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?

    • I think the Paramedic was right to increase the 02 to 6L. I am a Nurse.
    • I think the Paramedic was right to increase the 02 to 6L. I am a Paramedic or EMT.
    • I think ultimately the patients wished should have been honored. I am a Nurse.
    • I think ultimately the patients wishes should have been honored. I am a Paramedic or EMT.
    • I think the Paramedic should be reported to her agency for ignoring everyone. I am a Nurse.
    • I think the Paramedic should be reported to her agency for ignoring everyone. Paramedic/EMT.
    • I think this was a true emergency situation. I am a Nurse.
    • I think this was a true emergency situation. I am a Paramedic or EMT
    • I don't know, it's all too confusing
    • Leave me out of it. I don't want to participate.

148 members have participated

ZASHAGALKA, RN

3,322 Posts

Specializes in Critical Care.

Topic directly on point:

https://allnurses.com/forums/f22/copd-pts-2l-o2-194267.html

http://cmbi.bjmu.edu.cn/uptodate/critical%20care/other/The%20use%20of%20oxygen%20in%20patients%20with%20hypercapnia.htm

"Physicians have observed for many years that the administration of oxygen to patients with chronic obstructive pulmonary disease (COPD) may be followed by hypercapnia. Traditional teaching emphasizes that hypercapnia results from suppression of hypoxic ventilatory drive and warns that "patients will stop breathing" if given oxygen. However, this interpretation does not account for the many factors that contribute to the control of breathing in these patients, and has resulted in oxygen being withheld inappropriately from some patients with acute respiratory failure."

~faith,

Timothy.

Specializes in OB, M/S, HH, Medical Imaging RN.
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.

Canoehead, you may be one paddle short of a regatta but you are right on this one. I appreciate your calm and sensible approach and nicely said too. This really put the situation in perspective for me. Thanks!

Specializes in OB, M/S, HH, Medical Imaging RN.
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.

Thanks Angie, I will definately update. BTW I do know that her WBC on admit was 1.7.

Focker, CRNA

175 Posts

Well I do understand some of your concerns of the concept of increasing the O2 Long term but I dont know any medic that wouldnt put this person on short term non-rebreather to the ED to bring up those sats. I would suppose the next treatment for the medic would to give a couple of treatments aswell.

Once the medic is arrives it his/hers pt and they have protocols. These ppl are highly trained people while the EMT has no buisness touching that medics 02.

In the ED if the pt was 73% and there baseline is low 80's im most likely placing them on a non-rebreather while they set up for cont. neb tx.

No, with a long term COPD pt, just because their sats are 73% does not mean they are not getting enough O2 to the brain/organs. Over a long period of time with low sats like that, the body goes through compensatory changes, 2,3-DPG increases to increase release of O2 to the tissues (shift the oxy-hemoglobin curve), the hct goes up, perfusion is shifted to the vital organs, etc. They essentially go through a lot of the changes that someone adapting to high altitude would go through. The fact that the patient was mentating is good reason to not increase the O2, all that would accomplish is putting the pt. into CO2 narcosis because you took away their stimulus to breathe. They should be left on the same amount of O2 they are on and no changes should be made until they get to the hospital and a blood gas can be drawn. You will probably see a CO2 in the 60's or 70's and a low pao2, but if the pH is close to 7.4 the pt. is doing ok and you can just treat the other respiratory symptoms and infection (fever).

Just to illustrate my point, I took care of a woman who had an avm in her pulmonary vasculature which caused a massive R-L shunt. because the avm probably formed and grew over years, her body made compensatory changes. She was very sick and she was on a ventilator at near maximal settings, 100% O2, etc. and lived at 60% on the sat monitor. One day I took her on transport with her sats reading in the 40's and she was still able to respond to stimulation (nod/shake her head to questions, follow commands). Eventually she did die, but it she was an amazing demonstration of the body's ability to adapt.

Specializes in OB, M/S, HH, Medical Imaging RN.
No, with a long term COPD pt, just because their sats are 73% does not mean they are not getting enough O2 to the brain/organs. Over a long period of time with low sats like that, the body goes through compensatory changes, 2,3-DPG increases to increase release of O2 to the tissues (shift the oxy-hemoglobin curve), the hct goes up, perfusion is shifted to the vital organs, etc. They essentially go through a lot of the changes that someone adapting to high altitude would go through. The fact that the patient was mentating is good reason to not increase the O2, all that would accomplish is putting the pt. into CO2 narcosis because you took away their stimulus to breathe. They should be left on the same amount of O2 they are on and no changes should be made until they get to the hospital and a blood gas can be drawn. You will probably see a CO2 in the 60's or 70's and a low pao2, but if the pH is close to 7.4 the pt. is doing ok and you can just treat the other respiratory symptoms and infection (fever).

Thank you, you are awesome!

PANurseRN1

1,288 Posts

Specializes in Day Surgery/Infusion/ED.

Dutchgirl wrote:

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?

This is what I suspected was at the heart of the issue: You were put out that a "mere" paramedic didn't listen to you. Your comments reflect a clear lack of understanding of how the EMS system works, and your follow ups regarding the pt's current status don't square with your OP of your assessment of the pt. Was he critical or wasn't he? You said he wasn't, but obviously, he was much sicker than your assessment described.

Med/Surg Tele is not even in the same ballpark as providing critical care in the field. An experienced nurse should know that and respect the vital role EMS provides. I work in the ED, but I wouldn't begin to equate what I do with what medics do.

Think long and hard about reporting this. You could be buying yourself a world of hurt.

Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

I agree with NREMTP/RN.

If you did not think it was an emergency do not say that you called an ambulace so he wouldnt have to sit in an e.d. It sure sounds like it was an emergency, lets think about those ABC's and they would not have made him sit in the waiting room in that condition anyway. If that was truly the case then the family should have taken him in on their own especially since, according to your post, it seems it was their oppinion is that the paramedics put the guy on a vent last time.

The oxygen SHOULD be increased until the patients baseline oxygen saturation is maintained and according to your post a saturation of 73% was not this patients baseline. Also it takes more than a 10-15 minute ambulance ride for increased oxygen to decrease a COPD'ers respiratory drive, and because of this, the fact that the paramedic turned up the oxygen has nothing to do with the CO2 retention that required mechanical ventilation.

The patient was heading in that direction from what it sounds like and is anyone pointing fingers at the family or whomever for having the patient wait ALL DAY with severe hypoxia and a pneumonia by the sounds of things before going into the E.D., I am willing to bet that has A LOT more to do with the fact that he needed to be intubated rather than a paramedic increasing his oxygen saturation from 73% to a saturation closer to baseline!!

The funny thing is I just read another thread that was picking on non nursing people for writing oppinionated replys to RNs because they do not understand how RNs feel or what their job is like... So I guess it is only ok if RN's pick on other professionals for doing their job!

Swtooth

Kristiern1

56 Posts

Certainly with a WBC count of only 1.7 on admit speaks to some other underlying issues as well. My suspicion is that this patient was probably quite hypercapnic/hypoxic even before increased O2 and probably only the fact that they had long standing lung disease kept them compensated as long as they were. I think intubation was in this persons future regardless of oxygen. Good call on all parts getting them to the hospital.

Cattitude

696 Posts

Specializes in Lie detection.
in my experience hhn's are generally not able to manage an acute/critically ill patient with any real degree of competency.

:banghead:

wow, wow , and wow. with the increasingly ill pt's we have coming and staying home these days, it's sure nice to know we have your vote of confidence!:(

flashpoint

1,327 Posts

Usually, people call 911 because there is a situation they are unable to handle on their own. As a paramedic, it frustrates me to no end to have friends, family, or caregivers of our paitent telling us how to best care for them. Of course, we want to know thinks like he only has one lung, he breathes better sitting up, etc, but I hate being told things like, don't give him O2, he needs an IV, or "just drive." Paramedics are trained to handle situations emergently...that is what we do.

My course was three years long and I put in over 1500 hours of clinical time in the ambulance, 750 hours in the ER, and 250 hours in areas like the OR, peds, OB, and psych. I am required to take almost 100 hours of continuing education every two years, as well as maintaining ACLS, PALS, NRP, CPR, and EVOC. My medical director tests my competency every six months and I did a 100 hour field preceptorship before I was allowed to practice independently after I passed my National Registry exam. Hopefully, I am competent to do a little more than just provide a taxi service.

With O2 sats in the 70s, a temp of 102, and wheezes, I very much doubt that this patient would have sat in the ER waiting room for very long, if at all. A good traige nurse would have has the patient in a treatment room very shortly after arriving.

Our protocols state that we should NEVER withhold oxygen from a patient. Every paramedic and EMT book I have seen states that we should NEVER withhold oxygen from a patient. There are questions on the National Registry exam that indicate we should NEVER withhold oxygen from a patient. I guess the research that goes into all of that must be wrong. I completely understand why we don't give high flow O2 to COPD patients, but I have never seen or heard of a case where actual harm has been done after giving high flow O2 short term. From what I am reading about this patient, there is a good chance he would have been tubed and vented anyway.

I do think that the paramedic could have handled it a little differently. The "oh, my God," comment was a bit inappropriate...we were taught to keep our emotions a little better under control. I would have asked my partner, rather than bystnaders what was going on...that is a situation where you can't win either way. A lot of people get mad if they have to explain what is going on to more than one person, a lot of people get mad if they aren't asked to explain the situation to the second provider to arrive. If the patient asked not to have the O2 turned up, I might have left if where is was, depending on how far we were from the hospital...probably not though. I might have left if alone until we got in to the ambulance though, but again, I doubt it. We have protocols to follow and although we are obviously expected to use our own judgement as well, I have honestly never seen a patient harmed becasue we stuck to the protocol as it is written. It's too bad we can't get a better idea of what everyone on the team does.

clee1

832 Posts

Specializes in Hospice, Med/Surg, ICU, ER.
Thank you for your reply. I am charting now and will be doing a very thorough job and just the facts.

I did call the ER after the ambulance left, spoke to the doctor in charge and let him know what was going on and to turn the 02 down when the pt arrives. (I used to work there). He said "I sure will, we don't need her/him going into acidosis". Should I chart this also? That I called the ER doctor?

Yes. Document everything well. I suspect you have not heard the last of this entire episode.

Altra, BSN, RN

6,255 Posts

Specializes in Emergency & Trauma/Adult ICU.

I can only echo other posters ... I am in complete agreement with the paramedic's actions.

BTW, if the family had taken responsibility for getting this "non-emergent" patient to the hospital themselves, the patient would have been in triage only long enough for me to get the bare basics of the story - once I took a look at this febrile, wheezing individual w/sats of 73%, he would have been taken back immediately and I and any of my co-workers would have applied a NRB at 10-15L. An alert & oriented patient of course has the right to refuse treatment, but I cannot imagine any of our docs agreeing to rely on the mentation of a clearly hypoxic patient. It doesn't make sense. Show me some kind of written advanced directive - specifying that the pt. is comfort measures only or something of that sort - and it becomes a different situation. But I haven't read anything that indicates that any kind of written advance directive was in place.

I do not accept that the patient's current need for ventilation is the result of 10-15 minutes of administration of high-flow O2. WBCs of less than 2? To me that says underlying neutropenic issues, not evidence of lack of sepsis.

Hope the patient is improving.

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