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?

pulse ox's are the last tool i look at.

one time i had a pt in acute chf.

ap 160, rr 50, diaphoretic, hypotensive, using accessory muscles yet his pulse ox read 96%

i was trying to send him out (he was pt in an inpt hospice) and the paramedic kept on saying, "but his pulse ox is 96%!".

i kept on reminding him to look at the patient and not the machine.

grrrrr.

anyway, he was admitted with exacerbation of chf.

so pulse oximeters do not tell the entire story, nevermind its' accuracy.

leslie

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pulse ox's are the last tool i look at.

one time i had a pt in acute chf.

ap 160, rr 50, diaphoretic, hypotensive, using accessory muscles yet his pulse ox read 96%

i was trying to send him out (he was pt in an inpt hospice) and the paramedic kept on saying, "but his pulse ox is 96%!".

i kept on reminding him to look at the patient and not the machine.

grrrrr.

anyway, he was admitted with exacerbation of chf.

so pulse oximeters do not tell the entire story, nevermind its' accuracy.

leslie

Yet, it seems that the case here was a paramedic ONLY looking at the pulse ox and ignoring the patient's wishes based on that.

:typing

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Hey DutchGirl--Not tring to say you don't know what you are doing. I WOULD NOT have your job for $200.00 an hour!! I have every high respect in the world for someone who does HH or Hospice. I was just pointing out what I see in CCU every day - chronic COPD'ers that are on a vent at least once a month, and the family just doesn't get it. Please don't misunderstand me!! Contune & keep up the good work!!:D

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Agree wholeheartedly.

Whew ! Just read this ENTIRE thread BECAUSE........... I recently came across a very similar situation in which I was the HH nurse and I was called to teh pt's home because patient stated she was not able to get her breath, was not able to breathe well. She is CPOD with long hx. of pnx.

Get there and find that she had just been released from the hospital the noc before..for double pnx. This patient had both lungs, however. Check her VS, temp of 101.7, HR 136, lung sounds adventitious as all get out and no steth was needed to know that she was in serious trouble. 02 sat was 80. Mentation was ok still, but she was visibly struggling to breathe.

I took it upon myself to increase her usual 2L NC to 4L, and called 911.

My agerncy owner later questioned me about increasing her 02 "without an order" and while she was supportive, and didn't ream me out for it, she did say that this could have cost her HER license as well as mine, and shut down the agency.

So.... MY question in all this is this... where does NURSING JUDGEMENT come into play, or is it all a myth???

I will defend my decision to increase her 02 regardless. But I need to know WHEN we can do what we feel is right for the patient without an MD order.

So many of you have said you all would have done the same, or HAVE done the same.. but I've not heard many or any of you say that you first obtained an MD order to increase a pt's 02 in an emergency situation, be it in the hospital setting or out in the field.

I could really use some clarification on that end of it. Thanx! :)

Nursing judgement came into play when you were called to the house by the family. The biggest question the nurse has to ask is "WHAT IS MAKING THE SAT SO MUCH LESS THAN NORMAL?" AND the most common picture for a COPD'er is co2 retention with accompanying low o2 levels which is standard treatment in this situation to increase the oxygen..it is that gut feeling thing that you have to go with. This also depends on the rest of the assessment, breath sounds, temp, vital signs etc it is not based solely on the sat.

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Agree wholeheartedly.

Whew ! Just read this ENTIRE thread BECAUSE........... I recently came across a very similar situation in which I was the HH nurse and I was called to teh pt's home because patient stated she was not able to get her breath, was not able to breathe well. She is CPOD with long hx. of pnx.

Get there and find that she had just been released from the hospital the noc before..for double pnx. This patient had both lungs, however. Check her VS, temp of 101.7, HR 136, lung sounds adventitious as all get out and no steth was needed to know that she was in serious trouble. 02 sat was 80. Mentation was ok still, but she was visibly struggling to breathe.

I took it upon myself to increase her usual 2L NC to 4L, and called 911.

My agerncy owner later questioned me about increasing her 02 "without an order" and while she was supportive, and didn't ream me out for it, she did say that this could have cost her HER license as well as mine, and shut down the agency.

So.... MY question in all this is this... where does NURSING JUDGEMENT come into play, or is it all a myth???

I will defend my decision to increase her 02 regardless. But I need to know WHEN we can do what we feel is right for the patient without an MD order.

So many of you have said you all would have done the same, or HAVE done the same.. but I've not heard many or any of you say that you first obtained an MD order to increase a pt's 02 in an emergency situation, be it in the hospital setting or out in the field.

I could really use some clarification on that end of it. Thanx! :)

the difference between your scenario and the op, op patient WAS NOT struggling to breath......your case would be the classic "easier to defend upping the o2, than a dead patient"....if it happens again, call the doc (after calling 911,lol) and get the order......

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Specializes in ER.

jnette- does your boss have you call the doc before you start CPR, or does she rely on nursing discretion, lol.

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Specializes in Anesthesia.

Is there a way to turn this debate into a poll to see where the majority of people fall? It would also be interesting if we could tie in the response to what area of nursing you worked in also...Just a thought

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Question for the paramedics:

Does the act of calling 911 and low O2 sats which, may or may not be reliable, override the patient's rights to refuse treatment if mentation is intact?

From reading some of the posts, it seems that some of the paramedics think it does but, I was wondering if they could clarify their position and why.

Does anyone know what the law says in this situation?

:typing

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Specializes in ENT, NH LTAC, WOUND CARE.

no i don't think it was at all about being ignored. We all know that COPD pt should be on a dose of O2 due to the fact that the cn't recycle if you will the CO. To much O2 is toxic to their body. Why would they come in atomatically just boost it up to 6 no thats just trying to be mr/ms mocho. I have some friends who are emt and medics they tell me all the time that they beleive nurses don't know ****, so thats the mind set they arrive on the scene with.YES by all means he/she should be reported.

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Specializes in ICU, PACU, Cath Lab.
no i don't think it was at all about being ignored. We all know that COPD pt should be on a dose of O2 due to the fact that the cn't recycle if you will the CO. To much O2 is toxic to their body. Why would they come in atomatically just boost it up to 6 no thats just trying to be mr/ms mocho. I have some friends who are emt and medics they tell me all the time that they beleive nurses don't know ****, so thats the mind set they arrive on the scene with.YES by all means he/she should be reported.

I am sorry..but this is a load..I am not a nurse yet..I graduate in May..but I am an EMT-B. I do not see that the medic was trying to be "macho" they were probably just following their protocols. When I was in school for my EMT..we were taught about COPD, about the increase in O2 would decrease the drive to breathe, we were however taught that above all we need to treat to maintain life...if that meant turning up O2 and possibly decreasing their drive...so be it..at least they would be alive.

I also have issue with the fact that you think we all arrive on scene with an attitude and believe that nurses do not know anything...we are trained in different things as an EMT/Medic then you are as a nurse..the mindset is different. There are many things that I have been trained to do as a nurse, that I was not trained in as an EMT..and visa versa....so no many nurses do not know squat about in field care...just as EMS many times do not know squat about what nurses do in hospital.

Please stop lumping all medic's in this macho, Dr wanna be, know it all catergory...it just is not the case. The job of EMS and LPN/RN are just different..like comparing apples and oranges...JMO!!

RN in May...going back to school Jan 2008 for my NREMT-P!!

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Specializes in Utilization Management.
Question for the paramedics:

Does the act of calling 911 and low O2 sats which, may or may not be reliable, override the patient's rights to refuse treatment if mentation is intact?

From reading some of the posts, it seems that some of the paramedics think it does but, I was wondering if they could clarify their position and why.

Does anyone know what the law says in this situation?

:typing

I know that when a patient needs air, they often become confused, but a few minutes before that confusion, they think they're fine. Hypoxic patients are sometimes resistive to care, so it's really hard to tell. We routinely do things to patients in an emergent situation (such as diabetic ketoacidosis, for instance) that they might not "want" but that are necessary, such as supplemental O2.

Ask any ER nurse, it's pretty routine.

I had one patient in CHF who reported "a little" shortness of breath and whose mentition was a/oX3 right up until her sats decreased to 63% and she remained "with it" for about 2 minutes at that sat.

By then she was on a Venti or NRB, I forget which, and we were ready. She was quickly BiPap'd and she was unconscious for only a couple of hours and she had a complete return to a/o x3 status shortly after. No loss of brain cells there.

The entire point of keeping a patient oxygenated is to help perfuse the vital organs. Let's not forget that the body shuts down the brain--therefore, mentition--LAST.

My point here is that DG called EMS just before the patient's sats dropped to the point of losing mentition, and the EMS was trying to prevent the patient from going too far to be saved.

Ever see a patient fight a mask or NRB?

Patient might know her name and her location, but resists treatment because she needs air and the NRB makes her feel so claustrophobic that she has the sensation that it's causing her to smother, rather than understanding that it's giving her air.

Most of my COPDers are extremely claustrophobic and some won't even let me close the curtain to assess them.

Last night I had a patient whose heart rate dropped to 10--and stayed there. In the room, after waking patient up, patient's HR went up to 20, then 30. All the while, the monitor was correct, and the patient was a/o X3, and was satting in the high 90's, yet you can bet your bippy that I threw O2 @ 2L on her--because with a heart rate that low, her brain will not be perfusing for very long, and patient would not be able to maintain her mentition without supplemental oxygen.

Many chest pain patients sat just fine on room air, yet we routinely supplement oxygen for the same reason--if there is even a hint of a problem with perfusion, oxygen is called for.

It's even in ACLS protocols. Nowhere in ACLS protocol does it say "don't give supplemental O2 to CO2 retainers." Nowhere.

In this case, I sincerely believe that the timing of the whole event was so critical, that both DG and the EMS responded appropriately. Had one or the other not done so when they did, there would be no argument. I think we all agree that the patient was beginning to crash, and what we're discussing here at this point would've become moot when the patient actually, visibly did crash.

Apparently this patient finally crashed in the ER. But again, I have to echo the sentiments of other posters and say that the patient did not crash because someone gave supplemental O2; the patient finally crashed because the patient had something Very Big going on.

So that, in the end, the question never should have been, "was the patient able to refuse O2"; the questions should have been "was the standard of care met" and "did the patient survive."

OK, so some people would've given higher O2; others would not. Some think it was illegal to give the O2, others think it was unnecessary or detrimental, but regardless of the reasons for giving or not giving the O2, I guess some of us are just going to have to "agree to disagree."

That being said, my questions at this point center around what happened next.

I'm still curious about the patient. How about those BCs? What was the final Dx? How is the patient doing now? What did the patient's pulmo doc say about the supplemental O2?

And by the way, I still think that was a great catch, DG. Maybe I missed it, but please don't let my high praise for your actions get lost in the sauce of the O2/no O2 discussion here: I believe that you did save this patient's life, and I for one, think you're an AWESOME nurse!

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Specializes in ENT, NH LTAC, WOUND CARE.

I didn't say all emt/medic arrive on scene like this, I said I have freinds and former classmate who feel nurses don't know anything. I too have worked as an EMT for a private ambulance company and i have worked with many paramedics also. We do receive different trainning, what I learned as an EMT I did not learn in LPN school. I understand that but you would not be substaining life but for so long with that copd pt because the excess o2 would overload her because she can't make the exchange of CO, and I did learn that as an EMT and I know that he/she learned that as a Medic. Thats all I'm saying, no argrument intended here.

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