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?

[KyPinkRN]

" 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. /quote]

I hope you don't think that calling a private service would have gotten your patient treated differently in this situation. Before I entered nursing school I worked for a private service for 7 years and I can tell you this patient would have received the same treatment on my ambulance. They have protocols to follow and answer to the same state authority as 911. Whether you knew it at the time or not I would have considered this an emergent situation. COPD or not...febrile, o2 sats of 73%, and wheezes in the only lung is cause for prompt attention. Probably more prompt attention than a healthy person with those numbers because a person who is already compromised has less ability to recover.

[burn out]

I don't mean any disrespect or to flame anyone but I think you were out of line. First with the decision to call 911 and the medic arrived you needed to back out of the situation..you did your job you assessed the patient and determined they needed further medical care. You knew something was wrong but not what therefore you can not apply the same patient normal standards to the situation. For example that he tolerates a sat of 80 does not mean all is well and normal at 73 ,therfore do not increase the o2? Then to call the ER doc and cloud his judgement about the man's condition and instructing him to turn the o2 up (he can think for himself)...overstepping bounds. Yes the man's co2 was 152 in ICU and I also would venture to quess that it was at least that at home but we will never know because we can't do abg's at home. I see at times that your concern could have caused harm to the patient and you should have backed out when the medics got there.

[withasmilelpn]

When I worked in home care, we would have also had to notify the agency supervisor and the patients doctor. I'm curious to see if that was done? I also would've notified 911, but never to get "seen faster". It's my understanding that if it were not a true emergent situation a patient would still have to wait to be seen- ambulance patients are triaged also.

Anything that involves a respiratory problem as you described I would call 911 because I have seen apparently 'stable' patients in those situations go bad very quickly. 911 would be equipped to handle that if it occurred and it seems as if your patient was a very high risk.

As far as some of the posts here, I think some proffesionalism (sp?) is lacking. I totally understand the frustrations involved, but to judge an entire healthcare group- homehealth nurses, wannabee doctors- is just as bad as judging people for their color or sex, don't you think?

Frankly there are incompetant people in every aspect of the healthcare field. The ones that screwed up are going to stand out in your mind, but don't stand for an entire group of people.

My advice- withhold judgement, keep your mind open- there are always things to be learned in every situation, and use these opportunities to educate people.

[LeahJet, ASN, RN]

I haven't read all the posts so sorry if I am beating a dead horse......

but I personally think it would be silly and petty to report a medic for

doing the right thing.

As far as the patient/family refusing care (the o2)..... why on EARTH did they call 911 then?? That is such a pet peeve of mine. People coming to the ER on "the brink of death" and then refuse treatments/care.

This patient could have loaded up in the car with their 2L cannula and ridden to the ER.

[SmilingBluEyes]

I, for one, am learning so much from you all. Thank you for the opportunity to see varying opinions and learn.

[Shamira Aizza]

I'm thinking somewhere there are some paramedics on an EMS forum talking about this one-lung COPD patient he was called for, and when he arrived, he found the patient saturating at 73%, and some HH nurse told him that 2.5 liters was an appropriate liter flow, and if had only been called sooner, maybe this patient wouldn't have ended up on a ventilator.

I'm just saying...there's always two sides.

I'd also like to point out that an elevated CO2 is a VENTILATION issue, not an OXYGENATION issue...unless you are suggesting that a higher Fio2 for the duration of the transport actually contributed to hypoventilation (highly unlikely, and there is no clinical evidence to support this theory). Additionally, a COPDers respiratory drive is driven by hypoxia, and if this level of hypoxia was not initiating a ventilatory effort to bring the SaO2 to a more acceptable level of 80-85%, then additional supplemental O2 is required.

73% is abnormally low for a COPDer, and we don't necessarily know if this patient ended up on a ventilator because of loss of respiratory drive due to a brief run of higher flow oxygen, or if this patient was found to be profoundly acidotic because of progressive respiratory acidosis preceding the call to 911.

Ambulance transport increased metabolic demands for a patient, even if someone lifts them for every evolution of the transport. And a one-lung patient saturating at 74% doesn't leave much wiggle room. Increasing the FiOto to 6lpm for the transport was not improper.

[Cattitude]

as far as some of the posts here, i think some proffesionalism (sp?) is lacking. i totally understand the frustrations involved, but to judge an entire healthcare group- homehealth nurses, wannabee doctors- is just as bad as judging people for their color or sex, don't you think?

frankly there are incompetant people in every aspect of the healthcare field. the ones that screwed up are going to stand out in your mind, but don't stand for an entire group of people.

my advice- withhold judgement, keep your mind open- there are always things to be learned in every situation, and use these opportunities to educate people.

well said, and you made great points. frankly, i am very disappointed in the remarks made in previous posts in this thread by my own colleagues. yes there are incompetent nurses out there but as you stated so nicely, they're in every aspect of healthcare.

and yes, keep your minds open, very open. you never know what situation you may find yourself in, professionally or personally. you just may have a hh nurse who knows her stuff at your side!

[withasmilelpn]

Dutchgirl, the more I read about your situation, I do think things were not so black and white. I do think the paramedics could've shown more respect. I've dealt with all kinds -ones that truly listen when I give them report as to what occurred with my patient and ones who also ignore me. The best are the ones who act like they don't believe me like when my patient goes unresponsive, 911 is called and by the time they arrive they are responsive again. Sometimes the condescending attitudes I recieve are enough to enrage me into writing exactly the same kind of letter you wrote!

[Shamira Aizza]

That's a good point.

I'd also like to say that respect is a two-way street, and having worked as a paramedic before I became an RN, I wouldn't be so gracious to have my clinical decisions addressed openly in front of the patient and their family.

Bottom line is that the treatment was appropriate, and careful consideration should've been used before challenging the care of the paramedic, especially if you can't cite any clinical evidence to support any theory that short-term use of a higher FiO2 would be harmful.

I've gone to the homes of COPD patients that were visited by HH earlier that day, finding patients that were acutely ill, unresponsive, requiring intubation, bradycardic, or in cardiac arrest. And if I had a nickel for every time HH called for EMS and then left before we arrived, I could've paid off nursing school without having to work full-time.

[vamedic4, EMT-P]

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?

I think you are absolutely right to report this paramedic, and I hope she never cares for anyone I know! One thing you MUST acquire in order to function competently as a medic (or nurse, doctor, et cetera) is a HISTORY, and you base your treatment on your assessment of the patient, and the patient's HISTORY. This paramedic did neither. Report her, she makes us all look bad.

I disagree with other posters about calling 911 on this one though, if it were my grandmother I may have done it. Why?

1. As the OP stated, she normally sats in low 80s but now is in 70s despite breathing treatments...bells are ringing now, because what we're doing isn't working like it should.

2. Temp of 102, wheezing noted. Somethings brewing inside this patient that has the potential to send her south quickly if conditions are right.

Sepsis?? Probably. We can't judge until we see lab values but given her history, it is prudent to get her to a hospital where definitive care can be administered, and pronto.

I currently work in peds cardiology...and have for a number of years. This has allowed me to see treatment orders like O2 TKS 65-75%...for our kiddos with certain cyanotic heart defects. The principle is a bit different with adult COPD patients, but the end result is the same...too much O2 can be a VERY bad thing.

The last thing you want is to have this patient who is stable (for the moment at least) to decompensate and crash on you in the back of an ambulance. Not my idea of a good day.

I hope your patient is okay.

vamedic4

It's still cold in Texas

[Shamira Aizza]

I currently work in peds cardiology...and have for a number of years. This has allowed me to see treatment orders like O2 TKS 65-75%...for our kiddos with certain cyanotic heart defects. The principle is a bit different with adult COPD patients, but the end result is the same...too much O2 can be a VERY bad thing.

The last thing you want is to have this patient who is stable (for the moment at least) to decompensate and crash on you in the back of an ambulance. Not my idea of a good day.

I hope your patient is okay.

vamedic4

It's still cold in Texas

More than a bit different...a lot different. The saturation for those patients has nothing to do with CO2 driven respiratory drive or lung disease and function, but rather with the fact that the infant is mixing through a cardiac defect that needs to be repaired, or is mixing because of an artificial defect (or a purposefully maintained PDA) is required to keep them alive until vessels can be switched, etc. Additionally, these patients are typically under a minimal stimulation protocol to minimize O2 demand.

A COPD patient will not decompensate during an ambulance transport just because of temporary increases in FiO2, especially as small as increasing them from 2 lpm to 6 lpm. A patient saturating at 73% is not stable. Such a patient could be one-step from fatal acidosis.

[vamedic4, EMT-P]

Shamira your point is well taken...and I feel for the patient...

OT -any one of you know what 6 lpm via nasal cannula feels like???? :chuckle Next time you're at Wal Mart filling up your tires with air, stick that thing up your nose and squeeze the trigger...ugh!! I would have gradually increased the O2, instead of giving the full 6 right off the bat...perhaps upped her to 4 lpm and reassesed.

And while you are correct about the patient not decompensating from the oxygenation/ventilation issue...she had other issues that were in need of addressing. The point of my post remains...she needed more definitive care than was available at home, and getting her there by ambulance wasn't necessarily the wrong call. For all we know, she could have had some underlying issues related to dehydration as well. Sure, she COULD have made it had they loaded her into a car with some O2 on..but given everything else that was going on..why take that chance??

Just my $.02

vamedic4

Is it summer yet??