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?

[canoehead, BSN, RN]

From the EMT point of view, though I'm not one, he could have let the patient stay hypoxic, possibly getting worse and requiring intubation during the drive to the hospital, and not followed established protocols. OR he could provide the O2 and maintain the sats somewhat, possibly making the patient worse B/C lack of drive to breathe, with plans to intubate if the patient didn't maintain sats, as per their standard protocol.

Both decisions include the patient possibly getting worse and heading towards respiratory arrest. One of them followed protocols, and one didn't. I'd follow the protocols. JMHO.

[darrell]

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

EMT training in our area says that it is unlikely the patient will arrest in the short time we are oxygenating him (about 20 minutes +/-). On the other hand, the training also states we should be prepared to bag.

Again, the question is whether the EMT can diagnose in advance whether O2 will do more harm than good and the answer to that is obviously no. The opition as to whether O2 should provided at high flow rates to a hypoxic drive patient hopefully isn't even in question here. The rate should be decided by a doctor based on the individual PMH and monitored continuously for it's effect. It's not likely to be higher than 2LPM in most cases, I'd bet.

Imagine being a paramedic or nurse walking into someone's house with minimal HPI and wondering if there has been some significant occult-ish respiratory change in the past day or three. SOB, SaO2 of 76%, S/S hypoxia and reduced LOC - now decide whether you should keep the 2L or increase it? While you are at it, remember that your protocols say high flow and you will have to defend your decision, perhaps in court.

Here is a similar thread from an EMT site that might interest some nurses. I really believe that a deeper relationship between EMS and the nursing community would benefit the people who depend upon us!

http://www.emsvillage.com/forums/messageview.cfm?catid=55&threadid=429

Another site to peek at is http://jems.com.

D

[withasmilelpn]

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

Fascinating! Thanks for that great post! I guess then it all comes down to how good your lawyer is?!?

[PANurseRN1]

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......

As has been explained in countless previous posts, there are cirumstances when it is totally appropriate to temporarily increase the O2. Pathophysiology, people...you don't just knock out someone's respiratory drive in a couple of minutes.

[UM Review RN, ASN, RN]

Fascinating! Thanks for that great post! I guess then it all comes down to how good your lawyer is?!?

Am I sensing sarcasm here, withasmilelpn?

Please note that Lizz was referring to a potential NCLEX question.

If a lawyer was asking my rationale for upping the O2, my answer would be:

Giving supplemental oxygen is the standard of care for any patient in an emergent situation.

I believe we already established earlier in the thread that the patient's situation was truly emergent.

[Sheri257]

Please note that Lizz was referring to a potential NCLEX question.

Yeah but ... you can't dismiss that either. One of my teachers occassionally does some legal consulting and what she does is research what the latest nursing textbooks say about standards of practice for law firms.

If three or more textbooks pretty much say the same thing then, the lawyers can and will use it. That's what the lawyers are looking for.

And, there's a lot of textbooks that hammer on the "no more than 2L" COPD issue ... at least for nurses. Obviously based on these posts, it could be different for EMT's, etc.

Not that I'm saying that textbooks are the be all end all for legal cases but ... you can't dismiss it either because it could be a factor.

:typing

[cardiacRN2006, ADN, RN]

and, there's a lot of textbooks that hammer on the "no more than 2l" copd issue ... at least for nurses. obviously based on these posts, it could be different for emt's.

:typing

it is different for pre-hospital textbooks.

this is right out of a paramedic textbook, page 303...

"delivering an increased concentration of oxygen may increase the pao2, and therefore eliminate the drive to breathe. note: do not withhold oxygen from a patient who needs it. if you are concerned about eliminating the patient's hypoxic drive, be prepared to manage the airway."

how to prepare for the emt paramedic exam (paperback)

by [color=#003399]mark marchetta (author)

also, straight out of my nursing textbook,

"the nurse monitors clients at risk for oxygen-induced hypoventilation, apnea, and respiratory arrest. although oxygen induced hypoventilation is a serious concern, untreated or inadequately treated hypoxemia is a greater threat to life."

medical-surgical nursing, ignatavicius and workman, pg 491

the italics are the actual italics in the wording of the textbook, not my own.

[RXCT]

That book is right...

[Broombug]

it is different for pre-hospital textbooks.

this is right out of a paramedic textbook, page 303...

"delivering an increased concentration of oxygen may increase the pao2, and therefore eliminate the drive to breathe. note: do not withhold oxygen from a patient who needs it. if you are concerned about eliminating the patient's hypoxic drive, be prepared to manage the airway."

how to prepare for the emt paramedic exam (paperback)

by [color=#003399]mark marchetta (author)

also, straight out of my nursing textbook,

"the nurse monitors clients at risk for oxygen-induced hypoventilation, apnea, and respiratory arrest. although oxygen induced hypoventilation is a serious concern, untreated or inadequately treated hypoxemia is a greater threat to life."

medical-surgical nursing, ignatavicius and workman, pg 491

the italics are the actual italics in the wording of the textbook, not my own.

i agree with cardiacrn2006.

i didnt read every post but this is a sad discussion. i am a rn/rrt and i dont understand how anyone would even think that denying a severly hypoxic patient, copd or not, oxygen would be the right thing to do. hypoxic patients are confused and are not the best decision makers. sometimes i know some nurses, patients and family caregivers, view hyperventilating as s.o.b. not hypoventilating as this patient was doing.

if this patient's saturations were really in the 70s when the paramedic arrived then the patient was already hypoventilating meaning his/hers co2 was most likely sky high at that moment. 2 or 6 l/m o2, i'm willing to bet, didnt make any difference on whether this patient "bought the tube" or not. only a dnr in writing would have.

as a matter of fact it sounds to me the er doc felt that the patient needed more than 6l/m if he tubed him/her and placed them on a vent.

if you dont want the ems or any other medical proffesional to treat you when you are dying, please look into in and out-of-hospital advanced directives and living wills before an emergency occurs.

[Sheri257]

Edited for error.

[withasmilelpn]

Am I sensing sarcasm here, withasmilelpn?

Please note that Lizz was referring to a potential NCLEX question.

If a lawyer was asking my rationale for upping the O2, my answer would be:

Giving supplemental oxygen is the standard of care for any patient in an emergent situation.

I believe we already established earlier in the thread that the patient's situation was truly emergent.

No, not towards you. I really love all the great information you posted. I meant what I said, the post was fascinating. What I really feel though that we as caregivers constantly try to muddle through these 'grey' areas and try to give good care to our patients, and in the end it could rest in the hands of a non medical person to decide if you gave appropriate care. Please keep posting, I always learn a lot from your posts!

[UM Review RN, ASN, RN]

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.

My only solution is to go back to the original NCLEX test prep question, which does not adequately compare to the actual situation that this patient experienced.

In order to understand the Kaplan question better, maybe we need to answer a question with a question:

If even O2 at 2L can put a COPDer into respiratory arrest in 20 minutes, why do we give them O2 in the first place? Have you ever seen a COPDer who did not get O2 at 2L?