allergic reaction or anxiety attack???

[ZombieEMT]

The Department of Transportation, which as I last checked, is responsible for EMS on the federal level, but maybe I am wrong. Maybe the DOT just has these standards that they set and print, but in reality they mean nothing and that all real EMS providers should ignore them. If thats what you were looking for.

 

[ZombieEMT]

Everything I have read says consider assisting ventilation if respirations are below 8 or greater than 30 and signs of inadequate oxygenation are present. I do not recall ever hearing it was the standard to bag pts breathing more than 30 times a minute.

I do not know if this was a typo but it seems as if you are contradicting yourself. First sentance states you have read that you do assisst over 30 but second states you have never heard of doing so. Also, I do not kow if you read my earlier posts, but I am not suggesting we bag just to bag but rather bag when needed. I am not going to force a bag on someone that does not need it. Its not like I like to bag a patient or make them uncomfortable, but if need be done, its done.

 

[Aidey]

I do not know if this was a typo but it seems as if you are contradicting yourself. First sentance states you have read that you do assisst over 30 but second states you have never heard of doing so. Also, I do not kow if you read my earlier posts, but I am not suggesting we bag just to bag but rather bag when needed. I am not going to force a bag on someone that does not need it. Its not like I like to bag a patient or make them uncomfortable, but if need be done, its done.

I did not contradict myself. I said I had read one should CONSIDER assisting ventilation when there are indications of inadequate gas exchange and respirations are below 8 or above 30. What I have never heard is anything declaring it is a standard to use a BVM on anyone with respirations over 30. It is an option if indicated, not a standard. It also is not indicated in the scenario posted in the OP.

 

[usalsfyre]

So maybe the epi statement was off, and do not get the wrong idea because its not something I would do. However, I have heard stories of epi being used to treat respiratory ending positive when not an allergic reaction. Someting that might seem like an allergic might not actually be an allergic reaction, does that mean that the epi is completely ineffective? Right or wrong, but the epi is treating problems the body is having and not removing an allergen from the body? Is that not why we still transport after epi has been administered.

You have to have a somewhat firm differential before you start tossing medications around. If your patient is SOB due to cardiac issues and you administer epi, you have just made your patients day a lot worse. Not like "the hospital can fix it" worse, like DWPA (Death With Paramedic Assistance) malpractice bad. So epi, like many meds, is life saving when used correctly, deadly when not.

As for the BVM, I do not feel that I am wrong there. Again, there is a standard of care. How they feel compared to how they actually are is something that we have to considered.

Yep....but not how your thinking. I have not, in ten years and countless patient contacts, seen a respiratory patient who felt fine but was about to die. All of the really sick ones looked and felt...like they were about to die. Maybe this patient exist, but they're in such a small minority that you can't base practice around it. Converesely, I've seen a whole crapload of patients who felt like they were going to die, but they were actually of low acuity/not that bad when a good assesment was performed. Still needed treatment, but not the full court press.

I have multiple times bagged a patient in severe respiratory distress and done so successfully.

Define successfully. Asynchronous breaths where the patient is uncomfortable and fighting is not, in my mind, success.

You base your input on what? Have you tried more than once to bag a conscious patient? Have you tried at all or just went with what other people tell you..

Yep, once or twice . I base my input on the fact that it a)didn't work all that well b)increased the patient's anxiety c)PPV has other kinds of badness associated with it.

Talk to your patient, convince them its best, if they really need it.

Uhhhh, it's not best usually. Outside of the ridiculous EMT-Basic assertion, you won't find anyone that says bagging a patient who is otherwise meeting their ventilatory requirement on their own needs a BVM.

Do you frequently attempt to bag or just always go straight to NRB and ignore the standard.

Very few of my patients get suplemental O2 at all (THE HORROR!!!:blink. When they do get it, it's because I belive they have a hypoxic hypoxia, which is just about the only thing supplemental O2 actually helps with. Oxygen is not a magic gas that cures all ills.

There are standards for a reason.

MAST, Cadilac ambulances, demand valves, intracardiac and high dose epi and bicarb every 5 minutes were the standard at one time too. They were all wrong.

You want to bust on me

Not busting on you, trying to educate you that a great deal of the EMT-Basic curriculum is flat out wrong.

but if you havent really tried more than once, you dont really know.

I've tried many times. I've got a good experince base as both a medic and a basic to base this on. What your saying is not good for 90% of patients.

 

[abckidsmom]

I think we just got trolled. Well, I hope we just got trolled...

I just read that post out loud to my husband. Holy cow, I'm with you...I hope we got trolled, cause if not...

 

[MrBrown]

From a BLS perspective, Do Not Withhold Oxygen For Any Reason (just like you were trained). From a BLS level of training, a RR of 44 and HR of 150 of course requires high flow oxygen.

Yes of course it does, lets shove 15 litres of oxygen down his gob with a non-rebreathing mask!!

You do know that oxygen has proven to be harmful in certain groups of patients given their physiologic response to it right?

Stop doing what your poorly written textbook tells you, it's wrong.

 

[IAems]

Please Clarify

You do know that oxygen has proven to be harmful in certain groups of patients given their physiologic response to it right?

Stop doing what your poorly written textbook tells you, it's wrong.

I am more than open to education. Please, Cite some EMS specifc studies or sources and I would be more than happy to read them. And please don't cite the recent UCLA studies on O2 Therapy on pediatric patients as I have both read it and feel that that study pertains more to pediatric patients, which this patient is not. Like I said, "I am admitting ignorance in this one, short of minor vasoconstriction, an immediate diagnosis of pulmonary fibrosis (not in this patient's history), or a chronic history of COPD (not in this patient's history, and even if it was, the hypoxic drive will generally take longer than 30 minutes to be effected), what would be the detrimental effects of high flow O2 on this patient?" I guess more specifically, what, in this particular scenario, is the contraindication of O2 Therapy? Because the multiple complaints (SOB, Tachycardia, Tachypnea, and Anaphylaxis) can all be improved by O2 Therapy and are each individually indicative of O2 Treatment. And again, "an EMT-B can monitor how a patient responds to an intervention and adjust treatment accordingly".

 

[usalsfyre]

Please, Cite some EMS specifc studies or sources..

I'm on the run, so I can't look them up the studies refered to right now, but why must they be "EMS specific"? Do medications (including O2) somehow work differently outside the confines of the hospital?

 

[IAems]

Definitive vs. Pre-hospital

Definitive care is, by its very nature, different from pre-hospital care. We do not treat for long term, we stabilize patients to the best of our ability in an effort to get patients to definitive care. Most of the cautionary tales of hyperoxygenation and withholding O2 come from the definitive care setting (RN's, MD's, PA's, and NP's not educated in the pre-hospital field). And YES, I completely agree that for a definitive / long-term care patient, hyperoxygenation is a very bad thing. However, in a pre-hospital care setting, where, theoretically, the time spent with patient should be limited to a few hours at worst, it should not be a consideration, especially in a heavily urbanized area where a hospital is always a few miles away.

 

[usalsfyre]

Definitive care is, by its very nature, different from pre-hospital care.

Here is where I fundamentally disagree with you. Medicine is medicine, no matter if it's practiced on an ambulance, in an ICU, at an LTC or in a tent. Trying to say otherwise is making excuses.

We do not treat for long term, we stabilize patients to the best of our ability in an effort to get patients to definitive care. Most of the cautionary tales of hyperoxygenation and withholding O2 come from the definitive care setting (RN's, MD's, PA's, and NP's not educated in the pre-hospital field).

You do realize things you do initally on a call may have effects days and weeks later right?

And YES, I completely agree that for a definitive / long-term care patient, hyperoxygenation is a very bad thing. However, in a pre-hospital care setting, where, theoretically, the time spent with patient should be limited to a few hours at worst, it should not be a consideration, especially in a heavily urbanized area where a hospital is always a few miles away.

What your saying is "I know it's not good, but I'm not confident enough in my assesments to withhold oxygen and I'm relying on my short contact with the patient to prevent harm". A few hours CAN do bad thing. There's no reason for superphysiologic levels of oxygen for 99.99% of patients. Doing so, even in the short term, can cause harm. Why not perform better assesments so you don't have to risk harm?

 

[Aidey]

The body was designed to homeostase under certain parameters. Why screw with those parameters if you don't have to? The ambulance and what we do in it does not exist out of the space-time continuum. If hyper-oxygenation is a bad thing in a hospital, or nusing home, it is a bad thing in an ambulance. What we do will affect the patient, and there is absolutely no point in doing something that is not indicated.

 

[crazycajun]

2 hour onset time.

PT stated onset of SOB at the time of using wipes. PT stated it had gotten worse 2 hours later. Inhaled/absorbed chemicals affect PT's differently. I have seen onset immediate that was minor from chlorine exposure w/ SOB, sweats. PT rapidly deteriorated 3.5 hours later and went full cardiac arrest. Think of some chemical reactions like snake venom. The longer the toxin goes untreated the worse it gets.

 

[18G]

When are EMS instructors going to stop teaching EMT-B students that oxygen is harmless!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Oxygen in high concentrations HAS BEEN FOUND TO BE HARMFUL IN MI, CVA, NEONATAL RESUSCITATION, AND ROSC. The research is out there, GOOGLE IT.

Oxygen therapy is a BLS skill area... learn to do it appropriately.

And no, a resp rate alone is not a sole reason to "bag" someone especially if the cause (ie anxiety) is expected to only be transient and quickly improved. I have found pulse oximeter's to have an overall high degree of accuracy and are accurate more times than not.

 

[IAems]

Again, please clarify

What your saying is "I know it's not good, but I'm not confident enough in my assesments to withhold oxygen and I'm relying on my short contact with the patient to prevent harm". A few hours CAN do bad thing. There's no reason for superphysiologic levels of oxygen for 99.99% of patients. Doing so, even in the short term, can cause harm. Why not perform better assesments so you don't have to risk harm?

Becuase I knew someone would so this, I did google it. Let me illustrate how to cite a scientific quote. Refer to: http://docs.google.com/viewer?a=v&q=cache:GZ7jcY8rinUJ:medind.nic.in/jac/t03/i3/jact03i3p234.pdf+Patel,+Dharmeshkumar+N%3B+Goel,+Ashish%3B+Agarwal,+SB%3B+Garg,+Praveenkumar%3B+Lakhani,+Krishna+K+%282003&hl=en&gl=us&pid=bl&srcid=ADGEESi0EspwNsX6RYofhkF28qziMiq4_GQLiSJ_L8giNKUbmXR5JwEglxw85da4jusKiKrA8Kh-KRYiJBI6jk5KNjLzfV-fL7rNt7HVw6BdxKAJS_8rEGbVMox_HsN62D4xccNm_88h&sig=AHIEtbTBrTJwCOW9B1OzmfKWkXUDKWv4pQ

Specifically, please refer to the "Clinical Features" subsection which states, "100% oxygen can be tolerated at sea level for about 24 - 48 hours without any serious tissue damage. There is mild carinal irritation on deep inspiration after 3 - 6 hours of exposure of 2 ATA oxygen . . . [however] in the majority of patients, these symptoms subside 4 hours after cessation of exposure."

When my EMS instructor and preceptor explained the merit of oxygen therapy, it was done so with scientific reasoning, which, though I have asked for, I have not seen despite reading multiple threads on this and other sites regarding this topic. I am very confident in my assessment, and I am not going to withhold a therapy mandated by my local protocols, my Medical Director, and my medical knowledge which is further enforced by both the AAOS and Brady Pre-Hospital Care texts as well as the aforementioned study, unless someone here cites some sort of scientific evidence that suggests I do so. Please, if you know something I don't, let me in on it. However, if you do not, don't espouse the benefits of withholding therapies if you can't support your decision to do so.

 

[Handsome Rob]

Google it!!!

When are EMS instructors going to stop teaching EMT-B students that oxygen is harmless!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Oxygen in high concentrations HAS BEEN FOUND TO BE HARMFUL IN MI, CVA, NEONATAL RESUSCITATION, AND ROSC. The research is out there, GOOGLE IT.

Oxygen therapy is a BLS skill area... learn to do it appropriately.

And no, a resp rate alone is not a sole reason to "bag" someone especially if the cause (ie anxiety) is expected to only be transient and quickly improved. I have found pulse oximeter's to have an overall high degree of accuracy and are accurate more times than not.

I'm more than a little concerned that all of the paramedics here are nay-saying what is taught and telling the basics to move away from instructive texts, which I'm absolutley fine with WHEN YOU TELL THEM WHY!

"Google It" tells me one of two things: you either do not know what you are talking about and trying to be cool like the rest of the people who are saying whatever, or you are too lazy to take the time to instruct your junior healthcare providers and have no business on an 'educational' forum.

 

[18G]

I'm more than a little concerned that all of the paramedics here are nay-saying what is taught and telling the basics to move away from instructive texts, which I'm absolutley fine with WHEN YOU TELL THEM WHY!

"Google It" tells me one of two things: you either do not know what you are talking about and trying to be cool like the rest of the people who are saying whatever, or you are too lazy to take the time to instruct your junior healthcare providers and have no business on an 'educational' forum.

Actually... the reason I didn't spell out the research was because it has already been stated numerous times before on the forum AND I was in the middle of doing something else which didn't permit me to type a long reply with the research.

I don't always have someone hand feed me the information... I look it up for myself so I suggest you do the same.

I'll at least give you a head start on your research:

- CVA: AHA recommends mild-moderate CVA patients receive only room air. Evidence suggests better outcomes than when these patients receive oxygen.

- MI: Research dating back to the 1950's and recently validated in the 2000's show worsened myocardial ischemia, decreased cardiac output, narrowing of the coronary vessels, and no benefit with oxygen administration. Most MI patients are oxygenating just fine systemically. Oxygen administration has been proven to NOT increase oxygen delivery or reduce tissue death on the other side of the coronary occulsion.

- Neonatal Resuscitation: The NRP program guidelines were changed to reflect neonatal resuscitation to initially begin with room air only. This is something Europe has been doing forever. The US has been about the only one who insisted on using oxygen. Research shows decreased time to first breath, first cry, and overall better outcomes.

- ROSC: Oxidative damage as a result of the re-perfusion sends cells to their ultimate death and not restoration as you would think. Research here is ongoing but much evidence suggests minimal O2 titrated to saturation above 94%.

PA protocols specifically address the new evidence regarding oxygen administration and state to TITRATE OXYGEN ADMINISTRATION to patient needs. It is defined as an SpO2 above 94% and NOT high-flow.

Under neonatal resuscitation protocol it is also further broken down. A neonate does not present with an SpO2 in the typical normal range. If you check their saturation immediately after birth you will see 60% range, 70% range, etc until their body transitions to the extrauterine circulation.

The reason the SpO2 is broken down is so providers do not administer oxygen unnecessarily to these babies because of the negative effects and that it serves no purpose.

I have also read research that found COPD patients should have their oxygen saturation titrated to right around their baseline and not 100%. And no... this has nothing to do with that hypoxic drive myth either.

I spend prob half my time validating what I have been taught. I have even had a ED physician (also a Medical Command physician) along with an RN give me :censored::censored::censored::censored: because I requested orders for captopril (which we carry) in a obvious CHF patient. I asked the doc why I was denied and all he could say was, "generally patients are only on ACE inhibitors for long term use and we don't give them emergently"... I was quite taken back by this response. We carry captopril and evidence suggest much better outcome with early ACE inhibitor use. And not to mention many EMS systems and hospital ED's give early ACE inhibitors for CHF. They also claimed that no other medic had ever requested orders for captopril.

You need to take the lead and find out for yourself. Don't play follow the leader and believe everything your textbook says. It's unfortunate the textbook still teaches what it does about oxygen.

 

[18G]

Oh, and really the only reason EMT textbooks are saying 100% for everyone is because the curriculum does not adequately teach Basics how to assess a patients oxygenation status. So it's a empirical blanket treatment with no evidence to support it.

 

[usalsfyre]

I'm more than a little concerned that all of the paramedics here are nay-saying what is taught and telling the basics to move away from instructive texts, which I'm absolutley fine with WHEN YOU TELL THEM WHY!

"Google It" tells me one of two things: you either do not know what you are talking about and trying to be cool like the rest of the people who are saying whatever, or you are too lazy to take the time to instruct your junior healthcare providers and have no business on an 'educational' forum.

Did it ever occur to you that in telling you to look up the answer, you might learn and retain the information more readily than having it spoon-fed to you?

I'm well versed on the hows and whys. I got that way through my own research. Perhaps you should try the same.

 

[Aidey]

Did it ever occur to you that in telling you to look up the answer, you might learn and retain the information more readily than having it spoon-fed to you?

I'm well versed on the hows and whys. I got that way through my own research. Perhaps you should try the same.

+1

There is immense value is doing your own research.

 

[usalsfyre]

Becuase I knew someone would so this, I did google it. Let me illustrate how to cite a scientific quote. Refer to: http://docs.google.com/viewer?a=v&q=cache:GZ7jcY8rinUJ:medind.nic.in/jac/t03/i3/jact03i3p234.pdf+Patel,+Dharmeshkumar+N%3B+Goel,+Ashish%3B+Agarwal,+SB%3B+Garg,+Praveenkumar%3B+Lakhani,+Krishna+K+%282003&hl=en&gl=us&pid=bl&srcid=ADGEESi0EspwNsX6RYofhkF28qziMiq4_GQLiSJ_L8giNKUbmXR5JwEglxw85da4jusKiKrA8Kh-KRYiJBI6jk5KNjLzfV-fL7rNt7HVw6BdxKAJS_8rEGbVMox_HsN62D4xccNm_88h&sig=AHIEtbTBrTJwCOW9B1OzmfKWkXUDKWv4pQ

Specifically, please refer to the "Clinical Features" subsection which states, "100% oxygen can be tolerated at sea level for about 24 - 48 hours without any serious tissue damage. There is mild carinal irritation on deep inspiration after 3 - 6 hours of exposure of 2 ATA oxygen . . . [however] in the majority of patients, these symptoms subside 4 hours after cessation of exposure."

When my EMS instructor and preceptor explained the merit of oxygen therapy, it was done so with scientific reasoning, which, though I have asked for, I have not seen despite reading multiple threads on this and other sites regarding this topic. I am very confident in my assessment, and I am not going to withhold a therapy mandated by my local protocols, my Medical Director, and my medical knowledge which is further enforced by both the AAOS and Brady Pre-Hospital Care texts as well as the aforementioned study, unless someone here cites some sort of scientific evidence that suggests I do so. Please, if you know something I don't, let me in on it. However, if you do not, don't espouse the benefits of withholding therapies if you can't support your decision to do so.

I had an extensive response typed out, articles cited, the AHA referenced multiple times...it somehow got erased. I will simply say the info is readily available, on this forum, as I type this. Search for "oxygen and CVA", "Oxygen and MI", ect. What you cited isn't a study, it's a review article. That's six years old (which can be an eternity in medicine). It's also one which was seemingly picked to support your position (the definition of confirmation bias). You can't only pick the stuff you like, you've got to search out the stuff that disagrees with you too, then compare the two for relevance.

Every single set of protocols I have read has something about "clincal judgement" in them. Your protocols are built around the lowest common denominator. So ask yourself, are you that guy? Do you need to follow protocols to the letter because you can't rise above them? I firmly believe most people on this forum are actively trying to better themselves and are not some of the booger eaters I've worked with that needed extremely restrictive protocols.

Two last points. Be very, very careful trusting the "scientific reasoning" of other EMS providers. Many of them don't have the basic science background to form the type of reasoned arguments that won't be cut down in 30 seconds by anyone who knows better. Among other EMS providers their arguments may fly, but get them around nurses, RTs and physicians and it becomes obvious they have no idea what their talking about. Secondly (and lastly) stop reading EMT-Basic text. Their worthless beyond EMT-Basic class. Seek out chemistry, A&P, nursing and physician level text if you want to learn about medicine.