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

Nurses General Nursing

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

    • 222
      I think the Paramedic was right to increase the 02 to 6L. I am a Nurse.
    • 16
      I think the Paramedic was right to increase the 02 to 6L. I am a Paramedic or EMT.
    • 180
      I think ultimately the patients wished should have been honored. I am a Nurse.
    • 6
      I think ultimately the patients wishes should have been honored. I am a Paramedic or EMT.
    • 122
      I think the Paramedic should be reported to her agency for ignoring everyone. I am a Nurse.
    • 8
      I think the Paramedic should be reported to her agency for ignoring everyone. Paramedic/EMT.
    • 79
      I think this was a true emergency situation. I am a Nurse.
    • 9
      I think this was a true emergency situation. I am a Paramedic or EMT
    • 13
      I don't know, it's all too confusing
    • 7
      Leave me out of it. I don't want to participate.

148 members have participated

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?

Specializes in Utilization Management.
this patient was batteried, given a higher dose of a drug than she was willing to accept, what part of that are you not understanding?

The fever and hypoxia alone suggest an emergent situation that taken together, call the a/o X3 part into question.

I tell people if you do not want to be treated, do not call EMS.

paramedics are "wanna-be doctors"? Are you serious?

Specializes in ER.

In my experience paramedics are merely doctor wanna be's. How long do paramedics go to school?

Ah yes, the Paramedic is completely uneducated and can't possibly know anything about patients. There is no reason that the Paramedic should not listen to me, and just her ego got in the way.

Get over it.

And, for the record, Paramedics go to school for two years and are awarded and Associate Degree these days. That would seem to be about the same amout of time as your peers do.

Having done a fair number of HH encounters in both the field and the ER, I can honestly say that the perception of another poster that the HH nurses are ill equiped and ill prepared to handle an acute situation is true. I've had situations where a HH client had a stroke, was vomiting, and unable to care for the airway. One HH nurse admonished me for putting the patient onto his back so that I could intubate him. One HH nurse admonished me for turning the patient onto the affected side so that I could clear the airway. One admonished me (and tried to call my boss...who was me, from an operations standpoint!) for bagging a patient when she could not find a DNR.

But, hey, what do I know. I've only been seeing patients for 17 years!

Chip, RN, CCRN, EMT-CC, and a bunch of other letters!

Specializes in Lie detection.

Having done a fair number of HH encounters in both the field and the ER, I can honestly say that the perception of another poster that the HH nurses are ill equiped and ill prepared to handle an acute situation is true.

Chip, RN, CCRN, EMT-CC, and a bunch of other letters!

Please do not lump all HH nurses in together as being inexperienced in acute care situations. I have had many situations and have plenty of acute care experience to back me up. Some of us do have ICU or strong med/surg backgrounds. I have both.

I don't wanna-be a doctor...I wanna-be a firefighter, but I am too claustrophobic to put on an airpack.

:)

Specializes in OB, M/S, HH, Medical Imaging RN.

"Doctor wanna be" was a term used as a knee jerk reaction to the poster who oh so politely referred to HH nurses as incompetent to care for patients in acute situations. I apoligize to any paramedics for my reaction and choice of words.

I worked in the hospital for 31 years. As a charge nurse I ran many a code and respected for my skills. HH is a whole new ball of wax for me. The only tools at my disposal are BP cuff, stethoscope, thermometer and pulse oximeter. I did call the doctor....that was a no brainer. The doctor said call 911. The family was unwilling to transport the patient. The patient was just released from the hospital 2 days ago with a right shoulder fractured in 3 pieces. Surgery was not possible due to the respiratory risk and severe osteoarthritis due to years of prednisone. The patient is a DNR. Don't beret me as to why he/she is now on a vent. I don't know. And I also know it's obviously not the fault of the paramedic that he/she is on a vent. Please give me some credit.

CasbeezgirlRN thank you for your sensibility and the nice way you put things in perspective. When I first posted, I had just gotten home, I was so worked up and my fingers were just flying away. I have since spoken with my supervisor who was very supportive and pointed out that a better option would have been to call a private ambulance service for transport. The hospital is literally 2 miles from the home. She explained to me that once the ambulance, that I called, arrived that they are responsible for the patient and their actions whether they be right or wrong. She felt just as CasbeezgirlRN pointed out that right or wrong the paramedic should have acknowledged the family and then went about doing what she felt needed to be done.

I was so angry yesterday evening I could have spit nails. Having calmed down, although I don't agree with the 6L of 02, I realize that level for such a short trip wasn't a big deal. I resented the way she came in and was like "Oh my God! a sat of 73%", acted as though I was invisible and incompetent.

I spoke with the daughter today and she said her Dad/Mom had been in the low 70's since early that morning and never once complained about SOB or anything else for that matter. They thought the low sats were due to the amount of pain medicine he/she was taking and was waiting for it to wear off to see if his/her sats would come up. They didn't and with the temp decided to call the answering service. She also said that the ER doctor told the staff to turn the 02 down to 2L and her 02 sat had remained in the low 70's despite the 6L/min.

I'll let you know more about the patient and the diagnosis when I find out.

Specializes in Lie detection.
"CasbeezgirlRN thank you for your sensibility and the nice way you put things in perspective. .

Your welcome! HH is a whole different animal. Just for everyone's info, we really do try our very best NOT to call an ambulance for transport unless necessary of course. My agency uses several ambulette services for this purpose and I have sent pt's to the ER this way. However, sometimes, even if it's not a life threatening situation, it's a bit too unstable for an ambulette driver with NO medical training whatsoever. And no, I am not talking about a cold or a hangnail ;) .

If I feel the pt. may decompensate in the next few minutes, I'm calling the ambulance. And I base that decision on my COMPETENT nursing assessment:D .

Specializes in CVICU-ICU.

I've been following this post and havent said anything until now. I think the paramedic was also in the right to do what he was trained to do just as nurses do what we are trained to do. I now work in ICU and I know the therories behind COPD and CO2 retention but thats been mentioned enough already so I wont go into that however in one of the last post's by the OP I see where she says the patient was a DNR. Before working in ICU I spent 8 years in homecare and the rule of thumb was not to call paramedics for DNR patients because paramedics handle any call as a lifesaving call. Maybe that rule has changed because I've been out of HHC for 8 years now. I also wonder if the patient was a DNR why that info wasnt passed onto the hospital by the family in order to avoid a unwanted intubation. I guess that is my pet peeve being in ICU now.

Specializes in OB, M/S, HH, Medical Imaging RN.

the hospital knows this pt all too well and knows about the DNR. Everytime I resume this pt the hospital discharge states "DNR but agreed to temporary intubation". Makes no sense to me either. Alot about DNR's make no sense to me. I read about this elderly woman (80's) who wanted to be a DNR but her family said if she was ever in a critical situation they would tell the doctors and nurses that she was not a DNR and to do all that they could. This woman went out and had a large DNR tatooed on her chest!

What a woman!!!! :lol2:

Specializes in ICU.

As to paramedics being doctor wannabees, not in my case. I'm a degreed Chemical Engineer, and a RN wannabee. No incination to go MD - I'd rather keep a personal and family life, thank you very much!

As a medic since 1991 (& EMT a few years before that), you see lots of "stuff", and it's constantly drilled into you from the start of training that you must be AGGRESSIVE in the care of seriously screwed up patients. It's also emphasized that it's better to explain a sin of commission than a sin of omission.

I'd fault the medic for only going with 6lpm O2. I'm more inclined to go with a non-rebreather at 10-15lpm, but that's driven by my local protocols.

I've been on scenes where physicians and nurses have been there, but the responding crew rarely knows their background/certifications/capabilities. You may have a doc that's 25 years out of school, and has been a Dermatologist ever since (forgetting most of their ER time). If they claim to be a MD or a RN or a paramedic, that's taken with a large grain of salt. I've had people claiming to be paramedics from another state show up on my scene that didn't know 1 end of a stethoscope from another. When faced with a patient that looks sick, sounds sick, measures (by pulse ox, monitor, whatnot) sick, then the medic will tend to aggressively take charge, and treat the patient without delay. This is how we're "programmed." You don't have a lot of time to play 20 questions and assess the level of training of bystanders.

Obviously, most medics are not nurses or physicians. We may not have a full understanding of the underlying pathophysiology of a long term disease process that's plopped a sick patient in front of us. Then again, I suspect that if you grabbed your "average" MD or RN and dumped them in a muddy ditch at 2AM, facing an upside-down car, they might not exactly know the "best" way to handle things. Each medical professional has unique strengths they bring to the table.

If the family & medical personnel on scene expressed concerns about the amount of O2 to be given to the patient during transport, most ambulances have this neat invention called a PHONE. The medic could call & speak to medical control for their recommendation. If in doubt, though, we're taught to give O2.

After reading through this post, I am amazed at the similar attitudes of some (not all) of those chiming in saying they are medics. I can see why the OP had "knee-jerk reaction" to the offensive "I am better than you" attitude. I am not an ER or HH nurse, so my experience with medics is very limited. Of the handful I have met, they have all been in casual passing, all have felt the need to tell me how they "once did something better than a nurse." The moment they find out I am a nurse, all of the sudden, they feel like they have something to prove. The funny thing? One of them made up a story, a total blatant lie, just to tell me how he showed some ER nurses up. I know he was lying b/c he was talking about a large teaching hospital (where I happen to work) where "all the nurses were standing around trying to intubate a 6 week old." Do I really need to point out the part of that statement that sounds like bull? I am a full believer in everyone having a job that is necessary and an important part of the team, with different stregnths so I know the "stories" are not a response to me having a "better than you" attitude.

Would it have been so hard to acknowledge the nurse and family by stating that she was following set protocols that require increasing O2 on any hypoxic pt, regardless of potential for CO2 retention? How long would it take to say that.....3 sec max? "I am sorry you disagree, but I am following my protocols."

DNR does not= DNI

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