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

Nurses General Nursing

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  1. Chronic COPD'er, 1 lung, 02 @ 6L, What would you do?

    • 222
      I think the Paramedic was right to increase the 02 to 6L. I am a Nurse.
    • 16
      I think the Paramedic was right to increase the 02 to 6L. I am a Paramedic or EMT.
    • 180
      I think ultimately the patients wished should have been honored. I am a Nurse.
    • 6
      I think ultimately the patients wishes should have been honored. I am a Paramedic or EMT.
    • 122
      I think the Paramedic should be reported to her agency for ignoring everyone. I am a Nurse.
    • 8
      I think the Paramedic should be reported to her agency for ignoring everyone. Paramedic/EMT.
    • 79
      I think this was a true emergency situation. I am a Nurse.
    • 9
      I think this was a true emergency situation. I am a Paramedic or EMT
    • 13
      I don't know, it's all too confusing
    • 7
      Leave me out of it. I don't want to participate.

148 members have participated

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 felt it should be coming up after breathing treatments and wanted to call before it got too late in the evening.

She/he is a chronic COPD'er, who has only one lung, who functions well with 02 sats in the low 80's. She/he has 02 BNC @ 2.5L/min. When I got there she/he was sitting up talking to me. She/he said she/he didn't feel in the least SOB, 02 sat was 73%, Temp 102 and her/his one lung was full of wheezes. I felt as though she/he should go to the hospital but that it was not an emergency situation. The family fully agreed. They said she/he preferred to go by ambulance so she/he wouldn't have to sit in the ER. I agreed. We called 911.

An EMT got there and asked what was going on. I told him. A few minutes later the ambulance got there and a paramedic came in. She saw me but asked the EMT what was going on. "Oh my God a sat of 73% crank her up to 6L/min. I said no. I explained why. She said "well we have to get her 02 sat up because she's not perfusing 02 to her brain. I said she's talking to you. Please do not turn her up to 6L/min you'll do more harm. She did it anyway. The daughter said "the last time you guys did this she/he ended up with a CO2 of 134 and ended up on a ventilator". The patient said please don't do this to me. The paramedic ignored everyone. The EMT turned it back down to 2L/min the paramedic saw it and turned it back up to 6L/min. She told the patient she would put her/him on a non-rebreather once they got her/him in the ambulance!

I was told that once the paramedics arrive they are in charge and what they do is their responsibility but how ignorant to not listen to the nurse, the family and the patient?

I will make sure this paramedic gets reported. I wonder what you guys thoughts are?

Specializes in CT ,ICU,CCU,Tele,ED,Hospice.
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.

Specializes in ER/Geriatrics.
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!

:banghead:

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

Liz

Specializes in Medical Telemetry, LTC,AlF, Skilled care.
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.

Specializes in ER/Geriatrics.
Topic directly on point:

https://allnurses.com/forums/f22/copd-pts-2l-o2-194267.html

http://cmbi.bjmu.edu.cn/uptodate/critical%20care/other/The%20use%20of%20oxygen%20in%20patients%20with%20hypercapnia.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.

Exactly!

Liz

Specializes in Emergency Room.

I would have to agree with most of the above posters. When you called the ambalance, the EMT-P became the person directing this patient's care until arrival at the hospital. Do you really think it would have been okay for this pt to roll into a room not on Os, wheezing, one lung, and febrile? Any doc would look at the medic and say "HELLO???" And the excuse "the family didn't want me to" doesn't much cut it. I completely agree - this pt was heading towards an ETT, and nothing anyone did or didn't do was going to stop it.

Hopefully she is beginning her recovery and someone will speak to the family to let them know the intubation is not the medic's "fault."

Specializes in Cardiac.

if choosing between the lesser of 2 evils, i'd rather see them acidotic and vented than dead.

When I was an EMT, we were taught that if the pt is hypoxic, even though they are CO2 retainers, then you still give them the O2 they need.

We can wean off of the vent, but we can't wean them from dead. That's just what we learned.

If I were in this situation, I would have done the same thing as the medic.

Specializes in ER/Trauma.

Canoehead and Cotjockey nailed it.

Timothy (ZASHAGALKA) - Thanks for the links.

cheers,

Specializes in Lie detection.
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.

i too can see both point's of view. the only thing that i can see that might have mad better communication is the medic acknowledging the family and pt's words instead of ignoring them. maybe by just quickly telling them that this is protocol would have helped explain things. we all have policies to follow :eek:

this patient was batteried, given a higher dose of a drug than she was willing to accept, what part of that are you not understanding?

Specializes in Cardiac.

Best quote I learned in EMT school:

"always err in favor of the pt"

I'd rather defend myself against putting a pt on 6L 02, then allowing a pt with a pox in the 70s-80s become hypoxic and die.

Pretty simple, actually.

Again, pt didn't have to call 911. That act meant they thought it was an emergency too.

Specializes in Day Surgery/Infusion/ED.
this patient was batteried, given a higher dose of a drug than she was willing to accept, what part of that are you not understanding?

Batteried? Duracell or Energizer?

Imagine this: Pt says ' I don't want Cipro 400mg IV, I want 350mg instead."

The pt was not battered in that the pt was willing to accept O2 in the first place. If the pt had been flatly refusing the O2, then there might have been a case for battery. If the pt was competent, of course he could have refused any O2. With sats in the 70s, though, you'd have to wonder about his mentation.

I, for one, would need to know the patient's weight.

How else would I know if I'd have enough paralytics left after intubating the patient to pry the home health nurse off the back door of the ambo?

This patient was failing to improve with treatment and was heading for a tube. The nonrebreather was a good choice to preoxygenate prior to intubating, which I think the paramedic had the good sense to see coming.

In my state, on a the patient's physician who is "physically on scene and willing to accompany the patient to the ED" can override the jursidictional medical command authority. As someone posted, the patient can refuse care, but that puts the paramedic in a tight spot. I mean, determining competence in a patient who's hypoxic and probably will need to be intubated. is a crapshoot.

Pete Fitzpatrick

RN, CFRN, EMT-P

Writing from the Ninth Circle

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