Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 2

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   medicin79
    While this pt may normally function well with a low 02 sat; the description suggests she is decompensating. I'm a little confused by the concern that 'people die in the waiting room' and the statement that this 'wasn't an emergency'. As a side note; pt's are seen at the ED based on acuity, not mode of arrival. Calling 911 isn't going to get her in any faster, and is an inappropriate use of resources for nonemergency situations. While the medic's choice of words may not have been the best; the actions were standard of care for EMS.
  2. by   Medic/Nurse
    Hey there DuthchgirlRN -

    Please don't misunderstand my position. You have every right to disagree with me as I do with you. We disagree. I have disagreed with folks before - and hopefully we can all walk away with having learned something!

    Your OP made it sound as if this was NOT a sick patient - I will bet that NOTHING the paramedic did in the short time they cared for this patient is the REASON she is in the ICU now.

    The pCO2 of 150 plus is bad, but the permissive hypoxemia that continued in the HOME CARE (of what duration) of this patient along with the FEVER contributed to this patient outcome. Oh, and lets not forget the hemoglobin (read bleeding from somewhere) I'll also bet that this patient is in sepsis - this also makes for dramatic acid/base derangements, too! The paramedic is not responsible for all that -

    I'm advising you to tread carefully. It really gets my goat when I have folks that "report" other healthcare providers - when they themselves do not know what they do not know. I took your OP as a justification on whether to REPORT this paramedic or not. Well, the short answer is NO - NOT JUSTIFIED.

    You are looking to create a problem...and if I was this medic (and I'd get a complaint/report on me of this nature) I'd make sure that we all look at the entire clinical course of this patient! But to COMPLAIN on me because I gave a patient that was HYPOXIC oxygen is just...well...silly. To COMPLAIN on me, because I did not "listen" (meaning do what I was told) to a home health nurse and various family members while caring for a SICK patient...is just RECKLESS and VINDICTIVE. But, I understand that you may feel the need to make someone (the PARAMEDIC) look like the big, bad boogeyman here...everyone needs a boogeyman from time to time.

    When I was just a lowly little street medic I had wide varying experiences with HOME HEALTH NURSES - including one RN doing CPR on a patient that was begging her to stop! So...
    In my experience HHN's are generally not able to manage an acute/critically ill patient with any real degree of competency.

    Now just so you know. This patient was sicker than you realize - fever produces a mild acidosis state in the body as metabolic demands increase/respiratory rates increase in compensation and the cycle of CO2 retention that you are so well versed in is cascading in this patient. ADD to this clinical picture a HEMOGLOBIN of 7 and change - well, I will further doubt the accuracy of your saturation measures as there WAS NOT ENOUGH BLOOD/HEMOGLOBIN to get an accurate reading. In my area transport times are long, and I may have ended up intubating in the field - and not just because of CO2 retention. I think impending respiratory failure to be unavoidable in this NOT SICK patient.

    Now, I'm all for patients right to refuse. But this patient may not be able to make a fully informed decision due to the critical nature of her situation. And short of everything legal in order - the family does not get to decide on the fly either once I arrive and assume care. Once the call is made and I arrive, I have a duty to act in absence of specific criteria (dead, EMS DNR, state of injury incompatible with life).
    And, as such I WILL act. EVERYTIME. ANYWHERE. I can explain action over inaction. But, heck I can explain either!

    What about this patients care will you be able to explain?

    The more you stir the poo, the more likely it is to get on you!

  3. by   medicin79
    Just a quick question, since I'm not experienced with home health practices. If this wasn't perceived as an emergent situation; shouldn't the pt's PMD have been contacted, for admitting orders etc., prior to her going to the hospital?
  4. by   rnin02
    I think you made some great points, but I don't see mention of the patients Hemoglobin anywhere...am I missing something??? Which is entirely possible.

    Quote from NREMT-P/RN
    Hey there DuthchgirlRN -

    Please don't misunderstand my position. You have every right to disagree with me as I do with you. We disagree. I have disagreed with folks before - and hopefully we can all walk away with having learned something!

    Your OP made it sound as if this was NOT a sick patient - I will bet that NOTHING the paramedic did in the short time they cared for this patient is the REASON she is in the ICU now.

    The pCO2 of 150 plus is bad, but the permissive hypoxemia that continued in the HOME CARE (of what duration) of this patient along with the FEVER contributed to this patient outcome. Oh, and lets not forget the hemoglobin (read bleeding from somewhere) I'll also bet that this patient is in sepsis - this also makes for dramatic acid/base derangements, too! The paramedic is not responsible for all that -

    I'm advising you to tread carefully. It really gets my goat when I have folks that "report" other healthcare providers - when they themselves do not know what they do not know. I took your OP as a justification on whether to REPORT this paramedic or not. Well, the short answer is NO - NOT JUSTIFIED.

    You are looking to create a problem...and if I was this medic (and I'd get a complaint/report on me of this nature) I'd make sure that we all look at the entire clinical course of this patient! But to COMPLAIN on me because I gave a patient that was HYPOXIC oxygen is just...well...silly. To COMPLAIN on me, because I did not "listen" (meaning do what I was told) to a home health nurse and various family members while caring for a SICK patient...is just RECKLESS and VINDICTIVE. But, I understand that you may feel the need to make someone (the PARAMEDIC) look like the big, bad boogeyman here...everyone needs a boogeyman from time to time.

    When I was just a lowly little street medic I had wide varying experiences with HOME HEALTH NURSES - including one RN doing CPR on a patient that was begging her to stop! So...
    In my experience HHN's are generally not able to manage an acute/critically ill patient with any real degree of competency.

    Now just so you know. This patient was sicker than you realize - fever produces a mild acidosis state in the body as metabolic demands increase/respiratory rates increase in compensation and the cycle of CO2 retention that you are so well versed in is cascading in this patient. ADD to this clinical picture a HEMOGLOBIN of 7 and change - well, I will further doubt the accuracy of your saturation measures as there WAS NOT ENOUGH BLOOD/HEMOGLOBIN to get an accurate reading. In my area transport times are long, and I may have ended up intubating in the field - and not just because of CO2 retention. I think impending respiratory failure to be unavoidable in this NOT SICK patient.

    Now, I'm all for patients right to refuse. But this patient may not be able to make a fully informed decision due to the critical nature of her situation. And short of everything legal in order - the family does not get to decide on the fly either once I arrive and assume care. Once the call is made and I arrive, I have a duty to act in absence of specific criteria (dead, EMS DNR, state of injury incompatible with life).
    And, as such I WILL act. EVERYTIME. ANYWHERE. I can explain action over inaction. But, heck I can explain either!

    What about this patients care will you be able to explain?

    The more you stir the poo, the more likely it is to get on you!

  5. by   hogan4736
    Quote from NREMT-P/RN
    So you called 911 even though NO EMERGENCY existed.

    This decision was made to keep from "having to sit the the ER".

    ...

    you point out what caught my eye as well...

    3 cars in the driveway, a host of family at the house, but, out of ignorance and convenience, they called 911...

    911 abuse at it's best (at least from the OP's description)

    hope the patient is doing better...
  6. by   DutchgirlRN
    [quote=NREMT-P/RN;2039299]Hey there DuthchgirlRN -

    Please don't misunderstand my position. You have every right to disagree with me as I do with you. We disagree. I have disagreed with folks before - and hopefully we can all walk away with having learned something!
    Nice thought, hope you're right

    But, I understand that you may feel the need to make someone (the PARAMEDIC) look like the big, bad boogeyman here...everyone needs a boogeyman from time to time.
    I'm not looking for trouble nor looking for someone to blame for the patients situation. It was what it was. I disagree that the family's, the patient's and the nurses's comments should be disregarded as though she knows "everything". I know this patient well and her family knows her medical status like the back of their hands. That info should not be so easily dismissed.

    In my experience HHN's are generally not able to manage an acute/critically ill patient with any real degree of competency.
    You would not be referring to me? I've been an RN for 31 years in acute Med/Surg Telemetry. I've been doing HH for a little over a year now and it's a whole different ball of wax from the hospital. In my experience paramedics are merely doctor wanna be's. How long do paramedics go to school?

    Now just so you know. This patient was sicker than you realize - fever produces a mild acidosis state in the body as metabolic demands increase/respiratory rates increase in compensation and the cycle of CO2 retention that you are so well versed in is cascading in this patient. ADD to this clinical picture a HEMOGLOBIN of 7 and change - well, I will further doubt the accuracy of your saturation measures as there WAS NOT ENOUGH BLOOD/HEMOGLOBIN to get an accurate reading. In my area transport times are long, and I may have ended up intubating in the field - and not just because of CO2 retention. I think impending respiratory failure to be unavoidable in this NOT SICK patient.
    Ok I learned something new about 02 sats but again HH is different. I had no way of knowing her Hgb was low. She just got out of the hospital 2 days ago and all labs were WNL. This NOT SICK patient is then an emergency?

    What about this patients care will you be able to explain?

    The more you stir the poo, the more likely it is to get on you!
    I think I handled it correctly and professionally. We'll see in the week to come and I will let you know.
  7. by   medicin79
    Obviously there is an agenda here; paramedics are not 'doctor wannbe's'. The are however physician extenders, and are expected to operate in an acute care clinical mode. You are right, HH is different than EMS. It is foolish to apply the standards of one to the other. Rather than turn this issue into a confrontation about who is more right; why not take the time to educate the paramedics and to learn from them? I am a new grad nurse and a 27+ year paramedic. Little in my EMS education was applicable to nursing, and conversly my nursing education would not have prepared me to care for pt's in a field setting.
  8. by   canoehead
    I think this patient was going to be vented no matter what the paramedic did. You may have been completely and utterly right that the patient needed 2lpm, but that paramedic doesn't know you. He's walked into a situation that to an outsider looks crazy. Sats in the 70's, no SOB, one lung, fever, a 911 call for emergent care but everyone is telling him not to treat anything, just drive...I would have been pretty darn nervous. He was wise to stick to his protocols.

    I also have had EMT's tell me that they were taught to give the NRB during transport if sats are low, even if it is a CO2 retainer. The rationale is they need the oxygen and the patient can be treated for retention in the ER, but lost brain cells are forever. Also if the EMT experience is anything like the ER nurses' you cannot trust someone else's judgement. The weirder the situation is, the more likely they have confused the facts or don't understand the physiology (yes, even home health nurses). If they knew you or the family beforehand maybe...but with sats in the 70's, probably not.
  9. by   UM Review RN
    DG, I agree with whoever said the Pt was probably going septic. That, or possible aspiration pneumonia would generate a fever that high. Either way, that's the type of patient that can go downhill really quick, so I'm glad you called EMS. I think it was appropriate to do so.

    Likewise, we routinely turn up the air on Pts who are satting that low--let me stress this--for a short time. They will then either move to bipap or vent.

    I haven't been a nurse for 31 years, but I also feel that this patient had something big brewing and you caught on to it early enough so that the patient did survive.

    I'd love to know the final dx on this Pt. and I sure hope they did blood cultures.
  10. by   morte
    my question: what part of the word NO does the paramedic not understand? if she felt uncomfortable honoring that, then she should have consulted her superior.
  11. by   canoehead
    If the patient does not want the treatment offered they are free to tell the medic to leave. Refusing treatment makes an ambulance ride redundant- it would be better to call a cab, or have family transport.
  12. by   ZASHAGALKA
    Topic directly on point:

    http://allnurses.com/forums/f22/copd...o2-194267.html

    http://cmbi.bjmu.edu.cn/uptodate/cri...ypercapnia.htm

    "Physicians have observed for many years that the administration of oxygen to patients with chronic obstructive pulmonary disease (COPD) may be followed by hypercapnia. Traditional teaching emphasizes that hypercapnia results from suppression of hypoxic ventilatory drive and warns that "patients will stop breathing" if given oxygen. However, this interpretation does not account for the many factors that contribute to the control of breathing in these patients, and has resulted in oxygen being withheld inappropriately from some patients with acute respiratory failure."

    ~faith,
    Timothy.
    Last edit by ZASHAGALKA on Jan 28, '07
  13. by   DutchgirlRN
    Quote from canoehead
    Also if the EMT experience is anything like the ER nurses' you cannot trust someone else's judgement. The weirder the situation is, the more likely they have confused the facts or don't understand the physiology (yes, even home health nurses). If they knew you or the family beforehand maybe...but with sats in the 70's, probably not.
    Canoehead, you may be one paddle short of a regatta but you are right on this one. I appreciate your calm and sensible approach and nicely said too. This really put the situation in perspective for me. Thanks!

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