Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 9
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 31, '07Joined: Jun '06; Posts: 7,199; Likes: 7,935Quote from burn outdid you miss the part that no change in mentition was noted?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.
Jan 31, '07Specialty: 5 year(s) of experience in Telemetry, Nursery, Post-Partum ; Joined: Sep '06; Posts: 220; Likes: 22Quote from morteNone 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.did you miss the part that no change in mentition was noted?
Jan 31, '07Occupation: Med/Surg Specialty: 19 year(s) of experience in Ortho/MS, SICU,Home Health ; Joined: Dec '06; Posts: 711; Likes: 152Quote from emernurse\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.
Jan 31, '07Joined: Jun '06; Posts: 7,199; Likes: 7,935Quote from rnin02i 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 incompetentNone 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.
Jan 31, '07Occupation: Med/Surg Specialty: 19 year(s) of experience in Ortho/MS, SICU,Home Health ; Joined: Dec '06; Posts: 711; Likes: 152Quote from angel's rnjust a sidenote. dnr does not mean do not treat. i have people with dnr's that absolutely do not want resuscitation if their heart stops and if they stop breathing but do want to be treated for bronchitis,pneumonia,broken limbs,etc. especially with community dnr's which often look at the big picture. we don't usually sign them at the last minute when dad is hanging on by a thread. so we do have pt's with dnr's that still get appropriate treatment.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.
:roll :roll just had my 30th weding aniversary!!!!
Jan 31, '07Occupation: Medical Imaging RN~Special Procedures CT Specialty: 33 year(s) of experience in OB, M/S, HH, Medical Imaging RN ; Joined: Aug '04; Posts: 6,708; Likes: 1,449Quote from S.T.A.C.E.YI'm proud to say I'm an American and live in the deep south. I was born in Holland and have dual citizenship. My whole family imigrated here. Nursing in Holland is very different from here. The work is the same but the differences lie in the fact that it is strictly forbidden for nurses to work over 8 hours per day and over 40 hours per week. They feel it's not safe. If you want to go into Home Health you have to go back to school for an additional year to be certified in Home Health, the same is true with nurses who want to work in the ambulance, they go back to school. Also LTC, another year of specialized school.I'm confused. Are you in Holland or the USA???
Jan 31, '07Occupation: ER RN, Medic Specialty: ER ; Joined: Nov '04; Posts: 270; Likes: 50Quote from mortePlantiff's Attorney: "Can you explain to me what hypoxia is?"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
Paramedic: "It is when there is not enough oxygen to perfuse the organs."
Attny: "What are organs?"
Medic: "They are the different systems that carry out the work of the body."
Attny: "Such as?"
Medic: "The lungs work to exchange gas, getting rid of carbon dioxide and bringing in oxygen."
Attny: "And what happens if the lungs fail?"
Medic: "You would stop breathing."
Attny: "What if is wasn't that bad? What is Respitory Failure all about?"
Medic: "That is when the lungs don't do their job and you get a build up of waste products and carbon dioxide."
Attny: "And is that bad?"
Medic: "Yeah, that's bad."
Attny: "How do you treat it?"
Medic: "Give oxygen, maybe intubate the patient and breathe for him."
Attny: "How could you tell if a patient is in Respiratory Failure?"
Medic: "Well, he could be acting weird, or if the sat is low?"
Attny: "What is a sat?"
Medic: "It's a pulse oximetry reading."
Attny: "What does that do?"
Medic: "It gives and idea of how much oxygen is being carried on the hemeoglobin."
Attny: "And what's normal?"
Medic: "Usually 92% or above."
Attny: "And what was my client's Dad's?"
Attny: "And he wasn't in Respiratory Failure and didn't need additional oxygen?"
Game, set, match. Get out the checkbook.
You have to prove that a patient is competant in order to let him refuse. That's why RMAs and AMAs take so long to chart.
That's why the Paramedic was right to turn up the oxygen.
That's why the Paramedic should have thought about intubation.
Jan 31, '07Occupation: ER RN, Medic Specialty: ER ; Joined: Nov '04; Posts: 270; Likes: 50Quote from morteWe routinely do this in the ER - patients who are not competant to make decisions for themselves (usually mental health or chemically enhanced, but sometimes hypoxic). The laws vary from state to state (in MA it's a Section 12, in NY it's either a 9.39 or 9.41) that permit this to happen. There's also tort law on the subject.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......
Jan 31, '07Occupation: ER RN, Medic Specialty: ER ; Joined: Nov '04; Posts: 270; Likes: 50Quote from AnRNIamMileage on this varries from place to place. Both NY and MA have out of hospital DNRs that are required to be honored by EMS.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).
Remember, DNR means that if the heart stops, don't do CPR. It does not mean don't treat the patient (and my Medical Director expects us to intubated DNR patients in Respiratory Failure).
Jan 31, '07Occupation: ER RN, Medic Specialty: ER ; Joined: Nov '04; Posts: 270; Likes: 50Quote from angel's RNYou do not have to be in Hospice to have a DNR. Many patients locally have them and are not in a SNF, ALF, or in Hospice.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!!!!
Jan 31, '07Occupation: ER RN, Medic Specialty: ER ; Joined: Nov '04; Posts: 270; Likes: 50Quote from morteYou obviously aren't following the lawsuits and actions of the state EMS departments.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
I wouldn't expect you to - you're not a Paramedic.
I think I missed it along the way somewhere - where do you work?
Jan 31, '07Occupation: LTC Specialty: 9 year(s) of experience ; Joined: May '04; Posts: 3,422; Likes: 1,298oh boy...Last edit by Jo Dirt on Jan 31, '07
Jan 31, '07Occupation: ER RN, Medic Specialty: ER ; Joined: Nov '04; Posts: 270; Likes: 50Quote from motorcycle mamaI have "comfort care" patients who are taking their last breaths on NRB masks. It all depends on the patient.They don't even put activelydying people on more than a few L/M. This person needs an attitude adjustment.
I can think of a case last week where a patient was not enrolled in Hospice. Family had run out of morphine for the end stage CA of the everything. Patient presents to the ER via EMS, who had the comfort care form in hand (it's a MA thing). Patient remained on NRB, was given Morphine for the pain, arrangements were made for family to get a stock of morphine for home, and patient went home and died (on NRB) about 8 hours later.
Generalizations, like multiple guess choices that have "always" or "never" in them are usually wrong.