Pulse ox and upgrading

[Carlos Danger]

Indeed it is, but the tool by itself isn't worth much. Clinical correlation and watching trend data is what's helping. I'm going to get very, very busy if I see a patient who isn't doing well and whose SpO2 trend is declining. If my patient has an SpO2 in the mid-high 80's, and that's stable, along with good mentation (and not lethargic), I'm going to not be too worried. The patient has likely adapted to the situation.

People always say things like that when the conversation turns to pulse oximetry, and I don't really understand why.

An Sp02 of 85% is abnormal and is in fact indicative of a potentially life-threatening pathology. Sure, there may be some patients with long-standing disease for whom a low Sp02 is "normal" and they tolerate it well, but generally speaking, a low Sp02 should raise your hackles the same way a low blood pressure or a very high heart rate or an altered mental status does.

 

[Brandon O]

An Sp02 of 85% is abnormal and is in fact indicative of a potentially life-threatening pathology. Sure, there may be some patients with long-standing disease for whom a low Sp02 is "normal" and they tolerate it well, but generally speaking, a low Sp02 should raise your hackles the same way a low blood pressure or a very high heart rate or an altered mental status does.

You guys aren't disagreeing. A sat of 85% is abnormal. The question is whether it's a chronic and tolerated issue or an acute and decompensated one. (Occasional it could be acute but tolerated, but that's unusual, particularly the more extreme the abnormality.)

I think you'd both say that with a sat of 85%, you'd be very wary and investigate the patient's oxygenation status, but if everything else seemed normal you'd warily hand them off for another provider to work up and worry about in the long term.

 

[Ewok Jerky]

The question posed by the OP is whether this warrants an ALS upgrade or code 3 return.

Of course it's hypothetical and the decision will depend on a lot of the circumstances and the patient presentation. But for me, no, a n abnormal SpO2 by itself does not warrant either, especially because my nasal cannula is just as good as an ALS one.

if my patient is in acute distress, now I need to consider transport time vs response time of closest ALS unit. I have no problem tea sporting an ALS complaint if I will get them to the hospital quicker...and still alive. And I will use code 3 if I suspect imminent life threat like pneumo, MI, pulmonary edema (unless I have cpap), etc.

 

[cprted]

Not sure what your point is. Are you saying that BLS should not transport code 3 (only rarely, rarely, rarely) but rather wait for ALS if they think a patient is crumping?

There are very few patients out there that saving that extra 30 seconds - 2 minutes by transporting code 3 will actually have an impact. That goes for ALS or BLS.

 

[Ewok Jerky]

There are very few patients out there that saving that extra 30 seconds - 2 minutes by transporting code 3 will actually have an impact. That goes for ALS or BLS.

I agree with you when you consider short transport times. I am a firm believer in safe driving. But sometimes I really cannot justify bringing in a "big sick" patient Code 2 ie. Septic shock, stroke, maybe SOB or diff breathing etc.

My point was that if I have a time sensitive patient on my hands, I will transport Code 3 BLS if I can get there faster than an ALS intercept.

 

[Akulahawk]

You guys aren't disagreeing. A sat of 85% is abnormal. The question is whether it's a chronic and tolerated issue or an acute and decompensated one. (Occasional it could be acute but tolerated, but that's unusual, particularly the more extreme the abnormality.)

I think you'd both say that with a sat of 85%, you'd be very wary and investigate the patient's oxygenation status, but if everything else seemed normal you'd warily hand them off for another provider to work up and worry about in the long term.

Bingo!

What would make me very worried and suspicious about my equipment at the same time would be the rare acutely low but tolerated reading. Another way to think about this is if you're a pilot and you feel something's off with the airplane, you're not going to disregard your instruments and warning light panel. You're going to cross-check your instruments and warning lights. After you've done that, you'll have a better idea of what's wrong. Then you can develop a plan to deal with the problem. Same idea with doing patient assessments. I'm going to cross-check my equipment readings with my assessment findings. If one of those equipment pieces is giving me an abnormal reading that's not correlating with the other stuff, I'm going to troubleshoot the equipment and do it quickly. Sometimes the equipment is faulty, sometimes it's a harbinger of bad stuff to come...

We really aren't disagreeing... it's just that if you're not doing the "cross-checking" that we call clinical correlation, you could very potentially be putting yourself or others in danger by emergently running a patient in to the ED for care when such speedy travel isn't necessary, all because you're fixated on a number.

When do I upgrade to Code 3/Emergent transport? When I need to get my patient to the hospital with minimal delay because any delay could be detrimental to the patient. I very rarely upgrade...

 

[Handsome Robb]

Bingo!

What would make me very worried and suspicious about my equipment at the same time would be the rare acutely low but tolerated reading. Another way to think about this is if you're a pilot and you feel something's off with the airplane, you're not going to disregard your instruments and warning light panel. You're going to cross-check your instruments and warning lights. After you've done that, you'll have a better idea of what's wrong. Then you can develop a plan to deal with the problem. Same idea with doing patient assessments. I'm going to cross-check my equipment readings with my assessment findings. If one of those equipment pieces is giving me an abnormal reading that's not correlating with the other stuff, I'm going to troubleshoot the equipment and do it quickly. Sometimes the equipment is faulty, sometimes it's a harbinger of bad stuff to come...

We really aren't disagreeing... it's just that if you're not doing the "cross-checking" that we call clinical correlation, you could very potentially be putting yourself or others in danger by emergently running a patient in to the ED for care when such speedy travel isn't necessary, all because you're fixated on a number.

When do I upgrade to Code 3/Emergent transport? When I need to get my patient to the hospital with minimal delay because any delay could be detrimental to the patient. I very rarely upgrade...

This.

 

[Jason]

Back again ...
It seems many people have good thoughts and that this is a button pusher topic. And that many people seems to have similar thoughts about Pt care.
Maybe I was a bit strong in my 2 cents early. However, I still believe it's not a good standard of care for the critical patient or for anesthesia. I work in departments and staff with anesthesia and we use capnography to assist our evaluation of the Pt.
I also agree with some people, in that ... I rarely go CODE 3 to the hospital.
Pulse Ox, like other pieces of equipment, it's just a piece of the puzzle (or slice of the pie) that makes up the patient as a whole.

 

[Chewy20]

I guess I can see why people have issues with going L&S's with a PT, but on the other hand, if you are driving like you normally would without them and not trying to ricky bobby other cars there should not be that much of an issue. Yes there is bone head drivers, but if you are driving normally all the L&S's should do is let people know youre coming so they can try and traverse over to the right. I see where accidents can take place i.e. bombing into the other lane to pass cars that are having a hard time moving over, or people trying to get through a intersection to fast. This is all my opinion, but if the PT meets my protocols for code three then that's how they will be getting to the hospital.

And to the OP, use the pulseox to go along with your assessment. If the pulseox is around what you think it should be, then investigate more if found abnormal. They give us tools for a reason, granted pulseox can be invalid due to numerous things, it is usually a good indicator if what you have found matches the number.

 

[Carlos Danger]

Back again ...
It seems many people have good thoughts and that this is a button pusher topic. And that many people seems to have similar thoughts about Pt care.
Maybe I was a bit strong in my 2 cents early. However, I still believe it's not a good standard of care for the critical patient or for anesthesia. I work in departments and staff with anesthesia and we use capnography to assist our evaluation of the Pt.
I also agree with some people, in that ... I rarely go CODE 3 to the hospital.
Pulse Ox, like other pieces of equipment, it's just a piece of the puzzle (or slice of the pie) that makes up the patient as a whole.

You can believe what you want of course, but know that your opinion is at odds with the standards published by the American Society of Anesthesiologists, American Association of Nurse Anesthetists, and International Anesthesia Research Society, and probably others. The ASA has a large closed claims database that shows that a very large percentage of claims are found due to inadequate monitoring.....and continuous pulse oximetry is actually the only monitor that is considered absolutely mandatory for the entire course of every anesthetic procedure, whether MAC, general, or regional.

Of course you are aware that clinical signs of hypoxemia are not consistently evident until the Sp02 drops to at least 80%, at which point you are right on the steepest part of the oxyhemoglobin dissociation curve where things can go downhill very quickly. Also, you understand that capnography and pulse oximetry measure different things and that you can have profound hypoxemia with a normal capnograph, especially in the setting of a poorly perfused patient with an A-a gradient and impaired hypoxic pulmonary vasoconstriction, which all general anesthetics induce.

 

[Handsome Robb]

What are your protocols for code 3 transport?

Mine says ***paraphrased**** 'paramedic's discretion if the gain outweighs the risk'.

You could be driving the speed limit and being very cautious but all it takes at an intersection is one car that's missed and misses you and you just probably killed your partner and the patient.

Last time I caught my partner opposing with me in the back I told them to shut down after we cleared the intersection.

 

[Brandon O]

You can believe what you want of course, but know that your opinion is at odds with the standards published by the American Society of Anesthesiologists, American Association of Nurse Anesthetists, and International Anesthesia Research Society, and probably others. The ASA has a large closed claims database that shows that a very large percentage of claims are found due to inadequate monitoring.....and continuous pulse oximetry is actually the only monitor that is considered absolutely mandatory for the entire course of every anesthetic procedure, whether MAC, general, or regional.

For what it's worth, I'm not sure whether the anesthesia world is an appropriate comparison when it comes to prehospital assessment. Different environment, goals, and patients.

 

[Brandon O]

I have always felt, by the way, that getting the patient to faster relief of pain, nausea, or other symptoms is a perfectly good reason for judicious lights and sirens. But I'm not sure if y'all medics can fully sympathize with that.

 

[Handsome Robb]

I have always felt, by the way, that getting the patient to faster relief of pain, nausea, or other symptoms is a perfectly good reason for judicious lights and sirens. But I'm not sure if y'all medics can fully sympathize with that.

So you, your partner's, your patient's and everyone else who're on the road lives are less important than symptom relief in a single person? I highly doubt taking the nauseous patient emergent is going to do anything besides make them more nauseous. Same goes for that patient with a painful injury or any pain for that matter.

Emergent transportation, except in long drives or severe traffic save literally seconds. Maybe a minute or two tops.

Sorry, not trying to be a **** but I adamantly disagree with you and that's not just the medic in me talking.

 

[cprted]

I have always felt, by the way, that getting the patient to faster relief of pain, nausea, or other symptoms is a perfectly good reason for judicious lights and sirens. But I'm not sure if y'all medics can fully sympathize with that.

That's a terrible reason to go Code 3. I get where you're coming from, but it just isn't good risk/reward.

There are so many other areas where you can speed up a call to get a patient the treatments they need faster. Cutting down on scene times, efficient extrication, reducing chute times ... these are all things that will save way more time than lights and sirens ever will.

 

[Brandon O]

This is one of those situations where it really behooves people to understand that one EMS system is not like the next. I have saved many, many minutes on some of my transports with lights and sirens, and I would not be doing it if it couldn't be done safely. (That's not to say that it always saves time, or that it's absolutely always safe; I remember occasions when I accidentally took a lane or something and immediately realized there wasn't visibility and it was a Bad Idea to stay there. But that's exactly the kind of recognition that allows it to be safe in general. Use your noodle.)

I am also someone who will put on their hazards and drive at 2 MPH in the slow lane if that better serves the patient. Judgment is needed. I'm a big believer in keeping my butt alive, and there are people who don't have the ability to drive safely no matter how they do it, but using too broad a brush is a disservice here.

 

[Carlos Danger]

For what it's worth, I'm not sure whether the anesthesia world is an appropriate comparison when it comes to prehospital assessment. Different environment, goals, and patients.

I was responding specifically to the statement that pulse oximetry is not "the standard of care" in anesthesia or critical care. It absolutely is, and for good reason.

 

[Jason]

I was responding specifically to the statement that pulse oximetry is not "the standard of care" in anesthesia or critical care. It absolutely is, and for good reason.

Remi - You bring up excellent points. Valid and true. Maybe I worded some things wrongly. And I admit I might be jaded about the Pulse Ox in the field. Pulse Ox with good wave form is a good tool, not stand alone. I've gotten tired of too many First Responders telling me that the patient is ok, the Pulse Ox is 98% ... and can blatantly see the Patient struggling to breath. As for anesthesia, Pulse Ox is used, with a waveform, and in conjunction with capnography (two tools making assessment better than one). Many of the field Pulse Ox devices used on scene in my area are numeric only, waveform Pulse Ox is only on the Cardiac Monitor. So, in turn, I get people telling me how fine the Patient is and not having any urgency to give appropriate care.
I'm still a believer in basic assessment tools, my eyes, ears, ... My "toys" on the truck just add information to the puzzle that make each Patient.

 

[Chewy20]

What are your protocols for code 3 transport?

Mine says ***paraphrased**** 'paramedic's discretion if the gain outweighs the risk'.

You could be driving the speed limit and being very cautious but all it takes at an intersection is one car that's missed and misses you and you just probably killed your partner and the patient.

Last time I caught my partner opposing with me in the back I told them to shut down after we cleared the intersection.

Maybe I should have said in heavy traffic, both cities I have been in would take about 30 minutes to go two miles for the majority of the day if it were not for lights and sirens. You may get mad at your partner for going through an intersection, but if you come to a red light at an intersection and STOP, eventually people will stop after seeing you from all other 3 streets and then it would be safe to proceed at a slow speed. I don't know who your partners are but it sounds like you have been thrown around in the back of the box a lot and don't trust their driving. If the pt is stable (like most are) than no they may not be going into the ER with sirens blaring, but I have zero problem with going through a city or highway with them on.

 

[vcuemt]

Maybe I should have said in heavy traffic, both cities I have been in would take about 30 minutes to go two miles for the majority of the day if it were not for lights and sirens. You may get mad at your partner for going through an intersection, but if you come to a red light at an intersection and STOP, eventually people will stop after seeing you from all other 3 streets and then it would be safe to proceed at a slow speed. I don't know who your partners are but it sounds like you have been thrown around in the back of the box a lot and don't trust their driving. If the pt is stable (like most are) than no they may not be going into the ER with sirens blaring, but I have zero problem with going through a city or highway with them on.

"Let's head on out... lights and sirens, nice and easy," is how I've heard that before.