Emergency decisions

[CapeCodMermaid, RN]

We're having a discussion at my facility. I ( the DNS) say there are certain things we can do in an emergency without an MD order, and certain things we CAN NOT do without a doctor's order. Oxygen at 2-3 liters via nasal cannula or maybe up to 5 liters through a mask would be ok. I'm being told that 'we've always' put as much O2 on as the tank will allow if the resident is in distress. I found a notation in the chart that the resident had 'tremors' was not responding, and had an O2 sat of 95%. For some reason they put him on 15 lpm with a non rebreather without an MD order. They tell me they've always done this. I've told them I hope they carry malpractice insurance. Am I over reacting?

[Bella'sMyBaby]

Don't know about this specific situation.

But I would contact your BON to see if they could give you some direction on this.

[systoly]

No you're not over reacting. My question would be, why was CPR not initiated since the patient was non responsive and since we decided to place O2 at 15 LPM via NRB for an O2 sat of 95%. On second thought, bad idea, CPR might be started the next time this happens.

[CapeCodMermaid, RN]

I had to be sketchy in the information so my facility and the resident can't be identified. The man had a pulse of 82, resp rate of 18...maybe they'd all been smoking crack ...who knows.

[debRN0417]

I had to be sketchy in the information so my facility and the resident can't be identified. The man had a pulse of 82, resp rate of 18...maybe they'd all been smoking crack ...who knows.

The resident or the staff! Haha! Sorry....I would have flipped out too! 95% sat and 15L O2? Nope...

[diane227, LPN, RN]

There is not enough information to give you much specific advise here but when you make a decision, it is imperative that you take the following into consideration: What is best for the PATIENT. What do I need to do NOW to keep this patient alive of from suffering consequences of an action (like a fall). Your facility should have policies in place to address what to do in an emergency but don't get too caught up in that. There are times when you have to deviate from policy in order to protect the patient.

Now, given the information that you provided... if I had a patient that was having "tremors" and not responding, the first thing that you do is protect the airway. It is always: ABCD... airway, breathing, circulation and disability. You look at the patient and apply some oxygen. Now I can tell you that I do not get too excited about a saturation of 95%, especially if the patient has a hx of COPD or heart failure. Oxygen is not going to hurt the patient. You can always get the order later. But is the tremor from an elevated temperature, seizure, alcohol withdrawal? You have to explore further. And you need to call the doctor. And please do not forget to get a full set of vitals including an ACCURATE temperature, even if you have to do a rectal temp.

Now let me tell you that inaction will get you into trouble. Calling the doctor and not getting a response warrants follow up. If you cannot reach the doctor then you have to decide if you can call another doctor of if you just need to call 911. If something happens to this patient, if he suffers harm, the incident will have to be reported to the state. A surveyor will come out to investigate. If there is a failure to act or a delay that resulted in harm to the patient, the facility will receive a citation for this and could receive a fine or other sanctions.

Know your emergency procedures. Know how to call the doctor and what to do if the doctor cannot be reached. Know what amount of time you should have to wait for a return call from the doctor. Know how to reach your manager if needed, for additional advice. And remember, document everything that you do and all attempts made to call the doctor or to get other assistance.

[caliotter3]

You are not overreacting according to what I was taught: anything over 2 L, get an MD order. I wonder how do we know one way or the other? All I go on is "follow facility policy". In all the years I've been around now, I have to admit that not all places have a clear policy to follow.

[CapeCodMermaid, RN]

If you told a surveyor that you had to go outside the policy to protect the resident they would cite you.

The rest of the story: the man is fine now ... back to baseline and everyone has been re-educated about the use of so much supplement O2.

I was going to say something snarky about not needing a lesson in life support but thought better of it.

[debRN0417]

If you told a surveyor that you had to go outside the policy to protect the resident they would cite you.

The rest of the story: the man is fine now ... back to baseline and everyone has been re-educated about the use of so much supplement O2.

I was going to say something snarky about not needing a lesson in life support but thought better of it.

No surveyor in their right mind would cite you for doing everything you had to in order to protect your resident. You cannot/should not be cited based on policy. (granted some surveyors are not in their right minds)

[Nascar nurse, ASN, RN]

The resident or the staff! Haha! Sorry....I would have flipped out too! 95% sat and 15L O2? Nope...

My thoughts exactly.

In my state, the surveyors have cracked down ridiculously on oxygen in general. It is a "medication" & like any medication we must obtain a physician order prior to use at any rate! Surveyors were citing local facilities for allowing the aides to even re-set the rate after filling portable tanks, even tho they carry care guides with the exact liter flow in their pockets for reference.

15L tho...for a SAT rate of 95%. Craziness!