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

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   Shamira Aizza
    I'm thinking somewhere there are some paramedics on an EMS forum talking about this one-lung COPD patient he was called for, and when he arrived, he found the patient saturating at 73%, and some HH nurse told him that 2.5 liters was an appropriate liter flow, and if had only been called sooner, maybe this patient wouldn't have ended up on a ventilator.

    I'm just saying...there's always two sides.

    I'd also like to point out that an elevated CO2 is a VENTILATION issue, not an OXYGENATION issue...unless you are suggesting that a higher Fio2 for the duration of the transport actually contributed to hypoventilation (highly unlikely, and there is no clinical evidence to support this theory). Additionally, a COPDers respiratory drive is driven by hypoxia, and if this level of hypoxia was not initiating a ventilatory effort to bring the SaO2 to a more acceptable level of 80-85%, then additional supplemental O2 is required.

    73% is abnormally low for a COPDer, and we don't necessarily know if this patient ended up on a ventilator because of loss of respiratory drive due to a brief run of higher flow oxygen, or if this patient was found to be profoundly acidotic because of progressive respiratory acidosis preceding the call to 911.

    Ambulance transport increased metabolic demands for a patient, even if someone lifts them for every evolution of the transport. And a one-lung patient saturating at 74% doesn't leave much wiggle room. Increasing the FiOto to 6lpm for the transport was not improper.
  2. by   Cattitude
    Quote from withasmilelpn
    as far as some of the posts here, i think some proffesionalism (sp?) is lacking. i totally understand the frustrations involved, but to judge an entire healthcare group- homehealth nurses, wannabee doctors- is just as bad as judging people for their color or sex, don't you think?
    frankly there are incompetant people in every aspect of the healthcare field. the ones that screwed up are going to stand out in your mind, but don't stand for an entire group of people.
    my advice- withhold judgement, keep your mind open- there are always things to be learned in every situation, and use these opportunities to educate people.
    well said, and you made great points. frankly, i am very disappointed in the remarks made in previous posts in this thread by my own colleagues. yes there are incompetent nurses out there but as you stated so nicely, they're in every aspect of healthcare.

    and yes, keep your minds open, very open. you never know what situation you may find yourself in, professionally or personally. you just may have a hh nurse who knows her stuff at your side!
  3. by   withasmilelpn
    Dutchgirl, the more I read about your situation, I do think things were not so black and white. I do think the paramedics could've shown more respect. I've dealt with all kinds -ones that truly listen when I give them report as to what occurred with my patient and ones who also ignore me. The best are the ones who act like they don't believe me like when my patient goes unresponsive, 911 is called and by the time they arrive they are responsive again. Sometimes the condescending attitudes I recieve are enough to enrage me into writing exactly the same kind of letter you wrote!
  4. by   Shamira Aizza
    That's a good point.

    I'd also like to say that respect is a two-way street, and having worked as a paramedic before I became an RN, I wouldn't be so gracious to have my clinical decisions addressed openly in front of the patient and their family.

    Bottom line is that the treatment was appropriate, and careful consideration should've been used before challenging the care of the paramedic, especially if you can't cite any clinical evidence to support any theory that short-term use of a higher FiO2 would be harmful.

    I've gone to the homes of COPD patients that were visited by HH earlier that day, finding patients that were acutely ill, unresponsive, requiring intubation, bradycardic, or in cardiac arrest. And if I had a nickel for every time HH called for EMS and then left before we arrived, I could've paid off nursing school without having to work full-time.
  5. by   vamedic4
    Quote from DutchgirlRN
    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?
    I think you are absolutely right to report this paramedic, and I hope she never cares for anyone I know! One thing you MUST acquire in order to function competently as a medic (or nurse, doctor, et cetera) is a HISTORY, and you base your treatment on your assessment of the patient, and the patient's HISTORY. This paramedic did neither. Report her, she makes us all look bad.

    I disagree with other posters about calling 911 on this one though, if it were my grandmother I may have done it. Why?
    1. As the OP stated, she normally sats in low 80s but now is in 70s despite breathing treatments...bells are ringing now, because what we're doing isn't working like it should.
    2. Temp of 102, wheezing noted. Somethings brewing inside this patient that has the potential to send her south quickly if conditions are right.
    Sepsis?? Probably. We can't judge until we see lab values but given her history, it is prudent to get her to a hospital where definitive care can be administered, and pronto.


    I currently work in peds cardiology...and have for a number of years. This has allowed me to see treatment orders like O2 TKS 65-75%...for our kiddos with certain cyanotic heart defects. The principle is a bit different with adult COPD patients, but the end result is the same...too much O2 can be a VERY bad thing.
    The last thing you want is to have this patient who is stable (for the moment at least) to decompensate and crash on you in the back of an ambulance. Not my idea of a good day.


    I hope your patient is okay.

    vamedic4
    It's still cold in Texas :spin:
  6. by   Shamira Aizza
    Quote from vamedic4
    I currently work in peds cardiology...and have for a number of years. This has allowed me to see treatment orders like O2 TKS 65-75%...for our kiddos with certain cyanotic heart defects. The principle is a bit different with adult COPD patients, but the end result is the same...too much O2 can be a VERY bad thing.
    The last thing you want is to have this patient who is stable (for the moment at least) to decompensate and crash on you in the back of an ambulance. Not my idea of a good day.


    I hope your patient is okay.

    vamedic4
    It's still cold in Texas :spin:
    More than a bit different...a lot different. The saturation for those patients has nothing to do with CO2 driven respiratory drive or lung disease and function, but rather with the fact that the infant is mixing through a cardiac defect that needs to be repaired, or is mixing because of an artificial defect (or a purposefully maintained PDA) is required to keep them alive until vessels can be switched, etc. Additionally, these patients are typically under a minimal stimulation protocol to minimize O2 demand.

    A COPD patient will not decompensate during an ambulance transport just because of temporary increases in FiO2, especially as small as increasing them from 2 lpm to 6 lpm. A patient saturating at 73% is not stable. Such a patient could be one-step from fatal acidosis.
  7. by   vamedic4
    Shamira your point is well taken...and I feel for the patient...

    OT -any one of you know what 6 lpm via nasal cannula feels like???? :chuckle Next time you're at Wal Mart filling up your tires with air, stick that thing up your nose and squeeze the trigger...ugh!! I would have gradually increased the O2, instead of giving the full 6 right off the bat...perhaps upped her to 4 lpm and reassesed.

    And while you are correct about the patient not decompensating from the oxygenation/ventilation issue...she had other issues that were in need of addressing. The point of my post remains...she needed more definitive care than was available at home, and getting her there by ambulance wasn't necessarily the wrong call. For all we know, she could have had some underlying issues related to dehydration as well. Sure, she COULD have made it had they loaded her into a car with some O2 on..but given everything else that was going on..why take that chance??

    Just my $.02

    vamedic4
    Is it summer yet??
    Last edit by vamedic4 on Jan 29, '07 : Reason: just adding something!
  8. by   Kyrshamarks
    Quote from DutchgirlRN
    The only tools at my disposal are BP cuff, stethoscope, thermometer and pulse oximeter.
    You are forgetting the most improtant tool that you have at your disposal. YOUR NURSING JUDGEMENT.

    As a former Paramedica and as a ER ICU nurse now for 20 years I think a couple of things happened. Your judgement was off in this situation. The patient was an emergency with the symptoms that you described, one lung full of wheezes 3 days post hospital with high fever and COPD with sats in the 70's. That is an emergency by anyones book. Also your judement in calling the ER doc wrong. I agree with calling the ER to give them a heads up that the patient is on their way in but to tell the doc to turn down the O2 borders on diagnosing the patient and ordering treatment. The BON may look upon it as this was. Plus if I was a director of a HH compmay and I found out that a nurse told the doctor on the phone how to treat an ER patient with unsolicited advice I probably would fire that nurse due to the liability she potentially opens me up to. A bit of advice.
    Last edit by Kyrshamarks on Jan 29, '07 : Reason: because I cannot type worth a darn
  9. by   Altra
    I'm a little bit baffled why perceived "respect" or perceived lack of respect is being debated when the issue is treatment for an acutely hypoxic patient.

    We can all kiss & make up later ... the key at that moment was to better oxygenate that patient, who was clearly just a few short slippery steps from being truly emergent.

    I also want to repeat what I said in the other recent thread (Geriatric Nursing forum) re: hypoxia and COPD: please know that I will increase the O2 for any of you who are ever acutely SOB. I'd like to think that I could count on you all to do the same for me.
  10. by   morte
    Quote from MLOS
    I'm a little bit baffled why perceived "respect" or perceived lack of respect is being debated when the issue is treatment for an acutely hypoxic patient.

    We can all kiss & make up later ... the key at that moment was to better oxygenate that patient, who was clearly just a few short slippery steps from being truly emergent.

    I also want to repeat what I said in the other recent thread (Geriatric Nursing forum) re: hypoxia and COPD: please know that I will increase the O2 for any of you who are ever acutely SOB. I'd like to think that I could count on you all to do the same for me.
    MLOS, this patient was NOT SOB....
  11. by   flashpoint
    This patient did not feel SOB...I've gone several days where my asthma is really bad and when I finally go to the dcotor I am running around with sats of 85%. I've never felt like I was that low, but the labs and monitors indicate otherwise.
  12. by   morte
    SOB IS a sensation,
  13. by   DutchgirlRN
    Quote from vamedic4
    The last thing you want is to have this patient who is stable (for the moment at least) to decompensate and crash on you in the back of an ambulance. Not my idea of a good day.
    That's how I was feeling about it. I wish the family would of have taken her in the car but they refused.

    I spoke with my DON and she praised me for calling the ER doctor. Ok you can blast me now. I can take it. She was going to call the county ambulance service and talk about this matter but I haven't been back yet to see what the outcome was.

    The patient is doing well. Awaiting results of blood cultures.
    Last edit by DutchgirlRN on Jan 30, '07 : Reason: Spelling

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