Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 16

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

  1. by   cherbRN
    Quote from NREMT-P/RN
    So you called 911 even though NO EMERGENCY existed.

    This decision was made to keep from "having to sit the the ER".

    A paramedic was greeted by a HOME HEALTH NURSE that called 911 for a situation that WAS NOT in the opinion of a licensed registered nurse (you) or the family an emergency - the 911 crew found a patient that was found to have markedly decreased oxygen saturation - and you are standing there telling them NOT to give any additional oxygen other that to just maintain the 2L per NC. And now you are going to report the paramedic because she ignored you and gave additional oxygen to the patient.

    Paramedics operate on a set of standing orders called PROTOCOLS. They detail the acceptable care of a patient. I can GUARANTEE that there is not a protocol or standard of care ANYWHERE in this country that will support any paramedic that fails to provide oxygen for a patient with hypoxemia.

    Now, I guess what has you in that reportable frame of mind is that you were ignored. Unfortunately, as a paramedic YOU would not be my authority for care. My protocols and medical direction are my authority. I say REPORT away.

    I will also point out that calling 911 for a situation that is NOT AN EMERGENCY to keep from "waiting" can be considered a crime or even fraud as it relates to insurance. BE CAREFUL. It may not just be the care provider by "this paramedic" that will need to pass a test of necessity. I never have a problem with any call that gets careful review - I say start at the beginning!

    Now, as to the care. Not all paramedics have the option of varying oxygen delivery. In most locales its either a little (no hypoxia) or a lot (hypoxia). Most transport times are limited and in the time that I care for someone in the field I would rather not deprive them of OXYGEN. I know that retention of CO2 can be problematic in the overall management of a COPD patient, but I will maintain that permissive hypoxemia is not a good field practice. Some field medics do venti masks, a few others do CPAP and BIPAP - but the standard is to correct hypoxia. I would have provided additional oxygen to this patient.

    But really all of this dicussion is not necessary. You said she the patient was not in distress, but was desaturated (from the 80%'s - her baseline) and febrile (and I'm betting that her heart rate was a bit elevated too) with ONE lung full of wheezes. Hmmmm....

    Sounds like the paramedic did what the situation demanded. That may not be what you think to have been necessary, but after they started care of the patient you are "off the hook." I guess the lesson here is load 'em up and let the family or yourself take 'em to the hospital next time - that way you can do what you think is necessary for the patient. But if you call me - I'm going do what I can need to and what I can defend.

    Good luck and practice SAFE!

    Sorry if there are more posts to this comment. But I had to say something. Apparently COPD is not something you are very familiar with because giving a patient with COPD more than 2.5lpm of O2 will take away their stimulus to breathe. Chronic COPD'rs have become accustomed to the chronic levels of CO2 and their medulla becomes saturated with it, thus almost eliminating the normal stimulus to breathe (increased CO2) and then decreased O2 becomes the stimulus. GIve them more O2 and they will stop breathing. Savvy?
  2. by   ekl

    Great post,

    I've learned a lot and this has generated many questions for me; so I have to hit the books. It was nice to read all the post of people sharing their view points and knowledge.

    I have a question. How can pancreatitis have been overlooked? It is such a painful disease. Can anyone explain?

    The the profession bashing I could have done without. It almost lost me from this thread.

  3. by   bren3299
    Quote from swansongzoso
    Sorry if there are more posts to this comment. But I had to say something. Apparently COPD is not something you are very familiar with because giving a patient with COPD more than 2.5lpm of O2 will take away their stimulus to breathe. Chronic COPD'rs have become accustomed to the chronic levels of CO2 and their medulla becomes saturated with it, thus almost eliminating the normal stimulus to breathe (increased CO2) and then decreased O2 becomes the stimulus. GIve them more O2 and they will stop breathing. Savvy?
    Actually, most recent evidenced based research is dispelling the hypoxic drive theory. Not all COPD pts are true CO2 retainers, an even smaller precent are oxygen sensitive CO2 retainers. Even these types of pts (the retainers) will require high flow O2 in emergent situations. The key comes in not allowing O2 sats to be OVER 90% for an extended period of time. The should be closely monitored and titrated down. O2 sats in the 70's are considered life threatening and put a pt at risk for resp arrest or MI. I have seen our Chest Medicine MDs place known retainers on 10l of O2 for emergencies on many occaisions.

  4. by   cherbRN
    I have heard the same facts too. I think this case is somewhat different given the fact that she stats at 70's anyway and had no change in her LOC at that time. She was used to that level and only has ONE lung, so there is no way she would stat any higher than I would say 80% and being a chronic COPD'r I think 6LPM was just too high. Often times we forget that O2 is classified as a drug, and the patient and the family knew the consequences of high O2 from a previous experience and their wishes should have been granted.
    I see the threads about the EMT/Paramedics responding to an Unemergent "emergency" but the ambulance is used for transport as well. The family was not comfortable taking the patient, as most would not have been, the "just in case" factor. The RN could not treat the patient in the situation she was in, her home. So the only obvious answer was get her back to the hospital b/c she was not completely well, hence probably the reason she had home health to begin with. What other way was she to get there? Everyone is different, the EMT's were presented with a textbook situation and acted as their protocols entailed, but every patient is different and they were lucky to be in a situation where there were other observants that knew the patients history and how he/she reacted to certain things. Their requests should have been honored. At least they should have been taken into account. All im sayin! Have a great evening all!
  5. by   DutchgirlRN
    Quote from ekl

    Great post, I have a question. How can pancreatitis have been overlooked? It is such a painful disease. Can anyone explain?Thanks,
    My only possible explanation would be that she was on heavy narcotics.
  6. by   zefreakinme
    i believe the nurse should have stopped that paramedic with that awful response to the patient. i bet she knows how wrong the person is. i haven't been working since i just had my oath but we were taught that COPD cannot have more than 2L bcoz, smply bcoz the patient can take 02 but she/he cannot breathe out the CO2 (that would cause the lung of the patient to collapse)

    paramedics should be really taught or have a refreshing units. making mistake is not an option - it's life we are talking about.

    patients trust us.
  7. by   smartblnde
    The nurse, the family and, most importantly, the patient, knew that increasing the O2 to 6L would drop the CO2 level to such a low (for this patient), the patient would lose the drive to breathe. His/her body would think they were breathing just fine, if not better, than a typical day. Therefore, the patient ends up on a respirator. More than one answer would be appropriate for this situation.
  8. by   melpn
    One wheezy lung COPDer, febrile, sats in the 70s. Something clearly had to be done as she could have crashed fast. But in light of her usually maintaining sats in the low 80s (history is important, too) perhaps a small increase in O2 would have been more appropriate. 6L would likely have jacked up her CO2, killed her respiratory drive and made her acidotic. Don't
    medics have capnometers?
  9. by   darrell
    Quote from DutchgirlRN
    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".
    I am an SN (2nd semester RN), a tech in a respiratory ward and an EMT-B (a Basic), all of which combined gives me an interesting perspective on your situation. I've actually been in very similar, almost identical scenarios myself as the first responding EMT.

    Assuming my own area (Western New York) for a minute, I can tell you what I have to do in order to avoid endangering my certification, and that is to maintain SaO2 in the 90s. I don't always agree, but this is my proocol and it is based on the statistic that a tiny percentage of the population is actually using hypoxic drive to power respirations, and on the fact that I can not successfully diagnose COPD in the field as the cause of a low sat or dyspnea.

    My clearly-stated protocol is to apply high-flow O2 (non-rebreather at 12-15LPM) and to bag the person if the RR falls. I transport and let the ED decide where to keep the sat.

    This has specifically been reiterated in CME classes as applying to COPD cases.

    Also, my protocol, even as a basic, is that I can take instruction only from a medical doctor or a higher EMT. No RN, no NP, no PA. So, while I listen to nurses every time they speak (remember, I'm also a tech!), I can't write in my PCR that a nurse told me to keep the sat below 90.

    Our Paramedics have almost the same flow-rate protocols in this scenario and it is a recurring source of friction with families and home care. I know from my RN class and from my work in the respiratory ward that 88% is just fine for a known COPDer with no other actual issues. But I can't determine that status in the field and the Medical Director (the doctor whose license I am EMS-certified under) has decided that the potential complications of allowing the EMT to make this call outweigh the advantages.

    All this being said, it is also true that EMS can take direction from a medical doctor on-scene and continue enacting those directions if the doctor is willing to transport with the patient. Perhaps more significantly for you, we can also contact medical control and take online instruction from an ED doctor over the phone. We can also take instruction from the patient's doctor over the phone. Whether or not a doctor will authorize a low sat for transport is not something I can guess at right now and I can think of only one time it happened.

    Would you, as a doctor, risk breaking a long-standing, carefully-thought-out protocol over the phone, without seeing the patient, based only on PMH and involving an ABC-level intervention?

    Another thing to remember is that a patient who is CAOx3 and who can demonstrate an understanding of his situation can refuse any treatment, including O2. How this would affect a situation when we would need O2 at a home rate (as opposed to the no-O2 of a full refusal) is also an interesting question as the home rate would likely need to be supplied using the EMS systems if the crew did not want to transport the home equipment.

    I wrote a lot here because I see too much friction between nurses and EMS. The latter is all about rescue while the former is about healing. Two sides of the same coin, and both are concerned with patient welfare, yet there seems to be gaps that could be crossed yet more often are simply excuses for contention rather than opportunities to build bridges.

    Maybe that paramedic was just a clown, but maybe she was a professional trying to tend to a client, watch her own back and argue protocols with a nurse all at once. Personally, I'd love to have a doctor on-scene confirming the flow rate, but without that luxery I'm stuck balancing risks. If I pump her to 6LPM or higher and she needs ventilation before arrival, at least I'm within the safety boundaries set by the medical doctors who make up the rules. If I leave her sat low and she codes, then I'm having to live with my decision to second-guess a doctor.

    I don't like this scenario and I'd like to see it resolved, but I don't think we're going anywhere unless we get the doctors involved to address the protocols.

  10. by   darrell
    Quote from DutchgirlRN
    I realize that once the paramedic arrives that the patient is in their care but I find it very ignorant to ignore the nurse, the family member and the patient, when all 3 advised against the 6L of 02. It wasn't even open for discussion. It was her way or no way. That is dangerous! I've been an RN for 31 years and always remember..."First do no harm" and don't ever believe that you have all the answers, always be open to what others, especially the family has to say.
    I hear you, but the point about protocols is also a valid one. EMS provides for this scenario in training and the rule is that the responder must not assume that the patient is hypoxic due to COPD. In my area, at least, there is no special protocol for COPD.

    I'm not blindly defending the Paramedic, but please consider this when discussing. As an RN student and an EMT-B, there are times when I want to do something but find myself dragged along by the rules.

    A RR of zero is worse harm than a vent.
  11. by   ernurse4ill
    Quote from DutchgirlRN
    The pt could not wait in the waiting room in the condition in which she was in. People have died in waiting rooms.

    Ok, I don't think you should try to have it both ways here.... FIRST you say that the patient was in no acute distress and doing quite well with sats in the low 70's. THEN you say this about her condition was too poor for her to sit in the waiting room. Which is it????

    I agree that the medic should have listened to you, and at least discussed it without dismissing you. Perhaps explained why she HAD to act in the manner she did. BUT if this patient was serious enough that you were concerned that she could DIE in the ER waiting room, then I suppose short term O2 to get her to the hospital would not have caused any great harm, at least temporarily!
  12. by   nurse_drumm
    Regardless of weather or not this situation was "emergent", the point here is that the RN was advocating for the patient, and had the knowledge to know that increasing the 02 to 6L/min on a COPD'er could be detrimental to the patient.
    I'm not knocking the EMT here, but I have to ask (as a RN never having been an EMT), are the EMT's not trained or aware of the complications of a retainer? Especially if they were forwarned that this particular patient IS a retainer? And everyone asked/begged for the EMT NOT to turn up the O2 with logical and apparent reasons why? Please don't take this the wrong way, I'm mearly trying to educate myself......
  13. by   circusdog64
    It is always important to remember not to withhold oxygen in the presence of hypoxemia (reflective of the low SpO2 level). The EMS was correct in it's actions of titrating up with the oxygen. The report of a past event of hypercarbia via the family member may or may not be correct. People often misunderstand what the history is and exactly what happened at a past event. Did he/she truely get intubated because of hypercarbia? Why wasn't NPPV attempted? There seems to be more to the story. Also, it is important to remember:
    (#1.) Any SpO2 value under 80% is not truely reliable-it could be higher or lower as refective of the PaO2.
    (#2.) Remember the oxyhemoglobin dissocation curve when dealing with SpO2 levels and what the actual PaO2 is.
    (#3.) The only way to know if someone is truely a CO2 retainer working on the hypoxic drive is an ABG. Not all COPD patients (in fact only a small % really) are CO2 retainers.
    I am a RRT-NPS for 11 years now (and a current RN student).