Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do?

Nurses General Nursing

Published

  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?

Specializes in Peds Cardiology,Peds Neuro,Pedi ER,PICU, IV Jedi.
That's how I was feeling about it. I wish the family would of have taken her in the car but they refused.

I spoke with my DON and she praised me for calling the ER doctor. Ok you can blast me now. I can take it. She was going to call the county ambulance service and talk about this matter but I haven't been back yet to see what the outcome was.

The patient is doing well. Awaiting results of blood cultures.

DutchgirlRN..no one is here to blast you!!! You were frustrated and you sought out some thoughts from others, no need to blast anyone for asking the opinions of others.

Havre a great night.

vamedic4:nuke:

Up Vote Up Vote ×

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).

I'm really surprised to learn about this. In Texas, it's not the case (we even have our own forms and bracelets for out-of-hospital DNR's). The only times we start CPR would involve a suspected unnatural death or an invalid (unsigned, etc) DNR. People should be able to call for an ambulance without throwing out their right to keep a DNR.

Agree with you on the issue of the oxygen. Most research has shown that knocking out hypoxic drive occurs over hours or days, not within the few minutes of a typical EMS transport. The general thinking is that if a patient is so unstable as to be compromised by a few liters of oxygen, then that patient needs an ET tube anyway.

Up Vote Up Vote ×
Specializes in Emergency.
Just some interesting information on Ambulance services in Holland:

I'm confused. Are you in Holland or the USA???

Up Vote Up Vote ×
Specializes in Cardiac.
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."

ITA!

I'll say it again "always err in favor of the pt!"

Up Vote Up Vote ×

Hey there- the DNR statement was me. My thinking was if she made herslf a DNR, then she would'nt be going to the ER. Hospice would be taking care of her.

I still say that, even if the patient's SATS were in the 70's, that is probably where she lives. Didn't the original note say that she didn't really feel bad? No SOB? THen WHY call 911?!?!?!? If she lives in the 70's, another 15 min. in the back of the car with her home O2 probably wouldn't have hurt her. And like someone eles said, when the patient gets to the ER, triage would have sent her right to the back anyway. I really don't think that a compenent RN would make the patient sit in the waiting room "for hours". Thanks for letting me state my views -- can't do it at work, haven't "been there long enough to have an opinion"!!

:roll :roll Just had my 30th weding aniversary!!!!

Up Vote Up Vote ×

i highly doubt a paramedic would loose their lic over honoring a patients NO!....I could see her being sued over not........

PS I am in no way arguing the medical aspects of this issue

Up Vote Up Vote ×
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......

When working with copd patients we all know that they can normally run a higher co2 than a normal person, even higher than their o2 levels and there is always the 50/50 rule but we also know that when a copd gets into trouble they are usually retaining co2 and this must be the first consideration when caring for them in an emergency situation...frequently the co2 level can run 100 or greater and usually the o2 is very low thus requiring the increase in o2 delivery. When a person's co2 levels get too high this effects their mentation thus making them incompetent to make informed decisions...in our hospital a patient will get intubated with a co2 of 100 or greater no matter if they are screaming at the top of their lungs or not, unless a mpoa or medical surrogate tells them otherwise. The lab values drawn later at the hospital verified that the medica acted approprately, high co2 levels do not occur in 15 minutes on the drive to the hospital with extra o2.

Up Vote Up Vote ×
Specializes in Tele, ICU, ER.

I have to agree on the side of the medics in this, though I understand the HH nurse's frustration.

We have awesome EMS personnel in my city and their protocols are pretty solid. Occassionally annoying but solid.

I was at a baby shower once and one of the young ladies (early 20's) had an anxiety attack. This was someone I didn't know. Before I even knew what was going on, the family had called 911. Then came and got me. I assessed her (alway keep my steth/cuff in the car) and when EMS showed up, gave 'em a quick update on situation from what I could learn, and got outta the way. They did what they had to do. Girl was fine, of course, but my point here is that I got OUT of their way.

In the ER, on the recieving end of the ambulance ride, we ASSESS the patient ourselves as soon as they hit our bed. If this patient had come into my ER, we would have assessed him and determined ourselves, his O2 need and proceeded accordingly. Given his condition, I'd have had the Intubation equipment right next to him, too. The ambulance ride is governed by strong protocols which are meant to protect the patient en route, but once they hit the ER, WE determine what's needed. 99% of the time, the EMS folks have gotten everything started in the right direction and we move on from there. Sure, there are exceptions, where their protocol might not fit exactly, but EMS can't go on the assumption of the exceptions - they HAVE to follow those protocols. Those exceptions are why ambulance rides are FAST and ER staff pounce when these types of folks come in.

As for the family/HH folks not wanting the O2 upped, were I the EMS, I'd have blamed my protocols with something along the lines of "I'm sorry but I'm required to do this for the patient while en route, but it's a short ride and the ER folks will make a longer-term decision in just a few minutes." then slapped the O2 on and went.

One comment I really feel I must make though, even though I'm now babbling: If I had to know EVERY damn thing every other medical person knows, my head would explode. I count on EMS to know badda-bing what to do with someone hanging upside down in a car so that their airway is not compromised and thier c-spine is kept intact, all the while disengaging said patient from said car. I count on med-surg nurses to take what I send them and juggle all the details of their care that I simply don't have time to do. I count on ICU nurses to be so ingrained in the detail of thier patients' conditions that they catch the slightest change before it becomes a huge issue. I count on HH nurses to manage difficult disease processes (AND families) outside the hospital so that, for the most part, those folks don't hav to come back unless absolutely necessary. I count on RT to shift to the left, to the right, do the hokey pokey and "see" those alveoli just by listening to the patient.

My point? Nursing (and other medical folks) are no longer interchangable. In our insanely acute healthcare world, we HAVE to specialize simply so that there's someone available with EXPERT knowledge for a given situation, whether that situation involves an intraaortic balloon pump, a 15-car pile up, 12 sundowners trying to nosedive out of bed, or the next acute MI busting through the door. We MUST show respect for each other. No patient will have an optimum outcome as they move through the continuum of care unless ALL of their providers respect and trust their brothers/sisters on the medical team. We're all on the same team with the same goals.

Up Vote Up Vote ×
When working with copd patients we all know that they can normally run a higher co2 than a normal person, even higher than their o2 levels and there is always the 50/50 rule but we also know that when a copd gets into trouble they are usually retaining co2 and this must be the first consideration when caring for them in an emergency situation...frequently the co2 level can run 100 or greater and usually the o2 is very low thus requiring the increase in o2 delivery. When a person's co2 levels get too high this effects their mentation thus making them incompetent to make informed decisions...in our hospital a patient will get intubated with a co2 of 100 or greater no matter if they are screaming at the top of their lungs or not, unless a mpoa or medical surrogate tells them otherwise. The lab values drawn later at the hospital verified that the medica acted approprately, high co2 levels do not occur in 15 minutes on the drive to the hospital with extra o2.

did you miss the part that no change in mentition was noted?

Up Vote Up Vote ×
Specializes in Telemetry, Nursery, Post-Partum.
did you miss the part that no change in mentition was noted?

None of us have missed that per the HH-RN and the family there was "no change in mentation". The point is the EMS workers don't know this patient, and they have to do what they feel is best. That is the whole point.

Up Vote Up Vote ×
Specializes in Lie detection.

my point? nursing (and other medical folks) are no longer interchangable. in our insanely acute healthcare world, we have to specialize simply so that there's someone available with expert knowledge for a given situation, whether that situation involves an intraaortic balloon pump, a 15-car pile up, 12 sundowners trying to nosedive out of bed, or the next acute mi busting through the door. we must show respect for each other. no patient will have an optimum outcome as they move through the continuum of care unless all of their providers respect and trust their brothers/sisters on the medical team. we're all on the same team with the same goals.

\

very well said and something i feel was lost amongst the 40 or so repetitive posts stating the treatment for this pt. thanks emernurse for your words. i know that we need to respect each other and some of the posts in this thread have bothered me. 'nuff said.

Up Vote Up Vote ×
None of us have missed that per the HH-RN and the family there was "no change in mentation". The point is the EMS workers don't know this patient, and they have to do what they feel is best. That is the whole point.

i beg to differ, and as i said i am not arguing the medical aspects of this situation......no one has the right to impose their will on anyone without that person being judged incompetent

Up Vote Up Vote ×
+ Add a Comment