Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 4
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
Jan 28, '07Occupation: ER Nurse / Geriatric Assessment Nurse GNC(C) Specialty: 24 year(s) of experience in ER/Geriatrics ; From: CA ; Joined: Aug '06; Posts: 213; Likes: 108Quote from ZASHAGALKAExactly!Topic directly on point:
"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."
Jan 28, '07Specialty: ER ; Joined: Mar '06; Posts: 386; Likes: 232I would have to agree with most of the above posters. When you called the ambalance, the EMT-P became the person directing this patient's care until arrival at the hospital. Do you really think it would have been okay for this pt to roll into a room not on Os, wheezing, one lung, and febrile? Any doc would look at the medic and say "HELLO???" And the excuse "the family didn't want me to" doesn't much cut it. I completely agree - this pt was heading towards an ETT, and nothing anyone did or didn't do was going to stop it.
Hopefully she is beginning her recovery and someone will speak to the family to let them know the intubation is not the medic's "fault."
Jan 28, '07Joined: Jan '05; Posts: 4,765; Likes: 2,554Quote from earle58if choosing between the lesser of 2 evils, i'd rather see them acidotic and vented than dead.
When I was an EMT, we were taught that if the pt is hypoxic, even though they are CO2 retainers, then you still give them the O2 they need.
We can wean off of the vent, but we can't wean them from dead. That's just what we learned.
If I were in this situation, I would have done the same thing as the medic.
Jan 28, '07Occupation: Emergency Department Specialty: ER/Ortho-Neuro-Med-Surg ; From: US ; Joined: Sep '04; Posts: 11,171; Likes: 3,262Canoehead and Cotjockey nailed it.
Timothy (ZASHAGALKA) - Thanks for the links.
Jan 28, '07Occupation: Med/Surg Specialty: 19 year(s) of experience in Ortho/MS, SICU,Home Health ; Joined: Dec '06; Posts: 711; Likes: 152Quote from nursesaidebeni too can see both point's of view. the only thing that i can see that might have mad better communication is the medic acknowledging the family and pt's words instead of ignoring them. maybe by just quickly telling them that this is protocol would have helped explain things. we all have policies to followyou know, this is so true! so many folks in healthcare are quick to judge others on their performance. i can see both points of view in this situation. right or wrong it sounds like this patient was heading towards a vent and i doubt the paramedic's actions negatively affected the pt's outcome. it sounds like she did what she had learned and been taught through experience and training was right, and for that i don't think she can faulted. i can appreciate the op's concerns, but i think at some point we all in healthcare need to realize that sometimes it's just not our call.
Jan 28, '07Joined: Jun '06; Posts: 7,199; Likes: 7,935this patient was batteried, given a higher dose of a drug than she was willing to accept, what part of that are you not understanding?
Jan 28, '07Joined: Jan '05; Posts: 4,765; Likes: 2,554Best quote I learned in EMT school:
"always err in favor of the pt"
I'd rather defend myself against putting a pt on 6L 02, then allowing a pt with a pox in the 70s-80s become hypoxic and die.
Pretty simple, actually.
Again, pt didn't have to call 911. That act meant they thought it was an emergency too.
Jan 28, '07Occupation: Day Surgery/Infusion/ED Specialty: Day Surgery/Infusion/ED ; Joined: Feb '06; Posts: 1,405; Likes: 47Quote from morteBatteried? Duracell or Energizer?this patient was batteried, given a higher dose of a drug than she was willing to accept, what part of that are you not understanding?
Imagine this: Pt says ' I don't want Cipro 400mg IV, I want 350mg instead."
The pt was not battered in that the pt was willing to accept O2 in the first place. If the pt had been flatly refusing the O2, then there might have been a case for battery. If the pt was competent, of course he could have refused any O2. With sats in the 70s, though, you'd have to wonder about his mentation.
Jan 28, '07Joined: Apr '05; Posts: 69; Likes: 11I, for one, would need to know the patient's weight.
How else would I know if I'd have enough paralytics left after intubating the patient to pry the home health nurse off the back door of the ambo?
This patient was failing to improve with treatment and was heading for a tube. The nonrebreather was a good choice to preoxygenate prior to intubating, which I think the paramedic had the good sense to see coming.
In my state, on a the patient's physician who is "physically on scene and willing to accompany the patient to the ED" can override the jursidictional medical command authority. As someone posted, the patient can refuse care, but that puts the paramedic in a tight spot. I mean, determining competence in a patient who's hypoxic and probably will need to be intubated. is a crapshoot.
RN, CFRN, EMT-P
Writing from the Ninth Circle
Jan 28, '07Joined: Aug '04; Posts: 9,279; Likes: 4,302Quote from mortethis patient was batteried, given a higher dose of a drug than she was willing to accept, what part of that are you not understanding?
The fever and hypoxia alone suggest an emergent situation that taken together, call the a/o X3 part into question.
I tell people if you do not want to be treated, do not call EMS.
Jan 28, '07Joined: Jun '05; Posts: 77; Likes: 1paramedics are "wanna-be doctors"? Are you serious?
Jan 28, '07Occupation: ER RN, Medic Specialty: ER ; Joined: Nov '04; Posts: 270; Likes: 50[quote=DutchgirlRN;2039373]Quote from NREMT-P/RNAh yes, the Paramedic is completely uneducated and can't possibly know anything about patients. There is no reason that the Paramedic should not listen to me, and just her ego got in the way.In my experience paramedics are merely doctor wanna be's. How long do paramedics go to school?
Get over it.
And, for the record, Paramedics go to school for two years and are awarded and Associate Degree these days. That would seem to be about the same amout of time as your peers do.
Having done a fair number of HH encounters in both the field and the ER, I can honestly say that the perception of another poster that the HH nurses are ill equiped and ill prepared to handle an acute situation is true. I've had situations where a HH client had a stroke, was vomiting, and unable to care for the airway. One HH nurse admonished me for putting the patient onto his back so that I could intubate him. One HH nurse admonished me for turning the patient onto the affected side so that I could clear the airway. One admonished me (and tried to call my boss...who was me, from an operations standpoint!) for bagging a patient when she could not find a DNR.
But, hey, what do I know. I've only been seeing patients for 17 years!
Chip, RN, CCRN, EMT-CC, and a bunch of other letters!
Jan 28, '07Occupation: Med/Surg Specialty: 19 year(s) of experience in Ortho/MS, SICU,Home Health ; Joined: Dec '06; Posts: 711; Likes: 152[quote=chip193;2040951]Quote from DutchgirlRNPlease do not lump all HH nurses in together as being inexperienced in acute care situations. I have had many situations and have plenty of acute care experience to back me up. Some of us do have ICU or strong med/surg backgrounds. I have both.
Having done a fair number of HH encounters in both the field and the ER, I can honestly say that the perception of another poster that the HH nurses are ill equiped and ill prepared to handle an acute situation is true.
Chip, RN, CCRN, EMT-CC, and a bunch of other letters!