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

[DutchgirlRN, ASN, RN]

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?

[clee1]

As a former paramedic, lemme tell you that this person should be reported to his/her service's medical director.

It is true that outside of the hospital, the paramedic has the authority - but only a fool will continue with 6L of O2 on a COPD pt, especially after being told of the consequences by the pt, the family, and the nurse.

I sure hope you documented this episode well.

[chip193]

It depends on the service Medical Director and the ALS Coordinator - some of these folks won't let the Medics deviate from protocol at all. Others are more progressive and permit the Medics to think.

Patients, however, have the right to refuse anything (except CPR, unless it's thought about in advance and a DNR is in place!). The patient refusing the additional oxygen is where the problem is. Of course, the Medic would then have to show that the patient is able to make the decision to refuse the additional oxygen. And, of course, it's hard to do that with a sat of 73%.

[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.

[DutchgirlRN, ASN, RN]

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?

[Medic/Nurse, BSN, RN]

So you called 911 even though NO EMERGENCY existed.

This decision was made to keep from "having to sit the the ER".

A paramedic was greeted by a HOME HEALTH NURSE that called 911 for a situation that WAS NOT in the opinion of a licensed registered nurse (you) or the family an emergency - the 911 crew found a patient that was found to have markedly decreased oxygen saturation - and you are standing there telling them NOT to give any additional oxygen other that to just maintain the 2L per NC. And now you are going to report the paramedic because she ignored you and gave additional oxygen to the patient.

Paramedics operate on a set of standing orders called PROTOCOLS. They detail the acceptable care of a patient. I can GUARANTEE that there is not a protocol or standard of care ANYWHERE in this country that will support any paramedic that fails to provide oxygen for a patient with hypoxemia.

Now, I guess what has you in that reportable frame of mind is that you were ignored. Unfortunately, as a paramedic YOU would not be my authority for care. My protocols and medical direction are my authority. I say REPORT away.

I will also point out that calling 911 for a situation that is NOT AN EMERGENCY to keep from "waiting" can be considered a crime or even fraud as it relates to insurance. BE CAREFUL. It may not just be the care provider by "this paramedic" that will need to pass a test of necessity. I never have a problem with any call that gets careful review - I say start at the beginning!

Now, as to the care. Not all paramedics have the option of varying oxygen delivery. In most locales its either a little (no hypoxia) or a lot (hypoxia). Most transport times are limited and in the time that I care for someone in the field I would rather not deprive them of OXYGEN. I know that retention of CO2 can be problematic in the overall management of a COPD patient, but I will maintain that permissive hypoxemia is not a good field practice. Some field medics do venti masks, a few others do CPAP and BIPAP - but the standard is to correct hypoxia. I would have provided additional oxygen to this patient.

But really all of this dicussion is not necessary. You said she the patient was not in distress, but was desaturated (from the 80%'s - her baseline) and febrile (and I'm betting that her heart rate was a bit elevated too) with ONE lung full of wheezes. Hmmmm....

Sounds like the paramedic did what the situation demanded. That may not be what you think to have been necessary, but after they started care of the patient you are "off the hook." I guess the lesson here is load 'em up and let the family or yourself take 'em to the hospital next time - that way you can do what you think is necessary for the patient. But if you call me - I'm going do what I can need to and what I can defend.

Good luck and practice SAFE!

[DutchgirlRN, ASN, RN]

Sorry, I disagree. I just called to check on the patient who is now in ICU on a vent. Co2 level of 152.

I realize that once the paramedic arrives that the patient is in their care but I find it very ignorant to ignore the nurse, the family member and the patient, when all 3 advised against the 6L of 02. It wasn't even open for discussion. It was her way or no way. That is dangerous! I've been an RN for 31 years and always remember..."First do no harm" and don't ever believe that you have all the answers, always be open to what others, especially the family has to say.

The pt could not wait in the waiting room in the condition in which she was in. People have died in waiting rooms.

[PANurseRN1]

I have to agree. Activating EMS for a non-emergent situation just because you didn't want the pt to have to wait? Not cool. (Let me clarify here that I worked HH for years and work in the ED, so I'm not chiming in without a clue.)

EMS has established protocols to follow; if they take direction it is from the ED physician at the receiving hospital. For a certainty they do not answer to a home care nurse (not denigrating home care nurses, but you're just not in the chain of comand here).

Upping the O2 temporarily isn't going to make the pt become apneic that fast.

Calling 911 for a non-emergent case could put your pt in the position of being stuck with the bill. And how would you justify it? If you're questioned about it, it could really come back to bite you. You probably had good intentions, but if it's not an emergency, 911 is not appropriate.

[Creamsoda, ASN, RN]

You also have think that the patient now being on a vent was probably unavoidable. Sats in the 70's, one lung, wheezy, febrile...something was brewing, and with a person with one lung it probably wont take much to go down hill.

Cher

[PANurseRN1]

Sorry, I disagree. I just called to check on the patient who is now in ICU on a vent. Co2 level of 152.

I realize that once the paramedic arrives that the patient is in their care but I find it very ignorant to ignore the nurse, the family member and the patient, when all 3 advised against the 6L of 02. It wasn't even open for discussion. It was her way or no way. That is dangerous! I've been an RN for 31 years and always remember..."First do no harm" and don't ever believe that you have all the answers, always be open to what others, especially the family has to say.

The pt could not wait in the waiting room in the condition in which she was in. People have died in waiting rooms.

But you were very clear in your original post that your reason for calling an ambulance was because the pt did not want to wait and you chose to accommodate that request. That he ended up on a vent is irrelevant...your original post was clear in your assessment that it was not an emergency.

Once you activate EMS, it is out of your hands. It would be total chaos if crews had to answer to every Tom, Dick or Harry who had an opinion. Ultimately, it's the protocols they follow and medical command they answer to.

[tiredfeetED]

If the patient says do not increase my 02, that is there right! If they are alert/oriented. The medic does not have to agree with your plan of care and they are now the person responsible. Even a doctor, unless they care to ride in with the patient and personaly care for the patient can not direct the care of the patient.

I do not understand the pathophysiology of the C02 level of 152 related to increasing the o2 by 3 L by NC. This person obviously was going to end up in the ICU!! The thought of a SAT of 73% and wheezing/ febrile COPDer with 1 lung being very very scary EMERGENT situation! This is not a benign exam by anymeans.

I commend the medic!!!

[mediatix8]

How long was this patient on too much O2 when they ended up being ventilated and with a high CO2? I always thought that it took quite a while for that to happen because the ER always send up COPD admissions on a nonrebreaather. I titrate it down as long as to keep O2 sat at least 90%. If a patient is truely lacking oxygen, not having oxygen is more serious and much more of an urgent emergency than COPD retention... there is a passage to this effect in my med/surg book. I've only been a nurse for a little over a year but in the hospital I've never seen any MD orders saying OK to leave pt w/ O2 sat in the 70's... or even 80's. It's always at least 90%... in the hospital. I know people at home often will be fine at 85% or so. I don't see anyhting wrong with putting that pt on a nonrebreather until you get them to the ER and then the ER doc can run tests or ABG's or put them on whatever O2 he wants but I don't see how anything bad can happen during hte ambulance ride on a nonrebreather.