Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 17

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   darrell
    Quote from Nurse_Drumm
    I'm not knocking the EMT here, but I have to ask (as a RN never having been an EMT), are the EMT's not trained or aware of the complications of a retainer?
    Read my earlier quote for details, but essentially the answer is yes, EMTs are educated on the subject and no, they may not (at least in my area) adjust O2 delivery based on this. Only a doctor or Paramedic may give orders to an EMT, and only a doctor may give orders to a Paramedic, thus effectively tying both EMS professionals' hands in this situation.

    The EMT-P may not have been obstinate or cold (I wasn't there), but simply trying to deal for the umpteenth time with an old issue while still keeping the scene on track.

    You see, discussion and arguments at EMS scenes are not uncommon and part of the lead EMT's job is to keep things moving forward. If she agreed with the nurse privately, she may still have known from past experience the decision wasn't going to change and further discussion was eating up seconds.

    Again, I am an EMT-B, a respiratory floor tech and a student RN. I'm trying to be fair across the board here because in this case I think the protocols need to be looked at, not the personnel. Why not ask the patient's doctor or the local medical control to comment?

    D

    PS: I didn't mean to insinuate the protocols need changing, either. It's more than possible that research bears out the use of high flow for COPDers under these circumstances. What I meant to say is that perhaps a rider to call med control would be appropriate when requested by home health, the patient or family. If in the doctor's opinion this is not going to change anything, then perhaps an effort to educate the home team might be appropriate.
    Last edit by darrell on Feb 7, '07 : Reason: Addendum
  2. by   JanInTexas
    First of all, to DG: so sorry to hear that the patient died. But thank you for starting the topic, for hanging in there and keeping us updated throughout the entire 20+ pages, and for letting us know the final outcome.

    So, brand new RN BSN here. Graduated in December. Passed the NCLEX on 1/23. Employed on a GYN-ONC unit in a teaching hospital. I learned a lot from this discussion. It also gave me food for thought about several different issues. Even if I didn't agree with some of what was said, the 2+ hours I spent reading all of the posts was time well-spent.

    On the poll, I voted to up the O2. Yeah, like a lot of other folks who posted, we were taught that you don't give COPD patients too much O2 so that you don't knock out their hypoxic drive. However, last semester in our Critical Care Nursing class, we were taught that you don't withhold O2 from them if they need it--and that if they are hypoxic, they're probably going to be on a vent or some sort of respiratory support anyway.

    As far as respecting the wishes of the patient, it's a gray area for me in this case. We are taught that NO = NO! But, I don't think I would just walk away and say "whatever" when a patient says no. On the floor, if the patient says he/she doesn't want a test, procedure, medication, etc., I would definitely provide information so that the patient/family could make an informed decision--you know, this is what the treatment could do for you, these are the side effects, and this is the impact of choosing to refuse treatment. I could even call in a more experienced RN, or the Resident/Attending, to talk to the patient/family. I see nothing wrong with that. If the patient still refuses after that, well, okay then. However, the field (and I include the ED here) is very different from the floor. So, I'm still thinking about this...
    Last edit by JanInTexas on Feb 7, '07
  3. by   RXCT
    Quote from Cher1983
    You also have think that the patient now being on a vent was probably unavoidable. Sats in the 70's, one lung, wheezy, febrile...something was brewing, and with a person with one lung it probably wont take much to go down hill.

    Cher
    With a COPD'er the MAX O2 delivered should be 2-3 L. No greater than 3L due to their inability to blow-off the CO2. With only one lung; that's another story and I'm guessing the O2 will now be below the2-3L mark. Once paramedics arrive, it's out of your hands. Foolish to crank up to 6L without acknowledging the patients history. I would addressthe issue with the medic company and possibly they can "retrain" the person or offer addition education.
    But, then again I work LTC and Rehab and had had COPD patients with orders to increase O@ up to 5-6 L, doesn't help; only causes increased confusion if anything?????
    Last edit by RXCT on Feb 7, '07
  4. by   earth_to_hal
    I agree with Cher1983, Dutchgirl and others. From experience in MICU the fastest way to kill this person is to push O2, raise CO2 and have respiratory arrest. To be honest, I would call an AMBU for transport because it is impossible to get seen quickly in the ER any other way.
    Assessing the patient, finding them stable and transport
    should be the protocol. I've seen more pt's harmed by too much than too little O2 in a supervised setting.
  5. by   darrell
    Quote from JanInTexas
    As far as respecting the wishes of the patient, it's a gray area for me in this case. We are taught that NO = NO! But, I don't think I would just walk away and say "whatever" when a patient says no..
    Agreed. Resoundingly. In this case, however, the patient wanted transport and apparently was no saying no so much as attemping to convince the paramedic to do something outside her protocols. Something contrary to the standing orders the doctor (medical director) had provided.

    That the nurse or family was saying no is irrelevant from a legal standpoint, although Ievery EMT I can think of will eagerly consider input from sources close to the patient. In the final evaluation, though, the treatment must meet the paramedic's scope of practice.

    On the floor, there is time for intervention to convince a patient to take a med, accept a treatment, conform to a PT schedule. In my area, EMTs usually have 10-30 minutes with a patient from arrival on-scene to ED triage. God knows I wouldn't want to make the day worse for a patient in distress, but my job is to first to stabalize and transport. My protocols are geared to those goals and I feel they do a pretty decent job.

    Once I graduate, I will need to do RN protocols when working under that hat and follow EMS rules when on the ambulance. I hope that what I do will help draw EMS and nurses a bit closer because we really do want the same thing for our clients.
  6. by   Sheri257
    Well ... now I'm confused more than ever. There doesn't seem to be any consensus on this issue.

    Many of the posters on this thread had me convinced that 6L O2 for 15 minutes wouldn't do much damage and, even if it did, it's better than dead brain cells.

    And, as I recall, many cited research that extra O2 for a few minutes wouldn't do much damage.

    Now, I'm doing Kaplan questions for the NCLEX and they're saying even 2L O2 can put a COPD patient into respiratory arrest in as little as 20 minutes if it kills the hypoxic drive.

    I know this is academia and not the real world but ... this is really confusing.

    Last edit by Sheri257 on Feb 8, '07
  7. by   UM Review RN
    Quote from lizz
    Well ... now I'm confused more than ever. There doesn't seem to be any consensus on this issue.

    Most of the posters on this thread had me convinced that 6L O2 for 15 minutes wouldn't do much damage and, even if it did, it's better than dead brain cells.

    And, as I recall, many cited research that extra O2 for a few minutes wouldn't do much damage.

    Now, I'm doing Kaplan questions for the NCLEX and they're saying even 2L O2 can put a COPD patient into respiratory arrest in as little as 30 minutes if it kills the hypoxic drive.

    I know this is academia and not the real world but ... this is really confusing.

    I think the key words there are "if it kills the hypoxic drive."

    If you have no hypoxic drive at all, one could assume that Very Bad Things will be happening.

    Here's another take on this from an RT:

    http://home.pacbell.net/whitnack/Why..._Wind.htm.6306
    Last edit by UM Review RN on Feb 8, '07
  8. by   Altra
    Quote from lizz
    Well ... now I'm confused more than ever. There doesn't seem to be any consensus on this issue.

    ...

    Now, I'm doing Kaplan questions for the NCLEX and they're saying even 2L O2 can put a COPD patient into respiratory arrest in as little as 30 minutes if it kills the hypoxic drive.

    I know this is academia and not the real world but ... this is really confusing.
    If that were true, in the last year & a half in the ER I would have killed, by my best estimate, approximately 200 COPDers.

    Real world: many COPD patients get 10-15L O2 via NRB, or put on BiPAP, fall asleep for a couple of hours, and then feel much better. Sometimes they're not even admitted - they can be discharged home if other x-rays/labs done in the meantime don't indicate pneumonia or some other problem.
  9. by   canoehead
    From the EMT point of view, though I'm not one, he could have let the patient stay hypoxic, possibly getting worse and requiring intubation during the drive to the hospital, and not followed established protocols. OR he could provide the O2 and maintain the sats somewhat, possibly making the patient worse B/C lack of drive to breathe, with plans to intubate if the patient didn't maintain sats, as per their standard protocol.

    Both decisions include the patient possibly getting worse and heading towards respiratory arrest. One of them followed protocols, and one didn't. I'd follow the protocols. JMHO.
  10. by   darrell
    Quote from lizz
    Well ... now I'm confused more than ever. There doesn't seem to be any consensus on this issue
    EMT training in our area says that it is unlikely the patient will arrest in the short time we are oxygenating him (about 20 minutes +/-). On the other hand, the training also states we should be prepared to bag.

    Again, the question is whether the EMT can diagnose in advance whether O2 will do more harm than good and the answer to that is obviously no. The opition as to whether O2 should provided at high flow rates to a hypoxic drive patient hopefully isn't even in question here. The rate should be decided by a doctor based on the individual PMH and monitored continuously for it's effect. It's not likely to be higher than 2LPM in most cases, I'd bet.

    Imagine being a paramedic or nurse walking into someone's house with minimal HPI and wondering if there has been some significant occult-ish respiratory change in the past day or three. SOB, SaO2 of 76%, S/S hypoxia and reduced LOC - now decide whether you should keep the 2L or increase it? While you are at it, remember that your protocols say high flow and you will have to defend your decision, perhaps in court.

    Here is a similar thread from an EMT site that might interest some nurses. I really believe that a deeper relationship between EMS and the nursing community would benefit the people who depend upon us!

    http://www.emsvillage.com/forums/mes...5&threadid=429

    Another site to peek at is http://jems.com.

    D
  11. by   withasmilelpn
    Quote from Angie O'Plasty, RN
    I think the key words there are "if it kills the hypoxic drive."

    If you have no hypoxic drive at all, one could assume that Very Bad Things will be happening.

    Here's another take on this from an RT:

    http://home.pacbell.net/whitnack/Why..._Wind.htm.6306
    Fascinating! Thanks for that great post! I guess then it all comes down to how good your lawyer is?!?
  12. by   PANurseRN1
    Quote from Nurse_Drumm
    Regardless of weather or not this situation was "emergent", the point here is that the RN was advocating for the patient, and had the knowledge to know that increasing the 02 to 6L/min on a COPD'er could be detrimental to the patient.
    I'm not knocking the EMT here, but I have to ask (as a RN never having been an EMT), are the EMT's not trained or aware of the complications of a retainer? Especially if they were forwarned that this particular patient IS a retainer? And everyone asked/begged for the EMT NOT to turn up the O2 with logical and apparent reasons why? Please don't take this the wrong way, I'm mearly trying to educate myself......
    As has been explained in countless previous posts, there are cirumstances when it is totally appropriate to temporarily increase the O2. Pathophysiology, people...you don't just knock out someone's respiratory drive in a couple of minutes.
  13. by   UM Review RN
    Quote from withasmilelpn
    Fascinating! Thanks for that great post! I guess then it all comes down to how good your lawyer is?!?
    Am I sensing sarcasm here, withasmilelpn?

    Please note that Lizz was referring to a potential NCLEX question.

    If a lawyer was asking my rationale for upping the O2, my answer would be:

    Giving supplemental oxygen is the standard of care for any patient in an emergent situation.

    I believe we already established earlier in the thread that the patient's situation was truly emergent.

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