Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 20

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   ZippyGBR
    Quote from 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.
    yes given the clinicla picture of a a COPD patient on LTOT who is

    - febrile

    - SpO2 lower than usual

    - more wheezy that usual

    that starts ringing 'emrgency' bells in my head
  2. by   DutchgirlRN
    An Update:

    This patient did have a DNR in the home. The pt was put on a vent with his/her permission as a temporary measure to get the CO2 down.

    My agency did not report the paramedic because I asked them not to.

    When the ambulance radio'ed the ER that they were in route the ER doc gave them a direct order to turn the 02 down to 2L BNC, stating that he knows this patient very well.

    The family won't be suing. They knew the patients lifespan was less than 6 months. They just wanted their loved one to be comfortable and be cared for respectfully.
  3. by   Sheri257
    Quote from shawng007
    actually, it doesnt matter what the end result is, the patient has the right to refuse, and as i said, NO means NO.
    But there's all kinds of exceptions to that rule. If the patient is on drugs, alcohol, etc. ... or they've stroked out ... or they have head trauma, Alzheimer's, etc. The list goes on and on.

    If the situation involves mental impairment where they're not competent to make decisions even temporarily then, no doesn't mean no. And there's lots of research documenting cognitive impairment as a common phenomenon in chronic hypoxic COPD'ers.

    :typing
    Last edit by Sheri257 on Feb 18, '07
  4. by   cardiacRN2006
    Quote from shawng007
    i if that were my family i would sue, and i guarantee i would win too.

    No, actually, you wouldn't. You are not familiar with a paramedics' protocols.

    Quote from elizabeth321
    This is the scariest part of posts like this...people that aren't practising nursing according to any policy or procedure....just making decisions based on personal opinion.

    This thread wasn't about practicing nursing at all, it was about prehospital.
  5. by   fr.dad
    There are a number of factors being ignored or getting too little discussion in this thread.

    1. This pt [not some hypothetical text book pt, some other pt with a different set of circumstances who was treated in the past] does have a DNR in place. This pt does have a family member designated with a DPOA. Those facts have been established in earlier discussion in this thread.

    2. This pt is, by DG's description, A&Ox3 and competent to manage her affairs. She has been eating, shopping on eBay, playing cards and conversing with family all day with a PO2 in the low 70's. The only reason the family called for the home health nurse was because they thought the O2 levels should have come up after breathing treatments and it was getting late in the day.

    3. DG reported very emphatically several times that this was NOT AN EMERGENCY. Many posters here are looking at the PO2 levels and declaring an emergency in spite of the nurse's professional assesment. Then some are using that presumed emergency condition to justify overruling the pt's refusal and force treatment on her.

    4. Calling 911 does not waive a pt's right to refuse treatment. Pt refusals are a common part of the ambulance business. They happen every day. There are other conditions that do activate "implied consent" such as unconsciousness, underage status, prior adjudication, obviously impaired mental status. According to DG's description of this pt, no such condition existed at the time of this incident. What happened later in the ED or the ICU does not change the pt's right to refuse treatment at the time of this incident.


    5. Very little attention has been paid to assessing the pt's mental status, rather than assuming it without assessment. Nurses, Paramedics, and EMT's all receive training in assessing mental status. All should be using those skills, following those procedures as part of their decision process, rather than basing everything on what the meter shows. Many here are arguing for actually disregarding the patient's mental status to overrule her refusal of high flow O2. That is bad medical practice, whether pre-hospital or not.

    6. No one else has asked why the DPOA was not invoked by the family too address the presumtion of pt incompetence. If the pt is not competent to refuse the high flow O2, then the DPOA becomes effective and the Attorney-in-Fact is authorized to refuse on the pt's behalf.

    Fr.Dad
    Last edit by fr.dad on Feb 19, '07 : Reason: delete message, I'll rewrite it.
  6. by   cardiacRN2006
    .....
    Last edit by cardiacRN2006 on Feb 19, '07
  7. by   elizabeth321
    This thread wasn't about practicing nursing at all, it was about prehospital.[/quote]

    Don't be so concrete....much more has been mentioned other than prehospital.

    Liz
  8. by   fr.dad
    I apologize. If you check you will see I took that message down almost immediately. Actually, I re-read your post and realized I had mis-read your words so I removed my response.

    I hope you and I are the only ones who saw it, because it is gone now.

    Fr.Dad
  9. by   cardiacRN2006
    Quote from elizabeth321

    Don't be so concrete....much more has been mentioned other than prehospital.

    Liz

    Having being fortunate enough to work both in Prehospital and in the hospital, I am aware of that, Liz.


    My point was, a comment was made specifically about nursing I believe by you
    Originally Posted by elizabeth321
    This is the scariest part of posts like this...people that aren't practising nursing according to any policy or procedure....just making decisions based on personal opinion.

    Very few people in this situation would have acted on personal opinion alone. This thread was about what happens when your pt gets picked up by pre-hospital personnel.
    The HHRN, and the paramedic we in fact, working according to policy and procedures, and they were both right.

    However, in the field, we have a specific set of protocols that leave very little room for gray area.
    Once the pt is in the hands of Pre-hospital they are out of "nursing". And THAT was my point.
  10. by   cardiacRN2006
    Quote from fr.dad
    I apologize. If you check you will see I took that message down almost immediately. Actually, I re-read your post and realized I had mis-read your words so I removed my response.

    I hope you and I are the only ones who saw it, because it is gone now.

    Fr.Dad
    Thank you Fr.dad. I appreciate that. I'll edit my post...
  11. by   ICURN/UTEP
    Does sound like something was brewing. Question of should the o2 been cranked up, well the number one thing noted was pt. did not appear to be in distress. Treat the pt. not the monitor. However this para's actions could be defended if pt was tachycardic, and s/s of pt. trying to compensate for hypoxia. The extra o2 in the same sense could decrease this blue blowers hypoxic drive to breath thus decreasing amount of co2 blown off. Obviously pt. had to have some distress at some point other wise would not have been tubed and placed on vent. We know that copd ers are co2 retainers however a co2 of 152 is really excessive. Base deficit and ph where probably life threatening. Sounds also like this person has chronic problems and is going to have frequent bouts like this until eminent death. If this person does not want to go through intubation and ventilator support needs to lay down DNI/ DNR. Don't believe this paramedics actions are what caused resp. failure however does not look like extra 02 helped anything.
  12. by   fr.dad
    Other issues that should be getting more attention here:

    1. Hospice. While we did not know for sure earlier, the pt's condition and diagnosis have suggested all along that she is approaching the end of life. Medicine does not know how to heal advanced COPD, only how to provide care and comfort. In post #249 we learn that the family knows the pt's life expectancy is less than six months. I wonder why pt was not enrolled in a Hospice.

    2. In fairness to the Paramedic, I wonder whether she was given the necessary background facts, such as a copy of the DNR, the MD's orders about never exceeding 2.5 lpm O2 under any circumstances, the existence of the DPOA.

    3. Did DG have an option to call for a routine, non-emergency transport to the hospital? If so, why was that not done for this pt she deemed non-emergent? If not, why has her agency not made such arrangements possible? I do know that such things were in place and frequently used in the four communities, urban, sub-urban, and rural, in three states where I have been involved with EMS.

    4. Someone, possibly Social Services at the hospital, possibly the pt's pastor or attorney, possibly DG as her home health nurse, someone who knows about Advance Care Directives, Living Wills, and such things, ought to have tried to assist the pt to write the appropriate documents for her state to address this sort of circumstance. As someone has pointed out already, a DNR does not address treatments prior to the need for resuscitation. Again, I am thinking of Hospice. Generally Hospice people can be very helpful to pts and families to sort out these issues.


    Fr.Dad
  13. by   Sheri257
    Quote from fr.dad
    Very little attention has been paid to assessing the pt's mental status, rather than assuming it without assessment. Nurses, Paramedics, and EMT's all receive training in assessing mental status. All should be using those skills, following those procedures as part of their decision process, rather than basing everything on what the meter shows.
    Actually, I thought people were also addressing the medic's assessment ... i.e. raising the possibility that the medic did use their skills and may have had a completely different assessment than the nurse's.

    If I'm not mistaken, some of the medics on this thread described circumstances where a patient might seem fine to a nurse who's treated a patient for a long time and might not notice some things due to a gradual decline ... versus a medic who's never seen the patient before and looking at them with fresh eyes who might see something else.

    Since the patient was, in fact, intubated ... it seems possible that the medic might have had a completely different assessment.

    :typing
    Last edit by Sheri257 on Feb 19, '07

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