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

[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?

[darrell]

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.

I hear you, but the point about protocols is also a valid one. EMS provides for this scenario in training and the rule is that the responder must not assume that the patient is hypoxic due to COPD. In my area, at least, there is no special protocol for COPD.

I'm not blindly defending the Paramedic, but please consider this when discussing. As an RN student and an EMT-B, there are times when I want to do something but find myself dragged along by the rules.

A RR of zero is worse harm than a vent.

[ernurse4ill]

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

Ok, I don't think you should try to have it both ways here.... FIRST you say that the patient was in no acute distress and doing quite well with sats in the low 70's. THEN you say this about her condition was too poor for her to sit in the waiting room. Which is it????

I agree that the medic should have listened to you, and at least discussed it without dismissing you. Perhaps explained why she HAD to act in the manner she did. BUT if this patient was serious enough that you were concerned that she could DIE in the ER waiting room, then I suppose short term O2 to get her to the hospital would not have caused any great harm, at least temporarily!

[nurse_drumm]

Regardless of weather or not this situation was "emergent", the point here is that the RN was advocating for the patient, and had the knowledge to know that increasing the 02 to 6L/min on a COPD'er could be detrimental to the patient.

I'm not knocking the EMT here, but I have to ask (as a RN never having been an EMT), are the EMT's not trained or aware of the complications of a retainer? Especially if they were forwarned that this particular patient IS a retainer? And everyone asked/begged for the EMT NOT to turn up the O2 with logical and apparent reasons why? Please don't take this the wrong way, I'm mearly trying to educate myself......

[circusdog64]

It is always important to remember not to withhold oxygen in the presence of hypoxemia (reflective of the low SpO2 level). The EMS was correct in it's actions of titrating up with the oxygen. The report of a past event of hypercarbia via the family member may or may not be correct. People often misunderstand what the history is and exactly what happened at a past event. Did he/she truely get intubated because of hypercarbia? Why wasn't NPPV attempted? There seems to be more to the story. Also, it is important to remember:

(#1.) Any SpO2 value under 80% is not truely reliable-it could be higher or lower as refective of the PaO2.

(#2.) Remember the oxyhemoglobin dissocation curve when dealing with SpO2 levels and what the actual PaO2 is.

(#3.) The only way to know if someone is truely a CO2 retainer working on the hypoxic drive is an ABG. Not all COPD patients (in fact only a small % really) are CO2 retainers.

I am a RRT-NPS for 11 years now (and a current RN student).

[darrell]

I'm not knocking the EMT here, but I have to ask (as a RN never having been an EMT), are the EMT's not trained or aware of the complications of a retainer?

Read my earlier quote for details, but essentially the answer is yes, EMTs are educated on the subject and no, they may not (at least in my area) adjust O2 delivery based on this. Only a doctor or Paramedic may give orders to an EMT, and only a doctor may give orders to a Paramedic, thus effectively tying both EMS professionals' hands in this situation.

The EMT-P may not have been obstinate or cold (I wasn't there), but simply trying to deal for the umpteenth time with an old issue while still keeping the scene on track.

You see, discussion and arguments at EMS scenes are not uncommon and part of the lead EMT's job is to keep things moving forward. If she agreed with the nurse privately, she may still have known from past experience the decision wasn't going to change and further discussion was eating up seconds.

Again, I am an EMT-B, a respiratory floor tech and a student RN. I'm trying to be fair across the board here because in this case I think the protocols need to be looked at, not the personnel. Why not ask the patient's doctor or the local medical control to comment?

D

PS: I didn't mean to insinuate the protocols need changing, either. It's more than possible that research bears out the use of high flow for COPDers under these circumstances. What I meant to say is that perhaps a rider to call med control would be appropriate when requested by home health, the patient or family. If in the doctor's opinion this is not going to change anything, then perhaps an effort to educate the home team might be appropriate.

[JanInTexas]

First of all, to DG: so sorry to hear that the patient died. But thank you for starting the topic, for hanging in there and keeping us updated throughout the entire 20+ pages, and for letting us know the final outcome.

So, brand new RN BSN here. Graduated in December. Passed the NCLEX on 1/23. Employed on a GYN-ONC unit in a teaching hospital. I learned a lot from this discussion. It also gave me food for thought about several different issues. Even if I didn't agree with some of what was said, the 2+ hours I spent reading all of the posts was time well-spent.

On the poll, I voted to up the O2. Yeah, like a lot of other folks who posted, we were taught that you don't give COPD patients too much O2 so that you don't knock out their hypoxic drive. However, last semester in our Critical Care Nursing class, we were taught that you don't withhold O2 from them if they need it--and that if they are hypoxic, they're probably going to be on a vent or some sort of respiratory support anyway.

As far as respecting the wishes of the patient, it's a gray area for me in this case. We are taught that NO = NO! But, I don't think I would just walk away and say "whatever" when a patient says no. On the floor, if the patient says he/she doesn't want a test, procedure, medication, etc., I would definitely provide information so that the patient/family could make an informed decision--you know, this is what the treatment could do for you, these are the side effects, and this is the impact of choosing to refuse treatment. I could even call in a more experienced RN, or the Resident/Attending, to talk to the patient/family. I see nothing wrong with that. If the patient still refuses after that, well, okay then. However, the field (and I include the ED here) is very different from the floor. So, I'm still thinking about this...

[RXCT]

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

With a COPD'er the MAX O2 delivered should be 2-3 L. No greater than 3L due to their inability to blow-off the CO2. With only one lung; that's another story and I'm guessing the O2 will now be below the2-3L mark. Once paramedics arrive, it's out of your hands. Foolish to crank up to 6L without acknowledging the patients history. I would addressthe issue with the medic company and possibly they can "retrain" the person or offer addition education.

But, then again I work LTC and Rehab and had had COPD patients with orders to increase O@ up to 5-6 L, doesn't help; only causes increased confusion if anything?????

[earth_to_hal]

I agree with Cher1983, Dutchgirl and others. From experience in MICU the fastest way to kill this person is to push O2, raise CO2 and have respiratory arrest. To be honest, I would call an AMBU for transport because it is impossible to get seen quickly in the ER any other way.

Assessing the patient, finding them stable and transport

should be the protocol. I've seen more pt's harmed by too much than too little O2 in a supervised setting.

[darrell]

As far as respecting the wishes of the patient, it's a gray area for me in this case. We are taught that NO = NO! But, I don't think I would just walk away and say "whatever" when a patient says no..

Agreed. Resoundingly. In this case, however, the patient wanted transport and apparently was no saying no so much as attemping to convince the paramedic to do something outside her protocols. Something contrary to the standing orders the doctor (medical director) had provided.

That the nurse or family was saying no is irrelevant from a legal standpoint, although Ievery EMT I can think of will eagerly consider input from sources close to the patient. In the final evaluation, though, the treatment must meet the paramedic's scope of practice.

On the floor, there is time for intervention to convince a patient to take a med, accept a treatment, conform to a PT schedule. In my area, EMTs usually have 10-30 minutes with a patient from arrival on-scene to ED triage. God knows I wouldn't want to make the day worse for a patient in distress, but my job is to first to stabalize and transport. My protocols are geared to those goals and I feel they do a pretty decent job.

Once I graduate, I will need to do RN protocols when working under that hat and follow EMS rules when on the ambulance. I hope that what I do will help draw EMS and nurses a bit closer because we really do want the same thing for our clients.

[Sheri257]

Well ... now I'm confused more than ever. There doesn't seem to be any consensus on this issue.

Many of the posters on this thread had me convinced that 6L O2 for 15 minutes wouldn't do much damage and, even if it did, it's better than dead brain cells.

And, as I recall, many cited research that extra O2 for a few minutes wouldn't do much damage.

Now, I'm doing Kaplan questions for the NCLEX and they're saying even 2L O2 can put a COPD patient into respiratory arrest in as little as 20 minutes if it kills the hypoxic drive.

I know this is academia and not the real world but ... this is really confusing.

[UM Review RN, ASN, RN]

Well ... now I'm confused more than ever. There doesn't seem to be any consensus on this issue.

Most of the posters on this thread had me convinced that 6L O2 for 15 minutes wouldn't do much damage and, even if it did, it's better than dead brain cells.

And, as I recall, many cited research that extra O2 for a few minutes wouldn't do much damage.

Now, I'm doing Kaplan questions for the NCLEX and they're saying even 2L O2 can put a COPD patient into respiratory arrest in as little as 30 minutes if it kills the hypoxic drive.

I know this is academia and not the real world but ... this is really confusing.

I think the key words there are "if it kills the hypoxic drive."

If you have no hypoxic drive at all, one could assume that Very Bad Things will be happening.

Here's another take on this from an RT:

http://home.pacbell.net/whitnack/Why_the_Hypoxic_Drive_Theory_Sucks_Wind.htm.6306

[Altra, BSN, RN]

Well ... now I'm confused more than ever. There doesn't seem to be any consensus on this issue.

...

Now, I'm doing Kaplan questions for the NCLEX and they're saying even 2L O2 can put a COPD patient into respiratory arrest in as little as 30 minutes if it kills the hypoxic drive.

I know this is academia and not the real world but ... this is really confusing.

If that were true, in the last year & a half in the ER I would have killed, by my best estimate, approximately 200 COPDers.

Real world: many COPD patients get 10-15L O2 via NRB, or put on BiPAP, fall asleep for a couple of hours, and then feel much better. Sometimes they're not even admitted - they can be discharged home if other x-rays/labs done in the meantime don't indicate pneumonia or some other problem.