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?

[cardiacRN2006, ADN, RN]

.....

[elizabeth321]

This thread wasn't about practicing nursing at all, it was about prehospital.

Don't be so concrete....much more has been mentioned other than prehospital.

Liz

[fr.dad]

I apologize. If you check you will see I took that message down almost immediately. Actually, I re-read your post and realized I had mis-read your words so I removed my response.

I hope you and I are the only ones who saw it, because it is gone now.

Fr.Dad

[cardiacRN2006, ADN, RN]

Don't be so concrete....much more has been mentioned other than prehospital.

Liz

Having being fortunate enough to work both in Prehospital and in the hospital, I am aware of that, Liz.

My point was, a comment was made specifically about nursing I believe by you

Originally Posted by elizabeth321

This is the scariest part of posts like this...people that aren't practising nursing according to any policy or procedure....just making decisions based on personal opinion.

Very few people in this situation would have acted on personal opinion alone. This thread was about what happens when your pt gets picked up by pre-hospital personnel.

The HHRN, and the paramedic we in fact, working according to policy and procedures, and they were both right.

However, in the field, we have a specific set of protocols that leave very little room for gray area.

Once the pt is in the hands of Pre-hospital they are out of "nursing". And THAT was my point.

[cardiacRN2006, ADN, RN]

I apologize. If you check you will see I took that message down almost immediately. Actually, I re-read your post and realized I had mis-read your words so I removed my response.

I hope you and I are the only ones who saw it, because it is gone now.

Fr.Dad

Thank you Fr.dad. I appreciate that. I'll edit my post...

[ICURN/UTEP]

Does sound like something was brewing. Question of should the o2 been cranked up, well the number one thing noted was pt. did not appear to be in distress. Treat the pt. not the monitor. However this para's actions could be defended if pt was tachycardic, and s/s of pt. trying to compensate for hypoxia. The extra o2 in the same sense could decrease this blue blowers hypoxic drive to breath thus decreasing amount of co2 blown off. Obviously pt. had to have some distress at some point other wise would not have been tubed and placed on vent. We know that copd ers are co2 retainers however a co2 of 152 is really excessive. Base deficit and ph where probably life threatening. Sounds also like this person has chronic problems and is going to have frequent bouts like this until eminent death. If this person does not want to go through intubation and ventilator support needs to lay down DNI/ DNR. Don't believe this paramedics actions are what caused resp. failure however does not look like extra 02 helped anything.

[fr.dad]

Other issues that should be getting more attention here:

1. Hospice. While we did not know for sure earlier, the pt's condition and diagnosis have suggested all along that she is approaching the end of life. Medicine does not know how to heal advanced COPD, only how to provide care and comfort. In post #249 we learn that the family knows the pt's life expectancy is less than six months. I wonder why pt was not enrolled in a Hospice.

2. In fairness to the Paramedic, I wonder whether she was given the necessary background facts, such as a copy of the DNR, the MD's orders about never exceeding 2.5 lpm O2 under any circumstances, the existence of the DPOA.

3. Did DG have an option to call for a routine, non-emergency transport to the hospital? If so, why was that not done for this pt she deemed non-emergent? If not, why has her agency not made such arrangements possible? I do know that such things were in place and frequently used in the four communities, urban, sub-urban, and rural, in three states where I have been involved with EMS.

4. Someone, possibly Social Services at the hospital, possibly the pt's pastor or attorney, possibly DG as her home health nurse, someone who knows about Advance Care Directives, Living Wills, and such things, ought to have tried to assist the pt to write the appropriate documents for her state to address this sort of circumstance. As someone has pointed out already, a DNR does not address treatments prior to the need for resuscitation. Again, I am thinking of Hospice. Generally Hospice people can be very helpful to pts and families to sort out these issues.

Fr.Dad

[Sheri257]

Very little attention has been paid to assessing the pt's mental status, rather than assuming it without assessment. Nurses, Paramedics, and EMT's all receive training in assessing mental status. All should be using those skills, following those procedures as part of their decision process, rather than basing everything on what the meter shows.

Actually, I thought people were also addressing the medic's assessment ... i.e. raising the possibility that the medic did use their skills and may have had a completely different assessment than the nurse's.

If I'm not mistaken, some of the medics on this thread described circumstances where a patient might seem fine to a nurse who's treated a patient for a long time and might not notice some things due to a gradual decline ... versus a medic who's never seen the patient before and looking at them with fresh eyes who might see something else.

Since the patient was, in fact, intubated ... it seems possible that the medic might have had a completely different assessment.

:typing

[twotrees2]

Hey there DuthchgirlRN -

When I was just a lowly little street medic I had wide varying experiences with HOME HEALTH NURSES - including one RN doing CPR on a patient that was begging her to stop! So...

In my experience HHN's are generally not able to manage an acute/critically ill patient with any real degree of competency.

good lord - even my little kids arent that stupid - how the heck can that nurse still be a nurse - how can anyone think they need to do cpr on someone who can talk- yikes!!!

[twotrees2]

Well, that was my other question. Does the patient forfeit rights to refuse treatment after they call 911? Because I thought consent could be withdrawn at any time, even with emergencies. But, of course, I could be wrong which is why I am asking.

:typing

in my personal history implied consent stands- when my grandmother was having a stroke we took her to theER - she refused treatment ( thought not mentally capable to do so in our impression) they refused to take her- the nurse so kindly told us about calling the ambulance and then they couldnt refuse her - we had to go all the way back home and call an ambulance- they took her in and with the 2 hours was wasted becuse they refused to treat her - she ended up dying and may have lived had they treated her initially - maye not but we will never know for sure all because they refused to treat a confused elderly woman who was OBVIOUSLY even to those who did not know her NOT in her right mind ( draggng her rt side of her body , slurring her speech and walking in circles like a mad woman trying to open the door which wasnt there, hitting out at staff and even the family - and yes we even asked them to call cops and they refused - hindsight we shoudl have called the cops but that was before anyone knew anything medical at all in our family)

of course looking back this is tha same hospital who when i was a lass and drove myself to the hospital with rt arm pain and chest pain - did an ekg, accused me of being on drugs ( which i wasnt and they never even did a tox screen that i recall ) gave me a demerol hypo for pain and sent me DRIVING home - and within an hour i was calling an ambulance and JUST made it into the OR in time to prevent a grapefruit size cyst filled with gangrene from rupturing inside me - i was in hospital for a week and half after that iw as so ill - and never even got an apology from that er doc ( whom i did report and noting happened that i know of ) thank god he has long since retired!!!

i apologize for the off topic here- i too have learned much here- could have used it all last week when arguing with a doc about putting a resident on o2 to keep > 96%!!! when i tried to say i didnt feel that was appropraite before i could even say they had copd and we had pnuemonia on the wing i wanted an xray as well as o2>90 she said would you rather 98%? i went livid and blank as a black board with any explanation to stuff i knew - LOL never had that happen before - ) the resident had copd who was having some difficulties- i had to hand over phone to charge nurse to explain i was so blank lol ( who got order decreased to keep >90)

anyhow- thanks for all the refresher courses and explanantions - i love a good debate that teaches what we dont know and refreshes what we do know.

[ICURN2004]

i agree totally with this comment.. the patient was sick when the family called. i do agree that health care individuals should listen to the history of a patient and family. i also think the ambulance was the way to go not to make it convenant for the patient but to get quicker care. we as health care providers nurse, parametics and all have to make decisions every day and sometimes they are not the right ones but i can bet you that this parametic did not want to jepordize the patient and used critical thinking to make the decision that they did. maybe it was not a long term plan. you said when they get to the ambulance they would change the o2 to nonrebreather. Also a copd pt is already anxious, can you imaging the anxiety it caused for the health care TEAM to be fussing over him/her. Some times the vent is a blessing to give the patient a rest from working so hard. For sure there where other issues. hope your patient does well... i was wondering what the age of the patient was... (just wondering)

[DutchgirlRN, ASN, RN]

I was wondering what the age of the patient was... (just wondering)

66 y/o