Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 8

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   Altra
    Quote from rnin02
    it's much easier to defend putting on/turning up O2 in this case then to defend doing nothing but providing a ride to the hospital.
    Thank you.
  2. by   withasmilelpn
    Quote from TriageRN_34
    And one more thing since I am on a bit of a soap box...don't anyone DARE send a patient into an ER when they are just trying to avoid a wait time! This patient was serious enough to go in this way...but I see LTC's sending in their patients for basically NOTHING by ambulance just to avoid wait times...there is NOTHING that makes them more special than anyone that has waited out in an ER room for hours so they can be treated! It is people like this that send valid patients that can't wait back home to become even more seriously injured/ill and admitted for something that could have been fixed easily! I do know that many LTC's do not have someone to drive a patient in, and need to use ambulance...but try to avoid that...it is killing our EMS and taking them out of service for real emergencies!
    No long term care that I have ever worked for has'someone to drive them' Ambulance is the only means of transport. Bunion women sounds like poor assessment really. When I send them out they usually are very sick- urosepsis etc and of course a full code. I know that the ER gets resentful, trust me I have spent huge amounts of time explaining quality of life and DNR issues with families, sometimes successfully, sometimes to little avail. Please realize that LTC nurses are between a rock and a hard place. We are liable for our patients. We have limited means to assess people. That's why a lot of LTC nurses mottos are 'when in doubt, send them out". The families that are the most unrealistic are usually the first to shout 'negligence! We also have huge patient loads, so we can't give them as good of care and monitoring as the hospital can if they are borderline
    .
    A recent hit and run here showed that...poor 7 year old girl died because it took so long to get an ambulance because they were all busy with what we call BS patient calls and they had to pull one in from a great distance...
    How horrible! My prayers to the family!
    My hubby was furious because he was nearer, but had to take in a little old lady with a sore foot into the ER! GRRRRRRRR!!!!!
    (it was a bunion by the way...nothing a MD or pediatrist could have seen and DX!!!!, all because the woman wouldn't stop wearing closed toe shoes...this was time number 4 for her going in for this in one year!!!!).

    (oh hint...report them if you must or feel you should, their bedside mannor may need work...however, I would return the favor by pointing out the pulse ox readings and how long you let that go before calling 9-11 or even calling the MD??? *wink* ).
    By the way she did say that the family is the one who reported the pulse ox readings were low all day.
    Last edit by withasmilelpn on Jan 30, '07
  3. by   DutchgirlRN
    Quote from withasmilelpn
    By the way she did say that the family is the one who reported the pulse ox readings were low all day.
    Yes, Thanks for correcting that.


    Just some interesting information on Ambulance services in Holland:

    The Dutch health-care system includes three types of ambulance response. The first one is the emergency response, coded A1, in which the ambulance immediately responds using lights and siren.
    In cases without serious life threat and the patient is relatively stable with a GP present, an ambulance can be requested as an A2 emergency. For an A2 call, the ambulance will commence immediately but without lights and siren, which is much safer for the crew and causes less disturbance in the community. The ambulance must arrive within 30 minutes after an A2 call.
    If a patient needs to be admitted to a hospital or needs medical attention during inter-clinical transport, an ambulance is requested with a so-called B emergency (non-emergency).
    Personnel
    A major difference between a Dutch ambulance crew and those in other countries is that crew are registered nurses.
    Education
    The main medical care provider on an ambulance is a registered nurse. In addition to being a registered nurse, providers must obtain further certifications in intensive care, coronary care and/or anaesthesia nursing before applying to be an ambulance nurse. Besides on-the-job training, this one-year educational program is offered by the National Ambulance Education Foundation, the single national licensing body. Main objectives of the program include legal issues and working in the prehospital environment.
    Previous clinical experience and the required educational program guarantee a high level of medical knowledge and wide range of skills in the nurses.
    After becoming a registered ambulance nurse, post initial training and educational programs are also mandatory. One of the required programs is the NAEMT Prehospital Trauma Life Support Course. Nurses are trained in the PHTLS program on an advanced level, and drivers are trained on a basic level.
    Continuing education is organized on two levels: national and regional. The mentioned PHTLS courses are in the national program, as well as special paediatric courses. For regional education, a wide scale of topics are available and held in smaller groups, mostly at ambulance stations. A number of appointed and licensed training institutes carry out the educational programs.
    Doctors in an MMT have also had additional training to prepare them for the prehospital setting. For example, extra courses in extrication techniques are required. A nurse participating in an MMT is a senior ambulance nurse and has taken the same additional training as the MMT doctors.

    Photo courtesy of the author
    This level of training and education allows ambulance nurses to work on a rather independent and self-supporting basis. If an ambulance crew encounters a situation that aren't within their protocols, procedures or standing orders, providers can contact the medical manager of the ambulance service. If medical procedures must be applied that are beyond the possibilities of the ambulance nurse, providers can request for an MMT.
    All procedures are brought together in the National EMS protocols. These protocols are revised or adjusted every four years. Within these protocols, ambulance nurses are allowed to administer 31 different types of medication.
    Table 1: List of medications on Dutch ambulances

    Acetylsilicyt acid
    Adenosine
    Amiodaron
    Atropine
    Biperideen
    Budenoside
    Butylscopolamine
    Clemastine
    Denilox
    Dexamethason
    Diazepam
    Diclofenac
    Epinephrin
    Esketamine
    Fentanyl
    Furosemide
    Glucagon
    Glucose
    Haloperidol
    Ipratropiumbromide
    Magnesium sulphateMetoclopramide
    Morfine
    Naloxon
    Nitroglycerine
    Oxytocine
    Plasma substitution
    Ranitidine
    Salbutamol
    Sodium Bicarbonate
    Xylometazoline
    Ambulance nurses are also allowed to carry out many medical procedures, including thrombolysis, which is practiced on a common basis. The drug in use depends on the region of the ambulance service. In the case of thrombolysis, providers select the medication after deliberation with the admitting hospital staff.
    Equipment
    All ambulances in The Netherlands are equally equipped. Aluminium cases are stocked with medical appliances, such as syringes and medication. Other materials, such as scoop stretchers, backboards, splints and collars, are also stocked. All vehicles are equipped to perform both BLS and ALS, with enough supplies on board to treat three patients on scene in case of an MCI (depending the extend of care they need).
    All ambulances carry 12-lead ECG equipment, a monitor/defibrillator, a ventilator, infusion pumps and pulse oximeter.
    For communication, mobile radios are mounted inside. Every ambulance carries a cell phone as well.
    Especially in major cities with a medieval inner city, speed-lowering obstacles are commonly built in the road. Old inner cities are accessible for only pedestrians and cyclists, with the exception of emergency vehicles. To enter such an area, emergency providers carry several remote controls and special keys to bypass the mechanical obstacles, such as rising steps.
    All ambulances are equipped with a tracking system so dispatch can locate them and control their status. A digital routing system is also present in all ambulances, which is handy when in small villages and narrow inner city streets.
    For recognition, all ambulance personnel are dressed in blue and yellow uniforms. Helmets are present on the ambulance. In case more ambulances need to respond to a scene, the first arriving ambulance starts the incident management and identifies themselves by wearing green vests and by flashing or rotating a green light on their ambulance. All arriving crews can easily identify and respond to the first arrived crew. MMT personnel can be recognized by their red and yellow uniforms.
    Patient data in the ambulance are gathered and digitally processed by handheld computers.
    The Netherlands are well developed in health care and EMS. On Dutch ambulances you find a well trained and educated team, with separated tasks for each member of the crew. By having prehospital providers working in conjunction with house doctors on one side and MMT doctors on the other side, the patient can receive optimal care. In the chain of emergency care, Dutch EMS is certainly not the weakest link.
    http://www.jems.com/products/ambulances/articles/13512/
    Last edit by DutchgirlRN on Jan 30, '07
  4. by   AnRNIam
    The simple fact is that the Paramedic has a medical director (MD) that they work under. This medical director sets the protocol that the Paramedic has to follow regarding any treatment they render not a HHRN. If the protocol the Paramedic has states to give the O2 to a patient with a Sat. of 73%, she had to give O2 to that patient. No choice, no argument. Had she deviated from what her medical director and medical control set as protocol she could lose her license. Again, no choice, no argument.

    As for the DNR status someone mentioned (not sure who), in quite a few states, if a DNR is in place and 911 is called the DNR becomes invalid. A call to 911 is considered a call for help and request for treatment and supersedes the DNR. So, in calling 911 the OP would have invalidated a DNR for this patient if one would have been in place (not cutting on the OP, just food for thought for everyone).

    Myself, I was a Paramedic for 15 years and decided to go into nursing after we had kids. In all that time, I have never shut down a COPD'er by using a higher flow of O2 during a short ride to an ER. As the Paramedic in the OP did, I also would have went with 6-8L O2 in that situation (what little of it I know). If the patient would have complained of SOB or had a decreased LOC I may even have went higher on the O's.
  5. by   PANurseRN1
    Not getting the connection between what Dutch EMS crews are doing and what we do here.
  6. by   vamedic4
    Quote from DutchgirlRN
    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.
    DutchgirlRN..no one is here to blast you!!! You were frustrated and you sought out some thoughts from others, no need to blast anyone for asking the opinions of others.

    Havre a great night.

    vamedic4 :spin:
  7. by   EricJRN
    Quote from AnRNIam
    As for the DNR status someone mentioned (not sure who), in quite a few states, if a DNR is in place and 911 is called the DNR becomes invalid. A call to 911 is considered a call for help and request for treatment and supersedes the DNR. So, in calling 911 the OP would have invalidated a DNR for this patient if one would have been in place (not cutting on the OP, just food for thought for everyone).
    I'm really surprised to learn about this. In Texas, it's not the case (we even have our own forms and bracelets for out-of-hospital DNR's). The only times we start CPR would involve a suspected unnatural death or an invalid (unsigned, etc) DNR. People should be able to call for an ambulance without throwing out their right to keep a DNR.

    Agree with you on the issue of the oxygen. Most research has shown that knocking out hypoxic drive occurs over hours or days, not within the few minutes of a typical EMS transport. The general thinking is that if a patient is so unstable as to be compromised by a few liters of oxygen, then that patient needs an ET tube anyway.
  8. by   S.T.A.C.E.Y
    Quote from DutchgirlRN
    Just some interesting information on Ambulance services in Holland:
    I'm confused. Are you in Holland or the USA???
  9. by   cardiacRN2006
    Quote from MLOS
    Morte, let's think about the relationship between mentation & hypoxia.

    Then, let's think about whether or not you could defend your decision not to increase O2 on a patient w/SpO2 of 73% with the statement, "the patient refused."


    ITA!


    I'll say it again "always err in favor of the pt!"
  10. by   angel's RN
    Hey there- the DNR statement was me. My thinking was if she made herslf a DNR, then she would'nt be going to the ER. Hospice would be taking care of her.
    I still say that, even if the patient's SATS were in the 70's, that is probably where she lives. Didn't the original note say that she didn't really feel bad? No SOB? THen WHY call 911?!?!?!? If she lives in the 70's, another 15 min. in the back of the car with her home O2 probably wouldn't have hurt her. And like someone eles said, when the patient gets to the ER, triage would have sent her right to the back anyway. I really don't think that a compenent RN would make the patient sit in the waiting room "for hours". Thanks for letting me state my views -- can't do it at work, haven't "been there long enough to have an opinion"!!

    :roll :roll Just had my 30th weding aniversary!!!!
  11. by   morte
    i highly doubt a paramedic would loose their lic over honoring a patients NO!....I could see her being sued over not........

    PS I am in no way arguing the medical aspects of this issue
  12. by   burn out
    Quote from morte
    can you please point me in the directon of the chapter in law that says a paramedic is the only med prof that doesnt have to respect the word .....NO......
    When working with copd patients we all know that they can normally run a higher co2 than a normal person, even higher than their o2 levels and there is always the 50/50 rule but we also know that when a copd gets into trouble they are usually retaining co2 and this must be the first consideration when caring for them in an emergency situation...frequently the co2 level can run 100 or greater and usually the o2 is very low thus requiring the increase in o2 delivery. When a person's co2 levels get too high this effects their mentation thus making them incompetent to make informed decisions...in our hospital a patient will get intubated with a co2 of 100 or greater no matter if they are screaming at the top of their lungs or not, unless a mpoa or medical surrogate tells them otherwise. The lab values drawn later at the hospital verified that the medica acted approprately, high co2 levels do not occur in 15 minutes on the drive to the hospital with extra o2.
  13. by   EmerNurse
    I have to agree on the side of the medics in this, though I understand the HH nurse's frustration.

    We have awesome EMS personnel in my city and their protocols are pretty solid. Occassionally annoying <grin> but solid.

    I was at a baby shower once and one of the young ladies (early 20's) had an anxiety attack. This was someone I didn't know. Before I even knew what was going on, the family had called 911. Then came and got me. I assessed her (alway keep my steth/cuff in the car) and when EMS showed up, gave 'em a quick update on situation from what I could learn, and got outta the way. They did what they had to do. Girl was fine, of course, but my point here is that I got OUT of their way.

    In the ER, on the recieving end of the ambulance ride, we ASSESS the patient ourselves as soon as they hit our bed. If this patient had come into my ER, we would have assessed him and determined ourselves, his O2 need and proceeded accordingly. Given his condition, I'd have had the Intubation equipment right next to him, too. The ambulance ride is governed by strong protocols which are meant to protect the patient en route, but once they hit the ER, WE determine what's needed. 99% of the time, the EMS folks have gotten everything started in the right direction and we move on from there. Sure, there are exceptions, where their protocol might not fit exactly, but EMS can't go on the assumption of the exceptions - they HAVE to follow those protocols. Those exceptions are why ambulance rides are FAST and ER staff pounce when these types of folks come in.

    As for the family/HH folks not wanting the O2 upped, were I the EMS, I'd have blamed my protocols with something along the lines of "I'm sorry but I'm required to do this for the patient while en route, but it's a short ride and the ER folks will make a longer-term decision in just a few minutes." then slapped the O2 on and went.

    One comment I really feel I must make though, even though I'm now babbling: If I had to know EVERY damn thing every other medical person knows, my head would explode. I count on EMS to know badda-bing what to do with someone hanging upside down in a car so that their airway is not compromised and thier c-spine is kept intact, all the while disengaging said patient from said car. I count on med-surg nurses to take what I send them and juggle all the details of their care that I simply don't have time to do. I count on ICU nurses to be so ingrained in the detail of thier patients' conditions that they catch the slightest change before it becomes a huge issue. I count on HH nurses to manage difficult disease processes (AND families) outside the hospital so that, for the most part, those folks don't hav to come back unless absolutely necessary. I count on RT to shift to the left, to the right, do the hokey pokey and "see" those alveoli just by listening to the patient.

    My point? Nursing (and other medical folks) are no longer interchangable. In our insanely acute healthcare world, we HAVE to specialize simply so that there's someone available with EXPERT knowledge for a given situation, whether that situation involves an intraaortic balloon pump, a 15-car pile up, 12 sundowners trying to nosedive out of bed, or the next acute MI busting through the door. We MUST show respect for each other. No patient will have an optimum outcome as they move through the continuum of care unless ALL of their providers respect and trust their brothers/sisters on the medical team. We're all on the same team with the same goals.

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