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?

[ponytailman]

As most healthcare practioners understand, increasing straight o2 into a known copd'r is often counter productive, these initial symptoms indicate a need to open up her/his bronchioles. However, once 911 is called and is on scene, they call the shots, not the nurses, we can educate and or advise but ultimately the must act based on there training and/or care standards.

[DutchgirlRN, ASN, RN]

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

Please do not insult home health nurses as group. Hospitals are not the only place that nursing is practiced competently. We all know an incompetent hospital nurse but do not call the whole staff incompetent do we?

Due to insurance regulations doctors are sending patients home much earlier than they should. Home Health nursing is essential to their care and recovery. I am a competent home health nurse with 31 years hospital experience in acute care med/surg. Home Health, for me, is far more challenging because I have to rely on my assessment skills and my critical thinking skills. I have a brain, a stethoscope, thermometer, and BP cuff. It's not easy.

[Kurtz91]

First of all, both the nurse and the paramedic are right, and they are both wrong. There is no clear cut yes or no answer in this case; it is a judgement call. The nurse must remember that the paramedic is working under the medical controls license and specific protocols of practice and that ultimately it is their butt on the line in this situation; the paramedic needs to respect the fact that this nurse knows this patient and listen to her because that history and baseline information she can provide is invaluable; a healthcare provider who refuses to listen to any other perspective or appreciate a patient's history and baseline status, be they paramedic, nurse or physician, is heading for a disaster. Of course any time an alert and oriented patient refuses treatment that must be respected, although the healthcare provider has an ethical obligation to encourage any treatment they consider critical. As a former EMT and now a nurse I can certainly appreciate both perspectives and the difficulties faced on both sides.

Now on to the question of treatment. I have not read all 27 pages of replies because I don't have 5 hours to spare, but a few thoughts... Hemaglobin level and other lab values that were impossible to know at the time are irrelevant. Was capnography (CO2 monitoring) available? As has been pointed out, the high CO2 level recorded at the hospital may be due to oxygen induced hypoventilation, infection exacerbating COPD, or a combination of both; it is impossible to know if the O2 played a role without a prehospital ABG. This is a difficult situation - a patient who is febrile with a SpO2 decreased from baseline, and an underlying history of only one lung to begin with and COPD; this is not someone with a large margin of error to play with. I would have increased the O2 level and then gauged the patient's response and adjusted accordingly (keeping a close eye on the respiratory rate and depth and capnography if available). If this patient lives at an SpO2 of 83 and is now at 73, that is a marked decline and should be treated. At the same time that is a very different decline from you are I suddenly presenting an SpO2 of 73, so blasting the patient with high O2 may not be indicated unless smaller doses of oxygen are not helping. That said, if a COPD patient has a marked decrease in oxygenation and you increase the O2 delivery, even markedly, and they are still below their baseline I think you are at extremely low risk for giving "too much" oxygen; if someone is hypoxic showing a low SpO2 like that in the field then you need to recognize that they are just not getting enough oxygen. The hypoxic respiratory drive that this person lives with is not going to shut down unless the PaO2 (arterial oxygen level) increases markedly above baseline, and if they are showing a below baseline SpO2 in the field in this situation I think you have to assume that their PaO2 is still below baseline. In this case it sounds like a pneumonia is blocking alveoli effectively creating a shunt of blood that is not getting any gas exchange; maximizing the O2 delivery to the 'patent' portions of a emphysematous lung will hopefully improve gas exchange in those lung regions and increase oxygenation. As this patient only has one lung to begin with, I would err on the side of giving too much oxygen than too little. While having to put someone on a vent is a last resort, it is better than an anoxic brain injury. This is someone who could become seriously septic and deteriorate very quickly. If I can get this person's SpO2 up to upper 80s or low 90s (above this patients baseline) with a smaller increase in O2 then I probably would be happy with that, particularly if they are alert and oriented, not dyspnic and appear to be perfusing adequately. That this patient ultimately ended up on a vent is probably an indication of how sick they were as opposed to hyperoxygenation. Also keep in mind that this person has an infection and fever driving an increased metabolic demand for O2 and their tissues will be utilizing and extracting more oxygen from the blood than normal. Also you want to prevent this from deteriorating to a severe sepsis so early aggressive treatment can be lifesaving. So again, I would err on the side of more aggressive treatment. From my clinical experience it is very rare for a COPDer with an acute oxygenation problem to suddenly lose their hypoxic drive from too much O2. In the ED and prehospital I would never hesitate to give any level of oxygen though for a persistant oxygenation deficit. My guess is in this case that 6 lpm may have been enough though.

If I were you I would talk to the physician in charge about this case and get his thoughts about how to treat and why, and also talk to the paramedic about it. This should not be a battle of wills or finding fault; you are both there to provide care to the patient as best you can. This sounds like it could be a good learning case for both you and the paramedic if you can get together and discuss what you each were thinking and the rationale behind your reasoning. Good luck!

Edit - A low WBC count (like a high WBC count) is a clinical indicator of sepsis; that coupled with the fever and suspicion of infection d/t abnormal lung sounds and low SpO2 meets the clinical definition for sepsis/SIRS.

[Justan]

Nice post Kurtz! I knew I could count on you for a cogent post. :)

Like Kurtz, I have a history of working in EMS and working as a nurse. Having said that, fault should not be placed on DutchgirlRN for her lack of knowledge or understanding of EMS. The sad fact is, it seems the majority of medical professionals operate with a paucity of knowledge of the scope of the paramedic. This scope can be narrow or broad, depending upon the doctor, or doctors, who set protocol for the EMS service. A paramedic, while operating under a set of protocols from a doctor can appear to be acting like a cowboy, IE increasing O2 flow despite being told by a nurse, the family, and the patient, that it shouldn't be done. Despite what you may think DutchgirlRN, that paramedic listened to each of you, and thankfully, still did the right thing by increasing the LPM. This is where I get to say, in 20 years of EMS, if I had a nickel for each time a nurse, family member, or patient, told me to not increase the O2... You get the picture. The difficulty is that the patients and family members are taught that in no way are they to ever increase the O2 on a COPD patient as it will make them stop breathing. Generallly, they don't know the difference between hypoxic drive and a hard drive. So, should a paramedic listen to the patient and family members? Absolutely. Should that paramedic heed their advice? Absolutely not! Depending on the situation and the paramedic, this could an excellent time for patient education. So, for the short answer, it was not ignorant of the paramedic to not listen to you, the patient, or the family members. In fact, it would have been ignorant for that paramedic to have followed the medical advice of a nurse operating outside of medical control.

Like others in this thread have said, report away. Ultimately, you will appear petty and ignorant (lacking knowledge, not stupid) to most anyone actively in the EMS community, including the E.D. doctor. There are quite a number of EMS laws to live by in the field, such as, if you drop the baby, pick it up. Another law is to never withhold oxygen from a hypoxic patient. Oxygen is good. Interestingly, it also happens to be the standard of care across the entire nation. Go figure...

Don't get me started on the number of times I've walked in on a patient and an RN has a simple face mask, or a non-rebreather on a patient at 4/LPM.

[Kurtz91]

Thank you, but again this is not about finding fault or one person being right and one wrong. Both parties have valid concerns, and the patient has a complex disease process. Very few (if any) things we do to people in medicine have no negative sequelae, particularly in a complex pathology such as this person has. Ideally at the time both parties can discuss their concerns and come to a constructive consensus; thats how health care should work and what we all should strive for.

Think about it all at the most basic biochemical level. This person probably lives at a PaO2 in the 70s or 80s and PaCO2 in the 80s or 90s; their body has adapted to function that way. Why do we care about CO2? Two reasons, it drives primary respiration in most people (but less so in COPDers) and it can cause an acidosis when levels rise too high. Because this patient relies less on their CO2 drive for breathing, we are less concerned about that part of it. We do however want to avoid an acute uncompensated acidosis. We also need to be concerned that the PaO2 is high enough otherwise its all for naught. So if the PaO2 is low (which we should assume it was in this case) then it needs to be augmented. However we can easily shoot a persons PaO2 up to 300, 600 or higher by giving max O2; if we do that in this case there is valid concern that that may depress ventilation. If that happens CO2 will accumulate instead of being excreted and cause an acidosis; instead of growing CO2 levels prompting increased respiration as in a normal person, that may not happen in this case. If the person then becomes acidotic many different cellular processes are impaired and they can deteriorate rapidly. At that point they may then have to go on a ventilator just to get the CO2 down, which is undesirable. Intubating a patient and putting them on a ventilator should always be a last resort, especially as age and pathology increase. Vent associated complications are high and life-threatening; we frequently put patients on vents while at the same time thinking it will be a miracle if they ever get off it. So the nurse had a very valid concern in this case, particularly in light of the patient being alert and communicative and denying dyspnea, and the paramedic stating that they were going to administer high flow O2. Do not panic just because the pulseox says 73, look at the entire clinical picture and treat the patient not the monitor. But again, this patient is hypoxic (from their baseline) to a degree and I would definitely have increased the oxygen. If this patient normally had a SpO2 of 97 (like you or I) and now was 87 (a drop similar to what this patient experienced) would you go straight to a NRB? Probably not. Thats why I said I would try a NC with a smaller increase in O2 first, see how they responded, and adjust from there accordingly (or if you are truly concerned that this patient is critical then titrate down from a NRB). This person's body is accustomed to low PaO2s and has adapted to absorbing, transporting, and extracting oxygen in that state; if you can get their PaO2 up with a NC, pushing their PaO2 up further to 300+ with a NRB is not going to magically cure them. Anyway, this is my thought process and 2 cents in this case, hope it is helpful. Also don't forget that if you are ever in the field and in doubt as to what to do, contact the ED and ask the physician for guidance - thats why they are there! Again, always try to remember we are all on the same team and have the same goal of serving the patient as best we can; hopefully all parties can learn something from this case, both about the pathophysiology involved and about communication and teamwork (which can be a big challenge sometimes).

[kmoonshine, RN]

I'd have to say that the paramedics acted appropriately in this situation. They know nothing about the patient, situation, etc. And although you tried to provide a subjective history, they have to objectively look at the whole picture. They responded to a 911 "emergency" call, but were asked by you and the family to not provide emergency treatment? What they see and hear, along with the 911 call, tells them that this situation needs to be acted upon.

Also, it's sad to say that there are family members/caregivers out there who do not want the best for their loved one; for example, I had a situation where the family would intentionally overdose their 72-year old mother/grandmother on oxycontin, and wait 4 hours before calling for help. My point is that the paramedics are there to treat the patient based upon their assessment. And I in no way am implying that your intentions were hurtful, just presenting some of the things that happen in real life.

In situations like this, you have to deal with the life-threatening issue and worry about the consequences later. For example, if someone has coded, do you not perform CPR because you might break their ribs? Do you take your time and apply chlorhexidine to a patient's entire arm who is in asystole, wait for it to dry, then try to put in an IV? Infection at this point isn't a priority; you deal with it later. You try your best, but you're not going to say "Um, can someone hand me some chlorhexidine? No, it's in that drawer...to the left. Yeah, that's it, can you bring it here?"

I don't know if this has been mentioned in other posts, but perhaps the patient should have Advanced Directives which specifically states what they want and do not want for treatment. This way there could be no argument of whether or not a patient is decisional/not decisional when the patient refuses treatment. At this point any medical treatment provided against the patient's legally documented wishes would be assault and battery.

And something to also consider is code status; if a patient is full code, why not use oxygen to deal with the problem since intubation is an option? And if they are DNR, why not use oxygen to prevent the patient from dying, assuming they do not want to be intubated?

It's great to be a patient advocate and since you have a relationship with this patient and the family, you often get attached to them and it is painful to deal with the aftermath. Perhaps you should discuss the option of Advanced Directives with the patient and family to make sure that the patient's wishes are written in a legal document. It's reasonalbe to say that someone with one lung and COPD will most likely encounter situations like this in the future, and everyone should be prepared.

I'm also suggesting to involve the family because they should have copies of these documents easily accessible. Additionally, in some states, if a family wants CPR to be performed on their dying loved one who is DNR, healthcare workers must respond and begin CPR. Sometimes families are scared seeing their loved one dying and want something to be done, despite the patient having DNR orders. Families need to know what the dying process is like and need to be prepared as much as possible so they can fulfill their loved one's wishes.

[DutchgirlRN, ASN, RN]

Perhaps you should discuss the option of Advanced Directives with the patient and family to make sure that the patient's wishes are written in a legal document.

This patient died. We discuss Advanced Directives and DNR with the patient and family on admission. We get copies of them for the chart and for the folder in the home. This patient had a DNR.

[gauntlet102]

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!

Well ..I have to agree...that if this wasn't deemed a medical emergency by the nurse then the nurse should be reported..she seemed to talk the patient and the family into calling an ambulance for the sake of convience...thats why er's have triage.....I am a homecare nurse and I am also a volunteer firefighter/first responder and I wouldn't be too happy to be called out for a non-emergency call....you are taking paramedics out of service for what really isn't a medical emergency....at least in your opinion...hmmm...something to think about for next time

ps...I have had a couple of run ins with a few paramedics working in the homecare field...sometimes they question why the call was made...and I simply state that I deemed it a medical emergency and my job is done.....we must work together....carry on.....

[DutchgirlRN, ASN, RN]

Well ..I have to agree...that if this wasn't deemed a medical emergency by the nurse then the nurse should be reported..she seemed to talk the patient and the family into calling an ambulance for the sake of convience...thats why er's have triage.....I am a homecare nurse and I am also a volunteer firefighter/first responder and I wouldn't be too happy to be called out for a non-emergency call....you are taking paramedics out of service for what really isn't a medical emergency....at least in your opinion...hmmm...something to think about for next time

:deadhorse

[Justan]

I believe it's been mentioned before, but the paramedic is working under the license of a physician. That paramedic is also working (hopefully) within the confines of protocols which have been approved by that physician. Since the standard of care across the entire nation with a patient in this situation is to give high flow oxygen, and it could be said with a high degree of certainty that this is reflected in their protocols, your issue is with the physician, and not with the paramedic. A possible suggestion is to find that physician and explain to him why the protocol is in error.

As a side note, if the paramedic had followed your direction and the direction of the family, all it would take is one lawyer educated in medical practices to see this, explain it to the family and convince the family to sue for wrongful death. Say what you will about our litigious society, but when the family is presented with the idea of a huge sum of money, the fact that they complained about giving high flow oxygen to their loved one will be forgotten in the mad rush to get that big fat check. They wouldn't win, of course, but that doesn't mean there wouldn't be a settlement, just to appease the family. This also doesn't mean the family still won't sue, even though the paramedic followed her protocol and did everything by the book. I've been sued before for wrongful death, and fortunately, following protocol by the letter saved my neck.

Good luck in changing the mind of the physician about oxygen therapy. :)

[DutchgirlRN, ASN, RN]

If the last 2 posters took time to read the entire thread they would realize that

*I have agreed that the paramedic was correct to follow her protocol.

*The 6L of 02 did not kill the patient.

*The patient should have gone by car but the family refused.

*Once the ambulance arrived the patients care is out of the nurses hands.

*Home Health nurses are competent.

*Many of us learned a valuable lesson or two!

Good luck in changing the mind of the physician about oxygen therapy.

Not nice...

[amomanurse]

this paramedic obviosuly didnt do so well in A&P and chemistry (hummmmmm maybe paramedics dont have the education us nurses do) or she/he would have known the reaction to increasing to O2 would stimulate the production of CO2 in the pt and causing the pt resp distress!!!!!

hope this paramedic gets the diciplinary action he/she deserves before she/he is able to put another pt in danger!!!!! i am also in HH and i would have called his supervisor at the very minute and i agree, i hope u documented well!!! by the way, how did the pt come out of this in the end?

amomanurse