Hello! So I'm newer to the ER so I was hoping I might get some perspective on a scenario that came about the other day about a patient who came into our ER by EMS. The report given to me was the patient was found unresponsive by her parents in her bed after last seeing her the previous night reading. When EMS arrived to our hospital, the patient was only responsive to pain, vitals were w/in normal limits, pupils dialated, but reactive. However, I noticed she wasn't on any oxygen. Even though she was 98% on RA, I felt given how she was presenting that she might need some supplemental oxygen.
I questioned EMS about this and their response to me was it wasn't their protocol since her sats were fine. They looked at me like I was silly for asking. Okay, well....
Her parents arrive later. I start talking with them. They tell me they found a bottle of meds and all the pills weren't accounted for. For the life me I can't remember what meds they were only that it was a benzo. Also, they tell me that the patient had just recently caught her boyfriend cheating on her with another girl and the patient has a history of depression. this is starting to sound like a suicide attempt to me. Hours later, when the pt starts to wake up tells me she was in fact trying to kill herself.
Anyway, my question is was I wrong to ask them why they didn't put her on oxygen? Things aren't always what they seem. I've heard not to treat the monitor, but what I see. What do you think?
Anyone that presents to the ER that is unconscious for unknown reasons needs to have oxygen administered without exception regardless of O2 sat. Especially a kid described by the OP.
Until CO poisoning is definitively ruled out, these patients get oxygen, period.
Specializes in Critical Care, Emergency, Education, Informatics.
The problem with that concept is there is nothing to indicate CO poisoning. And I seriously doubt that based on the OP presentation that a gas would be drawn. So how about the unlikely chance she had a stroke? Increased O2 can cause vasoconstriction.
We need to get away from knee-jerk responses and apply those critical thinking skills we're supposed to have.
The problem with that concept is there is nothing to indicate CO poisoning. And I seriously doubt that based on the OP presentation that a gas would be drawn. So how about the unlikely chance she had a stroke? Increased O2 can cause vasoconstriction.
We need to get away from knee-jerk responses and apply those critical thinking skills we're supposed to have.
OK. I'll play along... those critical thinking skills we're supposed to have..... what kind of stroke? Hemorrhagic or embolic/occlusive?
Specializes in Critical Care, Emergency, Education, Informatics.
Exactly!
Based on the reported presentation, there were no more signs of a stroke as there were CO poisoning.
Suction handy, nasal airway, best mentoring available, Finger stick glucose, If she starts debating, I'd be more worried about her airway , rate or tidal volume.
Specializes in Emergency, Case Management, Informatics.
Why do we waste time doing vitals?
You've basically cherry-picked a part of my post and took it to an extreme that makes no sense to any rational person. Obviously, vitals are still taken and responded to. Vitals have value as a PART of a thorough assessment, but they are not the only thing an experienced clinician uses to make a decision.
Taking your own argument, if I see asystole on the monitor and my patient is talking to me, I should still go ahead and initiate CPR because the machine says my patient's heart has stopped. I'm sure you can agree, that's ridiculous.
People have been making the statement to treat the patient and not the vitals not because they're "not aware of just how valuable that data can be", but because they're acutely aware of the type of knee-jerk reactions that inexperienced medical professionals make.
I constantly learn new things every day I work. I often go home and research situations that presented in the ED. I've thoroughly enjoyed the discussion here and I've read some rationales that were useful. Also, thanks to those that responded from other areas of nursing. It's always nice to see how other specialties think.
You've basically cherry-picked a part of my post and took it to an extreme that makes no sense to any rational person. Obviously, vitals are still taken and responded to. Vitals have value as a PART of a thorough assessment, but they are not the only thing an experienced clinician uses to make a decision.
Taking your own argument, if I see asystole on the monitor and my patient is talking to me, I should still go ahead and initiate CPR because the machine says my patient's heart has stopped. I'm sure you can agree, that's ridiculous.
People have been making the statement to treat the patient and not the vitals not because they're "not aware of just how valuable that data can be", but because they're acutely aware of the type of knee-jerk reactions that inexperienced medical professionals make.
Asystole? Really? Isn't that taking it to the extremes?
What about the "passed out" patient you assume to just be a drunk? Just looks drunk...
Vitals are an important part of assessment.
Even in EMS, this "Treat the patient and not the monitor" was a big thing until they got 12 - Lead ECGs, glucometers and ETCO2 monitors. Now with more education, their assessments are starting to take new shape. Even ultrasound is now becoming a diagnostic tool on ambulances.
Inexperienced or those who get complacent often fail to fully assess because a patient "looks fine" or make assumptions without the data to back them up. And, if you don't believe what you initially see for vitals, assess and re-evaluate. I have seen some pretty unbelievable numbers on the monitors and luckily we noted them and re-evaluated regardless of how great the patient may have looked and initiated the appropriate care.
Asystole? Really? Isn't that taking it to the extremes?
What about the "passed out" patient you assume to just be a drunk? Just looks drunk...
Vitals are an important part of assessment.
Even in EMS, this "Treat the patient and not the monitor" was a big thing until they got 12 - Lead ECGs, glucometers and ETCO2 monitors. Now with more education, their assessments are starting to take new shape. Even ultrasound is now becoming a diagnostic tool on ambulances.
Inexperienced or those who get complacent often fail to fully assess because a patient "looks fine" or make assumptions without the data to back them up. And, if you don't believe what you initially see for vitals, assess and re-evaluate. I have seen some pretty unbelievable numbers on the monitors and luckily we noted them and re-evaluated regardless of how great the patient may have looked and initiated the appropriate care.
Regardless of how cutting edge your equipment is, the most important tool a clinician has is their brain. Which is why we will continue to treat the pt, not the monitor.
Regardless of how cutting edge your equipment is, the most important tool a clinician has is their brain. Which is why we will continue to treat the pt, not the monitor.
It seems to you the monitor is of no use.
Your brain is capable of collecting data from many sources and processing it.
How many patients laying on the street have you left behind because they "just looked drunk"?
Ever just assume a patient was drunk and not diabetic?
Can you spot hypertension if the patient is not symptomatic?
Do you just use the back of your hand instead of a thermometer?
Can you tell if a patient is just a case of anxiety and not metabolic acidosis or respiratory alkalosis? Young people with pulmonary emboli may look normal but be a little tachypneic who you might just call an anxiety attack.
We have these tools for a reason. Provide your brain with enough data to make appropriate clinical decisions.
Specializes in Emergency, Case Management, Informatics.
Asystole? Really? Isn't that taking it to the extremes?
Yes, it is. It was an illustration of the extremes you talked about in your first post.
Inexperienced or those who get complacent often fail to fully assess because a patient "looks fine" or make assumptions without the data to back them up.
Exactly which part of "Vitals have value as a PART of a thorough assessment" are you not comprehending?
At the core of this discussion is the issue of throwing oxygen on someone because of their unconscious presentation, despite the pulse oximetry being normal. We don't have the ETCO2 reading, blood gases, or any other information related to ventilation and perfusion.
In fact, when you're talking about ETCO2, you're talking more about the decision to bag/intubate than you are talking about supplemental oxygen. So, ultimately, that's a moot point. The core question is, do we just indiscriminately throw oxygen on someone because they're unconscious? The evidence says no.
Stop taking this extreme view -- based only on something in your head and not on anything presented in this thread -- that people aren't taking vital signs and aren't looking at the monitors. No one is suggesting that except for you. We're suggesting doing a thorough assessment, INCLUDING VITALS, and making a clinical decision based on the evidence.
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Anyone that presents to the ER that is unconscious for unknown reasons needs to have oxygen administered without exception regardless of O2 sat. Especially a kid described by the OP.
Until CO poisoning is definitively ruled out, these patients get oxygen, period.