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?

[morte, LPN, LVN]

can you please point me in the directon of the chapter in law that says a paramedic is the only med prof that doesnt have to respect the word .....NO......

[Altra, BSN, RN]

Morte, let's think about the relationship between mentation & hypoxia.

Then, let's think about whether or not you could defend your decision not to increase O2 on a patient w/SpO2 of 73% with the statement, "the patient refused."

[morte, LPN, LVN]

it doesnt make any difference....unless you are going to get a judge to come to the house,....the op knows this patient and gave no indication there was any gross change in mentition.....you cant impose your will on someone because you think you are right

[Cattitude]

reading this whole thread has really opened my eyes. i do deal with paramedics on occasion especially when i have really sick pt's at home that go back and forth to the hospital.

thank goodness i have had really courteous professional dealings so far. they do listen to me as asfar as requesting medical hx, present situation, i also provide them with an updated med. sheet to bring to the hospital. i've never been ignored or treated like the hh nurse that doesn't know anything. i let them do their thing and have helped them when i can (moving the pt, etc).

i have never called ems and left before they got there. that is the poorest of nursing care. but as stated in previous posts, there is incompetency in every profession. no one is immune.

[Altra, BSN, RN]

it doesnt make any difference....unless you are going to get a judge to come to the house

That is precisely the point. If there were to be a bad outcome and subsequent litigation, the judge/jury will not have been there at the house to see the patient. What they are going to see is that the patient had a recorded SpO2 of 73%, seriously hypoxic by any clinical standard, and yet O2 was not increased.

[morte, LPN, LVN]

That is precisely the point. If there were to be a bad outcome and subsequent litigation, the judge/jury will not have been there at the house to see the patient. What they are going to see is that the patient had a recorded SpO2 of 73%, seriously hypoxic by any clinical standard, and yet O2 was not increased.

are you purposefully misunderstanding?! my mention of a judge was to judge competence.....IF one were at the house (judge) he/she would not be able to preside in a case concerning patient.....you still havent addressed my request for citation of law about paramedics being the only med prof that are aloud to ignore a patients clearly stated NO, i have to presume that you cant.....as i figured......

[rnin02]

are you purposefully misunderstanding?! my mention of a judge was to judge competence.....IF one were at the house (judge) he/she would not be able to preside in a case concerning patient.....you still havent addressed my request for citation of law about paramedics being the only med prof that are aloud to ignore a patients clearly stated NO, i have to presume that you cant.....as i figured......

I think I would "ignore a patient's clearly stated NO" if they had an pulse ox of 73%, even if the other people present stated the pt's mentation had not changed simply because I have to use my best judgement in treating this patient during an emergency and I have no prior knowledge of this patient's mentation. While personally I would listen to the family and HHN report on the patient, including history, etc...I would still have to use my best judgement. And I'm sorry, but it's much easier to defend putting on/turning up O2 in this case then to defend doing nothing but providing a ride to the hospital. Maybe there's no specific "law" about paramedics not having to listen to a "NO" from a patient, but you have to use common sense and provide care that you judge to be best.

[Altra, BSN, RN]

it's much easier to defend putting on/turning up O2 in this case then to defend doing nothing but providing a ride to the hospital.

Thank you.

[withasmilelpn]

And one more thing since I am on a bit of a soap box...don't anyone DARE send a patient into an ER when they are just trying to avoid a wait time! This patient was serious enough to go in this way...but I see LTC's sending in their patients for basically NOTHING by ambulance just to avoid wait times...there is NOTHING that makes them more special than anyone that has waited out in an ER room for hours so they can be treated! It is people like this that send valid patients that can't wait back home to become even more seriously injured/ill and admitted for something that could have been fixed easily! I do know that many LTC's do not have someone to drive a patient in, and need to use ambulance...but try to avoid that...it is killing our EMS and taking them out of service for real emergencies!

No long term care that I have ever worked for has'someone to drive them' Ambulance is the only means of transport. Bunion women sounds like poor assessment really. When I send them out they usually are very sick- urosepsis etc and of course a full code. I know that the ER gets resentful, trust me I have spent huge amounts of time explaining quality of life and DNR issues with families, sometimes successfully, sometimes to little avail. Please realize that LTC nurses are between a rock and a hard place. We are liable for our patients. We have limited means to assess people. That's why a lot of LTC nurses mottos are 'when in doubt, send them out". The families that are the most unrealistic are usually the first to shout 'negligence! We also have huge patient loads, so we can't give them as good of care and monitoring as the hospital can if they are borderline

.

A recent hit and run here showed that...poor 7 year old girl died because it took so long to get an ambulance because they were all busy with what we call BS patient calls and they had to pull one in from a great distance...

How horrible! My prayers to the family!

My hubby was furious because he was nearer, but had to take in a little old lady with a sore foot into the ER! GRRRRRRRR!!!!!

(it was a bunion by the way...nothing a MD or pediatrist could have seen and DX!!!!, all because the woman wouldn't stop wearing closed toe shoes...this was time number 4 for her going in for this in one year!!!!).

(oh hint...report them if you must or feel you should, their bedside mannor may need work...however, I would return the favor by pointing out the pulse ox readings and how long you let that go before calling 9-11 or even calling the MD??? *wink* ).

By the way she did say that the family is the one who reported the pulse ox readings were low all day.

[DutchgirlRN, ASN, RN]

By the way she did say that the family is the one who reported the pulse ox readings were low all day.

Yes, Thanks for correcting that.

Just some interesting information on Ambulance services in Holland:

The Dutch health-care system includes three types of ambulance response. The first one is the emergency response, coded A1, in which the ambulance immediately responds using lights and siren.

In cases without serious life threat and the patient is relatively stable with a GP present, an ambulance can be requested as an A2 emergency. For an A2 call, the ambulance will commence immediately but without lights and siren, which is much safer for the crew and causes less disturbance in the community. The ambulance must arrive within 30 minutes after an A2 call.

If a patient needs to be admitted to a hospital or needs medical attention during inter-clinical transport, an ambulance is requested with a so-called B emergency (non-emergency).

Personnel

A major difference between a Dutch ambulance crew and those in other countries is that crew are registered nurses.

Education

The main medical care provider on an ambulance is a registered nurse. In addition to being a registered nurse, providers must obtain further certifications in intensive care, coronary care and/or anaesthesia nursing before applying to be an ambulance nurse. Besides on-the-job training, this one-year educational program is offered by the National Ambulance Education Foundation, the single national licensing body. Main objectives of the program include legal issues and working in the prehospital environment.

Previous clinical experience and the required educational program guarantee a high level of medical knowledge and wide range of skills in the nurses.

After becoming a registered ambulance nurse, post initial training and educational programs are also mandatory. One of the required programs is the NAEMT Prehospital Trauma Life Support Course. Nurses are trained in the PHTLS program on an advanced level, and drivers are trained on a basic level.

Continuing education is organized on two levels: national and regional. The mentioned PHTLS courses are in the national program, as well as special paediatric courses. For regional education, a wide scale of topics are available and held in smaller groups, mostly at ambulance stations. A number of appointed and licensed training institutes carry out the educational programs.

Doctors in an MMT have also had additional training to prepare them for the prehospital setting. For example, extra courses in extrication techniques are required. A nurse participating in an MMT is a senior ambulance nurse and has taken the same additional training as the MMT doctors.

Photo courtesy of the author

This level of training and education allows ambulance nurses to work on a rather independent and self-supporting basis. If an ambulance crew encounters a situation that aren't within their protocols, procedures or standing orders, providers can contact the medical manager of the ambulance service. If medical procedures must be applied that are beyond the possibilities of the ambulance nurse, providers can request for an MMT.

All procedures are brought together in the National EMS protocols. These protocols are revised or adjusted every four years. Within these protocols, ambulance nurses are allowed to administer 31 different types of medication.

Table 1: List of medications on Dutch ambulances

Acetylsilicyt acid

Adenosine

Amiodaron

Atropine

Biperideen

Budenoside

Butylscopolamine

Clemastine

Denilox

Dexamethason

Diazepam

Diclofenac

Epinephrin

Esketamine

Fentanyl

Furosemide

Glucagon

Glucose

Haloperidol

Ipratropiumbromide

Magnesium sulphateMetoclopramide

Morfine

Naloxon

Nitroglycerine

Oxytocine

Plasma substitution

Ranitidine

Salbutamol

Sodium Bicarbonate

Xylometazoline

Ambulance nurses are also allowed to carry out many medical procedures, including thrombolysis, which is practiced on a common basis. The drug in use depends on the region of the ambulance service. In the case of thrombolysis, providers select the medication after deliberation with the admitting hospital staff.

Equipment

All ambulances in The Netherlands are equally equipped. Aluminium cases are stocked with medical appliances, such as syringes and medication. Other materials, such as scoop stretchers, backboards, splints and collars, are also stocked. All vehicles are equipped to perform both BLS and ALS, with enough supplies on board to treat three patients on scene in case of an MCI (depending the extend of care they need).

All ambulances carry 12-lead ECG equipment, a monitor/defibrillator, a ventilator, infusion pumps and pulse oximeter.

For communication, mobile radios are mounted inside. Every ambulance carries a cell phone as well.

Especially in major cities with a medieval inner city, speed-lowering obstacles are commonly built in the road. Old inner cities are accessible for only pedestrians and cyclists, with the exception of emergency vehicles. To enter such an area, emergency providers carry several remote controls and special keys to bypass the mechanical obstacles, such as rising steps.

All ambulances are equipped with a tracking system so dispatch can locate them and control their status. A digital routing system is also present in all ambulances, which is handy when in small villages and narrow inner city streets.

For recognition, all ambulance personnel are dressed in blue and yellow uniforms. Helmets are present on the ambulance. In case more ambulances need to respond to a scene, the first arriving ambulance starts the incident management and identifies themselves by wearing green vests and by flashing or rotating a green light on their ambulance. All arriving crews can easily identify and respond to the first arrived crew. MMT personnel can be recognized by their red and yellow uniforms.

Patient data in the ambulance are gathered and digitally processed by handheld computers.

The Netherlands are well developed in health care and EMS. On Dutch ambulances you find a well trained and educated team, with separated tasks for each member of the crew. By having prehospital providers working in conjunction with house doctors on one side and MMT doctors on the other side, the patient can receive optimal care. In the chain of emergency care, Dutch EMS is certainly not the weakest link.

http://www.jems.com/products/ambulances/articles/13512/

[AnRNIam]

The simple fact is that the Paramedic has a medical director (MD) that they work under. This medical director sets the protocol that the Paramedic has to follow regarding any treatment they render not a HHRN. If the protocol the Paramedic has states to give the O2 to a patient with a Sat. of 73%, she had to give O2 to that patient. No choice, no argument. Had she deviated from what her medical director and medical control set as protocol she could lose her license. Again, no choice, no argument.

As for the DNR status someone mentioned (not sure who), in quite a few states, if a DNR is in place and 911 is called the DNR becomes invalid. A call to 911 is considered a call for help and request for treatment and supersedes the DNR. So, in calling 911 the OP would have invalidated a DNR for this patient if one would have been in place (not cutting on the OP, just food for thought for everyone).

Myself, I was a Paramedic for 15 years and decided to go into nursing after we had kids. In all that time, I have never shut down a COPD'er by using a higher flow of O2 during a short ride to an ER. As the Paramedic in the OP did, I also would have went with 6-8L O2 in that situation (what little of it I know). If the patient would have complained of SOB or had a decreased LOC I may even have went higher on the O's.

[PANurseRN1]

Not getting the connection between what Dutch EMS crews are doing and what we do here.