Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 22

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   Justan
    I believe it's been mentioned before, but the paramedic is working under the license of a physician. That paramedic is also working (hopefully) within the confines of protocols which have been approved by that physician. Since the standard of care across the entire nation with a patient in this situation is to give high flow oxygen, and it could be said with a high degree of certainty that this is reflected in their protocols, your issue is with the physician, and not with the paramedic. A possible suggestion is to find that physician and explain to him why the protocol is in error.

    As a side note, if the paramedic had followed your direction and the direction of the family, all it would take is one lawyer educated in medical practices to see this, explain it to the family and convince the family to sue for wrongful death. Say what you will about our litigious society, but when the family is presented with the idea of a huge sum of money, the fact that they complained about giving high flow oxygen to their loved one will be forgotten in the mad rush to get that big fat check. They wouldn't win, of course, but that doesn't mean there wouldn't be a settlement, just to appease the family. This also doesn't mean the family still won't sue, even though the paramedic followed her protocol and did everything by the book. I've been sued before for wrongful death, and fortunately, following protocol by the letter saved my neck.

    Good luck in changing the mind of the physician about oxygen therapy.
  2. by   DutchgirlRN
    If the last 2 posters took time to read the entire thread they would realize that

    *I have agreed that the paramedic was correct to follow her protocol.

    *The 6L of 02 did not kill the patient.

    *The patient should have gone by car but the family refused.

    *Once the ambulance arrived the patients care is out of the nurses hands.

    *Home Health nurses are competent.

    *Many of us learned a valuable lesson or two!

    Good luck in changing the mind of the physician about oxygen therapy.
    Not nice...
  3. by   amomanurse
    this paramedic obviosuly didnt do so well in A&P and chemistry (hummmmmm maybe paramedics dont have the education us nurses do) or she/he would have known the reaction to increasing to O2 would stimulate the production of CO2 in the pt and causing the pt resp distress!!!!!
    hope this paramedic gets the diciplinary action he/she deserves before she/he is able to put another pt in danger!!!!! i am also in HH and i would have called his supervisor at the very minute and i agree, i hope u documented well!!! by the way, how did the pt come out of this in the end?
    amomanurse
  4. by   DutchgirlRN
    Quote from amomanurse
    i hope u documented well!!! by the way, how did the pt come out of this in the end?amomanurse
    Unfortnately the patient passed away. The cause of death was acute pancreatitis.
  5. by   MacD
    Someone please explain this to me!!! As an BSN/RN student I know very well a COPDer is operating only on a secondary hypoxic drive and that high flow oxygen can knockout their respiratory drive. I also know that oxygen absorption and carbon dioxide release by the blood while related are independent mechanisms. I also have been told that no matter the protocols or doctors orders if they are wrong and I follow them I can expect to be sued/found at fault as well. How can anyone defend the use of high flow oxygen on a known COPD patient????
  6. by   TiffyRN
    Quote from DutchgirlRN
    If the last 2 posters took time to read the entire thread they would realize that

    *I have agreed that the paramedic was correct to follow her protocol.

    *The 6L of 02 did not kill the patient.

    *The patient should have gone by car but the family refused.

    *Once the ambulance arrived the patients care is out of the nurses hands.

    *Home Health nurses are competent.

    *Many of us learned a valuable lesson or two!


    Not nice...




    I have followed this thread since it's beginning. Is it frustrating to others like it is to myself that the recent posters haven't bothered to read the whole thing; or even say the last few posts?

    DutchGirl; I quoted you above simply to help update some of those who haven't kept up. There are many complex issues addressed in this thread; a lot of information can be gathered and so much can be learned; from Home Health nurses, acute care nurses, ED nurses, students, EMT's & Paramedics, and others. Even though this thread is very lengthy I encourage all those who feel like posting to first read at least the first 4-5 pages of comments first; at least to the point where the OP posts the patient's final outcome. It is good stuff.
  7. by   MacD
    I have followed the thread since the beginning. Lets see sats in the 70's COPD bad but not unknown. Alert and oriented but lethargic. High flow oxygen and knock out respiratory drive or live with what you have seems simple to me!!!
  8. by   TiffyRN
    Quote from cardiacrn2006
    it is different for pre-hospital textbooks.

    this is right out of a paramedic textbook, page 303...
    "delivering an increased concentration of oxygen may increase the pao2, and therefore eliminate the drive to breathe. note: do not withhold oxygen from a patient who needs it. if you are concerned about eliminating the patient's hypoxic drive, be prepared to manage the airway."

    how to prepare for the emt paramedic exam (paperback)
    by [color=#003399]mark marchetta (author)




    also, straight out of my nursing textbook,

    "the nurse monitors clients at risk for oxygen-induced hypoventilation, apnea, and respiratory arrest. although oxygen induced hypoventilation is a serious concern, untreated or inadequately treated hypoxemia is a greater threat to life."
    medical-surgical nursing, ignatavicius and workman, pg 491


    the italics are the actual italics in the wording of the textbook, not my own.


    also a link to an article regarding hypoxic drive in copd patients:
    http://cmbi.bjmu.edu.cn/uptodate/cri...ypercapnia.htm

    a link to an rt student's personal research with several links to professional articles on hypoxic drive in copd patients.
    http://home.pacbell.net/whitnack/why..._wind.htm.6306



    i pulled all these links and information directly from earlier in this thread.
  9. by   chip193
    Quote from MacD
    Someone please explain this to me!!! As an BSN/RN student I know very well a COPDer is operating only on a secondary hypoxic drive and that high flow oxygen can knockout their respiratory drive. I also know that oxygen absorption and carbon dioxide release by the blood while related are independent mechanisms. I also have been told that no matter the protocols or doctors orders if they are wrong and I follow them I can expect to be sued/found at fault as well. How can anyone defend the use of high flow oxygen on a known COPD patient????
    Not every COPD patient (in fact it is a small minority - in the 5-10% range) are actually using hypoxic drive. I wrote earlier why the actual problem isn't the 6 lpm via nc, but the ventilator that is the real problem.
  10. by   jill48
    It never ceases to amaze me that so many medical people (nurses,emt's,etc.) are oblivious to the fact that you cannot turn the O2 up on a COPD patient. I would have told the emt's to get out of the patient's room and don't touch his O2, or anything else for that matter. I would tell them I'm not comfortable letting you take my patient. Then I would have reported the emt to his/her employer, and whatever board governs them.
  11. by   CRNI-ICU20
    I have to agree with Dutchgirl....
    Protocols are good, because the thinking is that everyone will follow the protocols and care will be more standardized. The downside is that protocols are not bendable....people are basically taught to follow the protocol and ignore common sense....ie, we aren't supposed to THINK anymore....we are supposed to just follow the written recipe....
    The only thing is, not all patients fit into the protocol box....not all people are the same...not all situations are the same....
    While this patient was probably working on a pneumonia....it is clear that high levels of 02 in most situations with a COPD patient will knock their respiratory drive completely out....
    Before the paramedics arrived, he was not labored...he was just satting in the 70's....I say, don't correct the sat....because he was tolerating that...I would say correct the underlying cause of the sat...ie the pneumonia, with med nebs....steroids....antibiotics....and fluid resuscitation and GENTLE oxygen support....he probably wouldn't have ended up on a vent....just my opinion....
  12. by   EricJRN
    Quote from jill48
    It never ceases to amaze me that so many medical people (nurses,emt's,etc.) are oblivious to the fact that you cannot turn the O2 up on a COPD patient. I would have told the emt's to get out of the patient's room and don't touch his O2, or anything else for that matter. I would tell them I'm not comfortable letting you take my patient. Then I would have reported the emt to his/her employer, and whatever board governs them.
    Jill,

    We're both shocked at the level of misunderstanding regarding COPD and hypoxic drive, but we're shocked on opposite ends of the argument. The hypoxic drive theory has been progressively taking a well-documented beating in the literature over at least the last ten years. We know it doesn't affect very many COPD pts. When it does, it generally takes hours - far longer than the typical EMS transport. See the 'Prehospital Care' section of the link below for one example of a well-reasoned argument in favor of not withholding O2.

    http://www.emedicine.com/emerg/topic99.htm
  13. by   kmoonshine
    Quote from jill48
    It never ceases to amaze me that so many medical people (nurses,emt's,etc.) are oblivious to the fact that you cannot turn the O2 up on a COPD patient. I would have told the emt's to get out of the patient's room and don't touch his O2, or anything else for that matter. I would tell them I'm not comfortable letting you take my patient. Then I would have reported the emt to his/her employer, and whatever board governs them.
    Let's give the EMT's some credit here! They are our eyes and ears in the field and have so much responsibility with a fraction of the training we as nurses receive. They have to deal with hysterical family members while performing CPR on the patient in the middle of the living room, go into homes infested with cockroaches, pull people out of the snow, and at times deal with violent situations. So let's give them a break and thank them for all that they do for our patients and for us. Take the opportunity to help and TEACH our EMT's, don't blame them.

    Also, a couple of minutes on high oxygen isn't going to "knock" out a COPD patient's respiratory drive. In the "typical" patient with respiratory distress, low oxygen sats causes the body to work harder to take in more oxygen, inversely causing increased oxygen consumption and furthering the body's oxygen deficit. So, at times higher amounts of oxygen are warranted. The only thing that would truly confirm the patient's ability to oxygenate themselves would be to draw ABG's once at the hospital.

    FYI: Hypoxia kills quicker then hypercapnia

    Kudos to EricEnfermero for a well-stated post.

close