Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 14
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... Read More
Feb 1, '07Joined: Apr '06; Posts: 890; Likes: 1,991canoehead - great post.
Yes, we can all debate.
But, I get have SECONDS to make good decisions in the field - so I do NOT argue, debate, allow freelancing ... if it's my decision ... I WILL MAKE IT.
But the bottom line is just as you stated. NO DISCUSSION. I DON'T KNOW WHO IS RIGHT WHEN CONFLICTING FACTIONS ARE ON SCENE - The patient wants this, one kid that, a granddaughter something else. ENOUGH. If the patient is sick and no reasonable, prudent refusal - WE ARE GOING TO THE HOSPITAL.
I KNOW THAT DEATH IS VERY STILL...SO SOMETIMES YOU GOTTA MOVE FAST!
Feb 1, '07Joined: Oct '00; Posts: 8,768; Likes: 8,502Quote from NREMT-P/RNHa! I was just thinking that about your post. Finally! An agreement on this thread. lolcanoehead - great post.
Feb 1, '07Specialty: ER ; Joined: Mar '06; Posts: 386; Likes: 232This was obviously not a black and white situation for the medic. "Do I assume the pt is competent and completely aware of all pathophysiology, potential risks and complications, ignore the sat of 73% and forgo oxygen, or do I make the choice to treat now (knowing that 15 minutes of Os isn't going to knock out a COPD pt's drive to breathe) and oxygenate this patient's brain?"
And yes, part of EVERYONE'S practice is dictated by the risk for lawsuits. In this case, you would be putting your license on the line on the assumption that a pt was mentating properly with a sat of 73%.
Feb 1, '07Occupation: RN Joined: Nov '03; Posts: 4,389; Likes: 153Well ... the posters on this thread have convinced me on the consent issue. At the end of the day, any court or regulatory board is probably not going frown upon saving the patient's life, even if it temporarily violated consent.
The bottom line is the outcome which was: the patient needed to be vented and the patient obviously agreed to that so ... a temporary consent violation of 6L O2 for a 15 minute ambulance ride probably isn't going to be a viewed as big deal in the scheme of things.
If anything, the ABG's and vent probably proves that the patient wasn't as coherent as previously thought ... so erring on the side of caution, so to speak, was obviously the right call.
:typingLast edit by Sheri257 on Feb 1, '07
Feb 1, '07Occupation: Medical Imaging RN~Special Procedures CT Specialty: 33 year(s) of experience in OB, M/S, HH, Medical Imaging RN ; Joined: Aug '04; Posts: 6,708; Likes: 1,449This patient died today. She had been weaned from the vent. Her admit CO2 level was 162. She was on the acute med floor. Venti-mask @ 24%, CO2 level 44. WBC 2.7 Blood Cultures negative. Continued temp, was started on Dopamine.
Anyone wanna guess what was the cause of death?
**No it had nothing to do with the 02 and her respiratory status** Let me be quite clear on that.Last edit by DutchgirlRN on Feb 1, '07 : Reason: Spelling
Feb 1, '07Joined: Sep '03; Posts: 6,885; Likes: 12,486Wishing peace for the patient's family, and for you DutchgirlRN.
Feb 1, '07Occupation: ED Nurse Specialty: 10 year(s) of experience in Emergency Dept ; Joined: Jul '06; Posts: 280; Likes: 235Okay . . . so the paramedic has their protocols to follow and the nurse knows the history to try to inform them. I can understand both sides of that - Paramedic worried about the low sat, nurse worried about the COPD. The part that I think the paramedic does need written up for is the same thing ANYONE in the medical profession should get written up for. An alert and oriented patient refuses a portion of medical care and the medic FORCES it upon them. It doesn't sound like this was a factor of suicide or an impairment by drugs or alcohol. They broke one of the patient's most fundamental rights.
Feb 1, '07Occupation: Medical Imaging RN~Special Procedures CT Specialty: 33 year(s) of experience in OB, M/S, HH, Medical Imaging RN ; Joined: Aug '04; Posts: 6,708; Likes: 1,449Quote from lizzI will say this "one last time" her sats had been in the low 70's all day. She had breakfast, lunch, and dinner. Shopped on e-bay, Watched a movie and was sitting up playing cards with her daughter when I arrived. Mentating. Yes she definately was!If anything, the ABG's and vent probably proves that the patient wasn't as coherent as previously thought ... so erring on the side of caution, so to speak, was obviously the right call.:typing
Feb 1, '07Joined: Jul '05; Posts: 5,197; Likes: 6,225Quote from DutchgirlRNWhat did she die of....? I am kinda of thinking cancer, but who knows. Since she was probably on steroids she could have also been septic/immunosuppressed. Also, was cause of death based on autopsy or just most likely cause per the physician?This patient died today. She had been weaned from the vent. Her admit CO2 level was 162. She was on the acute med floor. Venti-mask @ 24%, CO2 level 44. WBC 2.7 Blood Cultures negative. Continued temp, was started on Dopamine.
Anyone wanna guess what was the cause of death?
**No it had nothing to do with the 02 and her respiratory status** Let me be quite clear on that.
One more question. Do you really think that the increased FiO2 in this patient over that short amount of time made any real difference in their outcome?
I am not trying to be sarcastic...just wondering.
Feb 1, '07Occupation: Medical Imaging RN~Special Procedures CT Specialty: 33 year(s) of experience in OB, M/S, HH, Medical Imaging RN ; Joined: Aug '04; Posts: 6,708; Likes: 1,449Quote from NREMT-P/RNNo wrong....I was vested in my pt's best interest.You even went so far as to call the ED doctor to attempt to direct care - so I know you were clearly vested in BEING RIGHT.
Would I do it again? No, thanks to many of you I realize that 6L in the short term will not hurt the pt.
My thanks to the other posters - I have learned a lot. I know that we may have differing views, but THANKFULLY we do!
Please practice SAFE!
Feb 1, '07Joined: Aug '04; Posts: 9,279; Likes: 4,302Sounds like it went into a cardiac problem, but I'm just guessing something so you'll give in and tell us.
I'm so sorry that she didn't make it, Dutchgirl.
Feb 1, '07Occupation: Day Surgery/Infusion/ED Specialty: Day Surgery/Infusion/ED ; Joined: Feb '06; Posts: 1,405; Likes: 47Let's go back to the second para. of the OP:
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.
There have been many posts that have expressed alarm over the pt not being assessed as in distress. None of us were there to actually assess the pt, but based on the findings posted, many of us were in total disagreement with this being seen as a non-emergent situation.
The main point that I got from the OP was that she was put out that the paramedic didn't follow her directions. What she failed to see was that she had a clearly deteriorating pt in front of her. Her follow up posts had more to do with proving she was "right" than listening to the advice from others who saw the situation for what it was.