar situation, the paramedics said they'd be back if my patient had a change in conciousness, I guess because it wouldn't be up for discussion!
Feb 6, '07I hit the wrong key by accident! Just so I don't look like a total loser, my answer to the poll is
"I think ultimately the patients wished should have been honored." I am a Nurse.
I think in this case the patient knows what is best for himself, and I don't think it was an emergency situation. The O2 Sats were in the 70's all day?!
Feb 6, '07I have a hard time with calling 911 to avoid an er wait. If I had been triaging this patient I would have looked at all the factors, no sob, easy resps etc and triaged her accordingly regardless of how she arrived. It's a common misconception in our et dept that pts in ambulances get seen first.
Feb 6, '07I read the entire thread!!! Took hours, as I had to leave and get groceries and accounting for "server too busy" messages. I am so impressed with the OP for sticking with the topic and updating us. My sympathies to her and the family.
I voted "the paramedic was right to increase O2". But I also feel that "The patient's wishes should ultimately be respected". I'm afraid though that if the patient wanted EMS to help her then those two things might not gel. I bet the medics could have provided a refusal form and left but the medics could not transport and not treat. I think the OP has learned some things from this event that will help her educate her patients (and their families) in the future.
I hope many here have learned something about EMS services. You are not just getting a ride to the hospital when you call 911. You get assessment and treatment. If that isn't needed; call the Non-Emergency Transport Van (yea, I guess not all communities have these).