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?

[Cattitude]

hey there- the dnr statement was me. my thinking was if she made herslf a dnr, then she would'nt be going to the er. hospice would be taking care of her.

:roll :roll just had my 30th weding aniversary!!!!

just a sidenote. dnr does not mean do not treat. i have people with dnr's that absolutely do not want resuscitation if their heart stops and if they stop breathing but do want to be treated for bronchitis,pneumonia,broken limbs,etc. especially with community dnr's which often look at the big picture. we don't usually sign them at the last minute when dad is hanging on by a thread. so we do have pt's with dnr's that still get appropriate treatment.

[DutchgirlRN, ASN, RN]

I'm confused. Are you in Holland or the USA???

I'm proud to say I'm an American and live in the deep south. I was born in Holland and have dual citizenship. My whole family imigrated here. Nursing in Holland is very different from here. The work is the same but the differences lie in the fact that it is strictly forbidden for nurses to work over 8 hours per day and over 40 hours per week. They feel it's not safe. If you want to go into Home Health you have to go back to school for an additional year to be certified in Home Health, the same is true with nurses who want to work in the ambulance, they go back to school. Also LTC, another year of specialized school.

[chip193]

it doesnt make any difference....unless you are going to get a judge to come to the house,....the op knows this patient and gave no indication there was any gross change in mentition.....you cant impose your will on someone because you think you are right

Plantiff's Attorney: "Can you explain to me what hypoxia is?"

Paramedic: "It is when there is not enough oxygen to perfuse the organs."

Attny: "What are organs?"

Medic: "They are the different systems that carry out the work of the body."

Attny: "Such as?"

Medic: "The lungs work to exchange gas, getting rid of carbon dioxide and bringing in oxygen."

Attny: "And what happens if the lungs fail?"

Medic: "You would stop breathing."

Attny: "What if is wasn't that bad? What is Respitory Failure all about?"

Medic: "That is when the lungs don't do their job and you get a build up of waste products and carbon dioxide."

Attny: "And is that bad?"

Medic: "Yeah, that's bad."

Attny: "How do you treat it?"

Medic: "Give oxygen, maybe intubate the patient and breathe for him."

Attny: "How could you tell if a patient is in Respiratory Failure?"

Medic: "Well, he could be acting weird, or if the sat is low?"

Attny: "What is a sat?"

Medic: "It's a pulse oximetry reading."

Attny: "What does that do?"

Medic: "It gives and idea of how much oxygen is being carried on the hemeoglobin."

Attny: "And what's normal?"

Medic: "Usually 92% or above."

Attny: "And what was my client's Dad's?"

Medic: "73%."

Attny: "And he wasn't in Respiratory Failure and didn't need additional oxygen?"

Game, set, match. Get out the checkbook.

You have to prove that a patient is competant in order to let him refuse. That's why RMAs and AMAs take so long to chart.

That's why the Paramedic was right to turn up the oxygen.

That's why the Paramedic should have thought about intubation.

[chip193]

are you purposefully misunderstanding?! my mention of a judge was to judge competence.....IF one were at the house (judge) he/she would not be able to preside in a case concerning patient.....you still havent addressed my request for citation of law about paramedics being the only med prof that are aloud to ignore a patients clearly stated NO, i have to presume that you cant.....as i figured......

We routinely do this in the ER - patients who are not competant to make decisions for themselves (usually mental health or chemically enhanced, but sometimes hypoxic). The laws vary from state to state (in MA it's a Section 12, in NY it's either a 9.39 or 9.41) that permit this to happen. There's also tort law on the subject.

[chip193]

As for the DNR status someone mentioned (not sure who), in quite a few states, if a DNR is in place and 911 is called the DNR becomes invalid. A call to 911 is considered a call for help and request for treatment and supersedes the DNR. So, in calling 911 the OP would have invalidated a DNR for this patient if one would have been in place (not cutting on the OP, just food for thought for everyone).

Mileage on this varries from place to place. Both NY and MA have out of hospital DNRs that are required to be honored by EMS.

Remember, DNR means that if the heart stops, don't do CPR. It does not mean don't treat the patient (and my Medical Director expects us to intubated DNR patients in Respiratory Failure).

[chip193]

Hey there- the DNR statement was me. My thinking was if she made herslf a DNR, then she would'nt be going to the ER. Hospice would be taking care of her.

I still say that, even if the patient's SATS were in the 70's, that is probably where she lives. Didn't the original note say that she didn't really feel bad? No SOB? THen WHY call 911?!?!?!? If she lives in the 70's, another 15 min. in the back of the car with her home O2 probably wouldn't have hurt her. And like someone eles said, when the patient gets to the ER, triage would have sent her right to the back anyway. I really don't think that a compenent RN would make the patient sit in the waiting room "for hours". Thanks for letting me state my views -- can't do it at work, haven't "been there long enough to have an opinion"!!

:roll :roll Just had my 30th weding aniversary!!!!

You do not have to be in Hospice to have a DNR. Many patients locally have them and are not in a SNF, ALF, or in Hospice.

[chip193]

i highly doubt a paramedic would loose their lic over honoring a patients NO!....I could see her being sued over not........

PS I am in no way arguing the medical aspects of this issue

You obviously aren't following the lawsuits and actions of the state EMS departments.

I wouldn't expect you to - you're not a Paramedic.

I think I missed it along the way somewhere - where do you work?

[Jo Dirt]

oh boy...

[chip193]

They don't even put activelydying people on more than a few L/M. This person needs an attitude adjustment.

I have "comfort care" patients who are taking their last breaths on NRB masks. It all depends on the patient.

I can think of a case last week where a patient was not enrolled in Hospice. Family had run out of morphine for the end stage CA of the everything. Patient presents to the ER via EMS, who had the comfort care form in hand (it's a MA thing). Patient remained on NRB, was given Morphine for the pain, arrangements were made for family to get a stock of morphine for home, and patient went home and died (on NRB) about 8 hours later.

Generalizations, like multiple guess choices that have "always" or "never" in them are usually wrong.

[vamedic4, EMT-P]

i have to agree on the side of the medics in this, though i understand the hh nurse's frustration.

we have awesome ems personnel in my city and their protocols are pretty solid. occassionally annoying but solid.

i was at a baby shower once and one of the young ladies (early 20's) had an anxiety attack. this was someone i didn't know. before i even knew what was going on, the family had called 911. then came and got me. i assessed her (alway keep my steth/cuff in the car) and when ems showed up, gave 'em a quick update on situation from what i could learn, and got outta the way. they did what they had to do. girl was fine, of course, but my point here is that i got out of their way.

in the er, on the recieving end of the ambulance ride, we assess the patient ourselves as soon as they hit our bed. if this patient had come into my er, we would have assessed him and determined ourselves, his o2 need and proceeded accordingly. given his condition, i'd have had the intubation equipment right next to him, too. the ambulance ride is governed by strong protocols which are meant to protect the patient en route, but once they hit the er, we determine what's needed. 99% of the time, the ems folks have gotten everything started in the right direction and we move on from there. sure, there are exceptions, where their protocol might not fit exactly, but ems can't go on the assumption of the exceptions - they have to follow those protocols. those exceptions are why ambulance rides are fast and er staff pounce when these types of folks come in.

as for the family/hh folks not wanting the o2 upped, were i the ems, i'd have blamed my protocols with something along the lines of "i'm sorry but i'm required to do this for the patient while en route, but it's a short ride and the er folks will make a longer-term decision in just a few minutes." then slapped the o2 on and went.

one comment i really feel i must make though, even though i'm now babbling: if i had to know every damn thing every other medical person knows, my head would explode. i count on ems to know badda-bing what to do with someone hanging upside down in a car so that their airway is not compromised and thier c-spine is kept intact, all the while disengaging said patient from said car. i count on med-surg nurses to take what i send them and juggle all the details of their care that i simply don't have time to do. i count on icu nurses to be so ingrained in the detail of thier patients' conditions that they catch the slightest change before it becomes a huge issue. i count on hh nurses to manage difficult disease processes (and families) outside the hospital so that, for the most part, those folks don't hav to come back unless absolutely necessary. i count on rt to shift to the left, to the right, do the hokey pokey and "see" those alveoli just by listening to the patient.

my point? nursing (and other medical folks) are no longer interchangable. in our insanely acute healthcare world, we have to specialize simply so that there's someone available with expert knowledge for a given situation, whether that situation involves an intraaortic balloon pump, a 15-car pile up, 12 sundowners trying to nosedive out of bed, or the next acute mi busting through the door. we must show respect for each other. no patient will have an optimum outcome as they move through the continuum of care unless all of their providers respect and trust their brothers/sisters on the medical team. we're all on the same team with the same goals.

very well put...and so completely true.

[burn out]

Let's look at it from another angle then. Say the medics listened to the hhRN and left the oxygen at 2.5 l and when the patient got to the hospital and an abg was drawn and the pco2 was 152 and the po2 was 20 and the ph 7.01 what defense does the medic give for not administering more oxygen..because the HH nurse told me to. I think the jury would hang the medic up to dry.

Once again the abg would justify the medic ignoring the patients request for not increasing the o2 because a pco2 level of 152 would automatically make him incompent no matter if he was oriented or not at my hospital.

[RunnerRN, BSN, RN]

Plantiff's Attorney: "Can you explain to me what hypoxia is?"

Paramedic: "It is when there is not enough oxygen to perfuse the organs."

Attny: "What are organs?"

Medic: "They are the different systems that carry out the work of the body."

Attny: "Such as?"

Medic: "The lungs work to exchange gas, getting rid of carbon dioxide and bringing in oxygen."

Attny: "And what happens if the lungs fail?"

Medic: "You would stop breathing."

Attny: "What if is wasn't that bad? What is Respitory Failure all about?"

Medic: "That is when the lungs don't do their job and you get a build up of waste products and carbon dioxide."

Attny: "And is that bad?"

Medic: "Yeah, that's bad."

Attny: "How do you treat it?"

Medic: "Give oxygen, maybe intubate the patient and breathe for him."

Attny: "How could you tell if a patient is in Respiratory Failure?"

Medic: "Well, he could be acting weird, or if the sat is low?"

Attny: "What is a sat?"

Medic: "It's a pulse oximetry reading."

Attny: "What does that do?"

Medic: "It gives and idea of how much oxygen is being carried on the hemeoglobin."

Attny: "And what's normal?"

Medic: "Usually 92% or above."

Attny: "And what was my client's Dad's?"

Medic: "73%."

Attny: "And he wasn't in Respiratory Failure and didn't need additional oxygen?"

Game, set, match. Get out the checkbook.

You have to prove that a patient is competant in order to let him refuse. That's why RMAs and AMAs take so long to chart.

That's why the Paramedic was right to turn up the oxygen.

That's why the Paramedic should have thought about intubation.

:yeahthat:

The above is pretty much what I think this all comes down to. We live in a very litigious society, and work in a field that is very susceptible to lawsuits. Unfortunately, a lot of what we do is to avoid becoming a party to a lawsuit (how much do you double chart to make sure it is completely evident that the patient is fine?) I think the medic in question could have been a little better in her bedside manner, explaining why she was doing what she was doing and not being so pushy, but I also think that is a side issue here.

I have nothing but respect for home health nurses (I can't do what you do) and I also respect my paramedics. The point is that when the family made the choice to call 911 (I know the OP tried to correct herself and say that the family COULDN'T take the pt in, in the original post, the reasoning was stated that they didn't want to wait in the WR) they also transferred care to the paramedic. I also would be very interested to see the ABG results.