Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 3

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   DutchgirlRN
    Quote from Angie O'Plasty, 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.
    Thanks Angie, I will definately update. BTW I do know that her WBC on admit was 1.7.
    Last edit by DutchgirlRN on Jan 28, '07
  2. by   Focker
    Quote from tiredfeetED
    Well I do understand some of your concerns of the concept of increasing the O2 Long term but I dont know any medic that wouldnt put this person on short term non-rebreather to the ED to bring up those sats. I would suppose the next treatment for the medic would to give a couple of treatments aswell.
    Once the medic is arrives it his/hers pt and they have protocols. These ppl are highly trained people while the EMT has no buisness touching that medics 02.
    In the ED if the pt was 73% and there baseline is low 80's im most likely placing them on a non-rebreather while they set up for cont. neb tx.
    No, with a long term COPD pt, just because their sats are 73% does not mean they are not getting enough O2 to the brain/organs. Over a long period of time with low sats like that, the body goes through compensatory changes, 2,3-DPG increases to increase release of O2 to the tissues (shift the oxy-hemoglobin curve), the hct goes up, perfusion is shifted to the vital organs, etc. They essentially go through a lot of the changes that someone adapting to high altitude would go through. The fact that the patient was mentating is good reason to not increase the O2, all that would accomplish is putting the pt. into CO2 narcosis because you took away their stimulus to breathe. They should be left on the same amount of O2 they are on and no changes should be made until they get to the hospital and a blood gas can be drawn. You will probably see a CO2 in the 60's or 70's and a low pao2, but if the pH is close to 7.4 the pt. is doing ok and you can just treat the other respiratory symptoms and infection (fever).

    Just to illustrate my point, I took care of a woman who had an avm in her pulmonary vasculature which caused a massive R-L shunt. because the avm probably formed and grew over years, her body made compensatory changes. She was very sick and she was on a ventilator at near maximal settings, 100% O2, etc. and lived at 60% on the sat monitor. One day I took her on transport with her sats reading in the 40's and she was still able to respond to stimulation (nod/shake her head to questions, follow commands). Eventually she did die, but it she was an amazing demonstration of the body's ability to adapt.
  3. by   DutchgirlRN
    Quote from Focker
    No, with a long term COPD pt, just because their sats are 73% does not mean they are not getting enough O2 to the brain/organs. Over a long period of time with low sats like that, the body goes through compensatory changes, 2,3-DPG increases to increase release of O2 to the tissues (shift the oxy-hemoglobin curve), the hct goes up, perfusion is shifted to the vital organs, etc. They essentially go through a lot of the changes that someone adapting to high altitude would go through. The fact that the patient was mentating is good reason to not increase the O2, all that would accomplish is putting the pt. into CO2 narcosis because you took away their stimulus to breathe. They should be left on the same amount of O2 they are on and no changes should be made until they get to the hospital and a blood gas can be drawn. You will probably see a CO2 in the 60's or 70's and a low pao2, but if the pH is close to 7.4 the pt. is doing ok and you can just treat the other respiratory symptoms and infection (fever).
    Thank you, you are awesome!
  4. by   PANurseRN1
    Dutchgirl wrote:

    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?
    This is what I suspected was at the heart of the issue: You were put out that a "mere" paramedic didn't listen to you. Your comments reflect a clear lack of understanding of how the EMS system works, and your follow ups regarding the pt's current status don't square with your OP of your assessment of the pt. Was he critical or wasn't he? You said he wasn't, but obviously, he was much sicker than your assessment described.

    Med/Surg Tele is not even in the same ballpark as providing critical care in the field. An experienced nurse should know that and respect the vital role EMS provides. I work in the ED, but I wouldn't begin to equate what I do with what medics do.

    Think long and hard about reporting this. You could be buying yourself a world of hurt.
  5. by   AnnieOaklyRN
    I agree with NREMTP/RN.

    If you did not think it was an emergency do not say that you called an ambulace so he wouldnt have to sit in an e.d. It sure sounds like it was an emergency, lets think about those ABC's and they would not have made him sit in the waiting room in that condition anyway. If that was truly the case then the family should have taken him in on their own especially since, according to your post, it seems it was their oppinion is that the paramedics put the guy on a vent last time.

    The oxygen SHOULD be increased until the patients baseline oxygen saturation is maintained and according to your post a saturation of 73% was not this patients baseline. Also it takes more than a 10-15 minute ambulance ride for increased oxygen to decrease a COPD'ers respiratory drive, and because of this, the fact that the paramedic turned up the oxygen has nothing to do with the CO2 retention that required mechanical ventilation.

    The patient was heading in that direction from what it sounds like and is anyone pointing fingers at the family or whomever for having the patient wait ALL DAY with severe hypoxia and a pneumonia by the sounds of things before going into the E.D., I am willing to bet that has A LOT more to do with the fact that he needed to be intubated rather than a paramedic increasing his oxygen saturation from 73% to a saturation closer to baseline!!

    The funny thing is I just read another thread that was picking on non nursing people for writing oppinionated replys to RNs because they do not understand how RNs feel or what their job is like... So I guess it is only ok if RN's pick on other professionals for doing their job!

    Swtooth
  6. by   Kristiern1
    Certainly with a WBC count of only 1.7 on admit speaks to some other underlying issues as well. My suspicion is that this patient was probably quite hypercapnic/hypoxic even before increased O2 and probably only the fact that they had long standing lung disease kept them compensated as long as they were. I think intubation was in this persons future regardless of oxygen. Good call on all parts getting them to the hospital.
  7. by   Cattitude
    Quote from nremt-p/rn
    in my experience hhn's are generally not able to manage an acute/critically ill patient with any real degree of competency.


    wow, wow , and wow. with the increasingly ill pt's we have coming and staying home these days, it's sure nice to know we have your vote of confidence!
    Last edit by Cattitude on Jan 28, '07
  8. by   flashpoint
    Usually, people call 911 because there is a situation they are unable to handle on their own. As a paramedic, it frustrates me to no end to have friends, family, or caregivers of our paitent telling us how to best care for them. Of course, we want to know thinks like he only has one lung, he breathes better sitting up, etc, but I hate being told things like, don't give him O2, he needs an IV, or "just drive." Paramedics are trained to handle situations emergently...that is what we do.

    My course was three years long and I put in over 1500 hours of clinical time in the ambulance, 750 hours in the ER, and 250 hours in areas like the OR, peds, OB, and psych. I am required to take almost 100 hours of continuing education every two years, as well as maintaining ACLS, PALS, NRP, CPR, and EVOC. My medical director tests my competency every six months and I did a 100 hour field preceptorship before I was allowed to practice independently after I passed my National Registry exam. Hopefully, I am competent to do a little more than just provide a taxi service.

    With O2 sats in the 70s, a temp of 102, and wheezes, I very much doubt that this patient would have sat in the ER waiting room for very long, if at all. A good traige nurse would have has the patient in a treatment room very shortly after arriving.

    Our protocols state that we should NEVER withhold oxygen from a patient. Every paramedic and EMT book I have seen states that we should NEVER withhold oxygen from a patient. There are questions on the National Registry exam that indicate we should NEVER withhold oxygen from a patient. I guess the research that goes into all of that must be wrong. I completely understand why we don't give high flow O2 to COPD patients, but I have never seen or heard of a case where actual harm has been done after giving high flow O2 short term. From what I am reading about this patient, there is a good chance he would have been tubed and vented anyway.

    I do think that the paramedic could have handled it a little differently. The "oh, my God," comment was a bit inappropriate...we were taught to keep our emotions a little better under control. I would have asked my partner, rather than bystnaders what was going on...that is a situation where you can't win either way. A lot of people get mad if they have to explain what is going on to more than one person, a lot of people get mad if they aren't asked to explain the situation to the second provider to arrive. If the patient asked not to have the O2 turned up, I might have left if where is was, depending on how far we were from the hospital...probably not though. I might have left if alone until we got in to the ambulance though, but again, I doubt it. We have protocols to follow and although we are obviously expected to use our own judgement as well, I have honestly never seen a patient harmed becasue we stuck to the protocol as it is written. It's too bad we can't get a better idea of what everyone on the team does.
  9. by   clee1
    Quote from DutchgirlRN
    Thank you for your reply. I am charting now and will be doing a very thorough job and just the facts.

    I did call the ER after the ambulance left, spoke to the doctor in charge and let him know what was going on and to turn the 02 down when the pt arrives. (I used to work there). He said "I sure will, we don't need her/him going into acidosis". Should I chart this also? That I called the ER doctor?
    Yes. Document everything well. I suspect you have not heard the last of this entire episode.
    Last edit by clee1 on Jan 28, '07
  10. by   Altra
    I can only echo other posters ... I am in complete agreement with the paramedic's actions.

    BTW, if the family had taken responsibility for getting this "non-emergent" patient to the hospital themselves, the patient would have been in triage only long enough for me to get the bare basics of the story - once I took a look at this febrile, wheezing individual w/sats of 73%, he would have been taken back immediately and I and any of my co-workers would have applied a NRB at 10-15L. An alert & oriented patient of course has the right to refuse treatment, but I cannot imagine any of our docs agreeing to rely on the mentation of a clearly hypoxic patient. It doesn't make sense. Show me some kind of written advanced directive - specifying that the pt. is comfort measures only or something of that sort - and it becomes a different situation. But I haven't read anything that indicates that any kind of written advance directive was in place.

    I do not accept that the patient's current need for ventilation is the result of 10-15 minutes of administration of high-flow O2. WBCs of less than 2? To me that says underlying neutropenic issues, not evidence of lack of sepsis.

    Hope the patient is improving.
  11. by   nuangel1
    Quote from Kristiern1
    Certainly with a WBC count of only 1.7 on admit speaks to some other underlying issues as well. My suspicion is that this patient was probably quite hypercapnic/hypoxic even before increased O2 and probably only the fact that they had long standing lung disease kept them compensated as long as they were. I think intubation was in this persons future regardless of oxygen. Good call on all parts getting them to the hospital.
    well said .i agree .if the pt was sick enough to call 911 ,which it sounds she was,the paramedic has to operate under his/her protocols for transport that short 6l nc would not have caused the pt to be vented.with low sat,fever and the whezzes,pt prob has pneumonia.she sounds like she needed to be vented.i appreciate the nurse family concern but it is the paramedics license.also with a sat 73% i am not sure the pt is able to make that decision .if you as the nurse did not feel this was an emergency situation for the pt you should have called the pts md 1st and not 911.
  12. by   elizabeth321
    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!

    I'm with you.....sorry dutchgirl you are way OFF the mark on this one.

    Liz
  13. by   nursesaideBen
    Quote from cotjockey
    It's too bad we can't get a better idea of what everyone on the team does.
    You know, this is SO TRUE! So many folks in healthcare are quick to judge others on their performance. I can see both points of view in this situation. Right or wrong it sounds like this patient was heading towards a vent and I doubt the Paramedic's actions negatively affected the pt's outcome. It sounds like She did what she had learned and been taught through experience and training was right, and for that I don't think she can faulted. I can appreciate the OP's concerns, but I think at some point we all in healthcare need to realize that sometimes it's just not our call.

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