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?

i know it was ingrained during nsg school, to never give beyond 2-3l/min to one w/copd, since high o2 levels decrease their stimulus to breathe.

but looking at the big picture, i've since learned that short term high flo o2, is not damaging and in many instances, a life-saver.

if choosing between the lesser of 2 evils, i'd rather see them acidotic and vented than dead.

so i've had to 'unlearn' much of what's been taught and relearn what their absolute realities are.

however, this is not written in stone and if a pt told me not to use high flow oxygen, i'd have to question their personal experiences and give them benefit of my doubts.

leslie

While this pt may normally function well with a low 02 sat; the description suggests she is decompensating. I'm a little confused by the concern that 'people die in the waiting room' and the statement that this 'wasn't an emergency'. As a side note; pt's are seen at the ED based on acuity, not mode of arrival. Calling 911 isn't going to get her in any faster, and is an inappropriate use of resources for nonemergency situations. While the medic's choice of words may not have been the best; the actions were standard of care for EMS.

Specializes in Flight, ER, Transport, ICU/Critical Care.

Hey there DuthchgirlRN -

Please don't misunderstand my position. You have every right to disagree with me as I do with you. We disagree. I have disagreed with folks before - and hopefully we can all walk away with having learned something!

Your OP made it sound as if this was NOT a sick patient - I will bet that NOTHING the paramedic did in the short time they cared for this patient is the REASON she is in the ICU now.

The pCO2 of 150 plus is bad, but the permissive hypoxemia that continued in the HOME CARE (of what duration) of this patient along with the FEVER contributed to this patient outcome. Oh, and lets not forget the hemoglobin (read bleeding from somewhere) I'll also bet that this patient is in sepsis - this also makes for dramatic acid/base derangements, too! The paramedic is not responsible for all that - ;)

I'm advising you to tread carefully. It really gets my goat when I have folks that "report" other healthcare providers - when they themselves do not know what they do not know. I took your OP as a justification on whether to REPORT this paramedic or not. Well, the short answer is NO - NOT JUSTIFIED.

You are looking to create a problem...and if I was this medic (and I'd get a complaint/report on me of this nature) I'd make sure that we all look at the entire clinical course of this patient! But to COMPLAIN on me because I gave a patient that was HYPOXIC oxygen is just...well...silly. To COMPLAIN on me, because I did not "listen" (meaning do what I was told) to a home health nurse and various family members while caring for a SICK patient...is just RECKLESS and VINDICTIVE. But, I understand that you may feel the need to make someone (the PARAMEDIC) look like the big, bad boogeyman here...everyone needs a boogeyman from time to time.

When I was just a lowly little street medic I had wide varying experiences with HOME HEALTH NURSES - including one RN doing CPR on a patient that was begging her to stop! So...

In my experience HHN's are generally not able to manage an acute/critically ill patient with any real degree of competency.

Now just so you know. This patient was sicker than you realize - fever produces a mild acidosis state in the body as metabolic demands increase/respiratory rates increase in compensation and the cycle of CO2 retention that you are so well versed in is cascading in this patient. ADD to this clinical picture a HEMOGLOBIN of 7 and change - well, I will further doubt the accuracy of your saturation measures as there WAS NOT ENOUGH BLOOD/HEMOGLOBIN to get an accurate reading. In my area transport times are long, and I may have ended up intubating in the field - and not just because of CO2 retention. I think impending respiratory failure to be unavoidable in this NOT SICK patient.

Now, I'm all for patients right to refuse. But this patient may not be able to make a fully informed decision due to the critical nature of her situation. And short of everything legal in order - the family does not get to decide on the fly either once I arrive and assume care. Once the call is made and I arrive, I have a duty to act in absence of specific criteria (dead, EMS DNR, state of injury incompatible with life).

And, as such I WILL act. EVERYTIME. ANYWHERE. I can explain action over inaction. But, heck I can explain either!

What about this patients care will you be able to explain?

The more you stir the poo, the more likely it is to get on you!

:banghead:

Just a quick question, since I'm not experienced with home health practices. If this wasn't perceived as an emergent situation; shouldn't the pt's PMD have been contacted, for admitting orders etc., prior to her going to the hospital?

Specializes in Telemetry, Nursery, Post-Partum.

I think you made some great points, but I don't see mention of the patients Hemoglobin anywhere...am I missing something??? Which is entirely possible.

Hey there DuthchgirlRN -

Please don't misunderstand my position. You have every right to disagree with me as I do with you. We disagree. I have disagreed with folks before - and hopefully we can all walk away with having learned something!

Your OP made it sound as if this was NOT a sick patient - I will bet that NOTHING the paramedic did in the short time they cared for this patient is the REASON she is in the ICU now.

The pCO2 of 150 plus is bad, but the permissive hypoxemia that continued in the HOME CARE (of what duration) of this patient along with the FEVER contributed to this patient outcome. Oh, and lets not forget the hemoglobin (read bleeding from somewhere) I'll also bet that this patient is in sepsis - this also makes for dramatic acid/base derangements, too! The paramedic is not responsible for all that - ;)

I'm advising you to tread carefully. It really gets my goat when I have folks that "report" other healthcare providers - when they themselves do not know what they do not know. I took your OP as a justification on whether to REPORT this paramedic or not. Well, the short answer is NO - NOT JUSTIFIED.

You are looking to create a problem...and if I was this medic (and I'd get a complaint/report on me of this nature) I'd make sure that we all look at the entire clinical course of this patient! But to COMPLAIN on me because I gave a patient that was HYPOXIC oxygen is just...well...silly. To COMPLAIN on me, because I did not "listen" (meaning do what I was told) to a home health nurse and various family members while caring for a SICK patient...is just RECKLESS and VINDICTIVE. But, I understand that you may feel the need to make someone (the PARAMEDIC) look like the big, bad boogeyman here...everyone needs a boogeyman from time to time.

When I was just a lowly little street medic I had wide varying experiences with HOME HEALTH NURSES - including one RN doing CPR on a patient that was begging her to stop! So...

In my experience HHN's are generally not able to manage an acute/critically ill patient with any real degree of competency.

Now just so you know. This patient was sicker than you realize - fever produces a mild acidosis state in the body as metabolic demands increase/respiratory rates increase in compensation and the cycle of CO2 retention that you are so well versed in is cascading in this patient. ADD to this clinical picture a HEMOGLOBIN of 7 and change - well, I will further doubt the accuracy of your saturation measures as there WAS NOT ENOUGH BLOOD/HEMOGLOBIN to get an accurate reading. In my area transport times are long, and I may have ended up intubating in the field - and not just because of CO2 retention. I think impending respiratory failure to be unavoidable in this NOT SICK patient.

Now, I'm all for patients right to refuse. But this patient may not be able to make a fully informed decision due to the critical nature of her situation. And short of everything legal in order - the family does not get to decide on the fly either once I arrive and assume care. Once the call is made and I arrive, I have a duty to act in absence of specific criteria (dead, EMS DNR, state of injury incompatible with life).

And, as such I WILL act. EVERYTIME. ANYWHERE. I can explain action over inaction. But, heck I can explain either!

What about this patients care will you be able to explain?

The more you stir the poo, the more likely it is to get on you!

:banghead:

So you called 911 even though NO EMERGENCY existed.

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

...

you point out what caught my eye as well...

3 cars in the driveway, a host of family at the house, but, out of ignorance and convenience, they called 911...

911 abuse at it's best (at least from the OP's description)

hope the patient is doing better...

Specializes in OB, M/S, HH, Medical Imaging RN.
Hey there DuthchgirlRN -

Please don't misunderstand my position. You have every right to disagree with me as I do with you. We disagree. I have disagreed with folks before - and hopefully we can all walk away with having learned something![/Quote] Nice thought, hope you're right

But, I understand that you may feel the need to make someone (the PARAMEDIC) look like the big, bad boogeyman here...everyone needs a boogeyman from time to time.
I'm not looking for trouble nor looking for someone to blame for the patients situation. It was what it was. I disagree that the family's, the patient's and the nurses's comments should be disregarded as though she knows "everything". I know this patient well and her family knows her medical status like the back of their hands. That info should not be so easily dismissed.

In my experience HHN's are generally not able to manage an acute/critically ill patient with any real degree of competency.

You would not be referring to me? I've been an RN for 31 years in acute Med/Surg Telemetry. I've been doing HH for a little over a year now and it's a whole different ball of wax from the hospital. In my experience paramedics are merely doctor wanna be's. How long do paramedics go to school?

Now just so you know. This patient was sicker than you realize - fever produces a mild acidosis state in the body as metabolic demands increase/respiratory rates increase in compensation and the cycle of CO2 retention that you are so well versed in is cascading in this patient. ADD to this clinical picture a HEMOGLOBIN of 7 and change - well, I will further doubt the accuracy of your saturation measures as there WAS NOT ENOUGH BLOOD/HEMOGLOBIN to get an accurate reading. In my area transport times are long, and I may have ended up intubating in the field - and not just because of CO2 retention. I think impending respiratory failure to be unavoidable in this NOT SICK patient.

Ok I learned something new about 02 sats but again HH is different. I had no way of knowing her Hgb was low. She just got out of the hospital 2 days ago and all labs were WNL. This NOT SICK patient is then an emergency?

What about this patients care will you be able to explain?

The more you stir the poo, the more likely it is to get on you!

I think I handled it correctly and professionally. We'll see in the week to come and I will let you know.

Obviously there is an agenda here; paramedics are not 'doctor wannbe's'. The are however physician extenders, and are expected to operate in an acute care clinical mode. You are right, HH is different than EMS. It is foolish to apply the standards of one to the other. Rather than turn this issue into a confrontation about who is more right; why not take the time to educate the paramedics and to learn from them? I am a new grad nurse and a 27+ year paramedic. Little in my EMS education was applicable to nursing, and conversly my nursing education would not have prepared me to care for pt's in a field setting.

Specializes in ER.

I think this patient was going to be vented no matter what the paramedic did. You may have been completely and utterly right that the patient needed 2lpm, but that paramedic doesn't know you. He's walked into a situation that to an outsider looks crazy. Sats in the 70's, no SOB, one lung, fever, a 911 call for emergent care but everyone is telling him not to treat anything, just drive...I would have been pretty darn nervous. He was wise to stick to his protocols.

I also have had EMT's tell me that they were taught to give the NRB during transport if sats are low, even if it is a CO2 retainer. The rationale is they need the oxygen and the patient can be treated for retention in the ER, but lost brain cells are forever. Also if the EMT experience is anything like the ER nurses' you cannot trust someone else's judgement. The weirder the situation is, the more likely they have confused the facts or don't understand the physiology (yes, even home health nurses). If they knew you or the family beforehand maybe...but with sats in the 70's, probably not.

Specializes in Utilization Management.

DG, I agree with whoever said the Pt was probably going septic. That, or possible aspiration pneumonia would generate a fever that high. Either way, that's the type of patient that can go downhill really quick, so I'm glad you called EMS. I think it was appropriate to do so.

Likewise, we routinely turn up the air on Pts who are satting that low--let me stress this--for a short time. They will then either move to bipap or vent.

I haven't been a nurse for 31 years, but I also feel that this patient had something big brewing and you caught on to it early enough so that the patient did survive.

I'd love to know the final dx on this Pt. and I sure hope they did blood cultures.

my question: what part of the word NO does the paramedic not understand? if she felt uncomfortable honoring that, then she should have consulted her superior.

Specializes in ER.

If the patient does not want the treatment offered they are free to tell the medic to leave. Refusing treatment makes an ambulance ride redundant- it would be better to call a cab, or have family transport.

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