Would you look at that! A study talking about harmful affects of hyperoxia.

[Veneficus]

If anything, the internet has made me cynical and despairing about "research" which is the reporting of an interesting hint some real research needs to be done on.

The biggest factor I think is poorly controlled (other than skewed/incomplete reporting/data) is the fact that the more desperately sick someone is, the more measures get thrown at them; since their outcomes are going to be worse, the measures get a skewed reportage of poor outcomes. A case can be made (and has been in the lay press) that being admitted to the ICU increases your chances of not leaving the hospital alive....OF COURSE.

I think what is causing you so much concern, as it does me, is making sweeping and simplified conclusions on clinical data.

Of all the studies I deal with, clinical studies are probably the most dfficult to really make definate conclusions out of.

For example, this topic.

We know from labratory models that clinical conditions like ARDS and pulmonary fibrosis are multifactorial. Attributing a specific outcome in an emergency setting to a specific intervention in my mind is a fools errand. The study will always be flawed and the conclusions will always highly suspect.

The argument is that clinical studies are required in an emergency setting. But I am not sure I agree with that. With so many variables unaccounted for in a dynamic system, often with multiple simultaneous treatments, it amounts to little more than guessing or the inability to correlate. I am of the mind that any useful studies are going to have to be performed in lab or highly controlled clinical environments and extrapolated to the emergency field. I acknowledge that it is an extremely slow process and at times exceedingly boring.

Otherwise when you look at an outcome, and then claim in a limited population, what you are saying is "we guess right sometimes."

As KB points out in his critique of the oxygen causing major harm study, and I fully agree with, there is no way that high flow oxygen has such a profound effect in such a short period. Particularly when I saw nothing of the severity of the disease process, comorbidities, simultaneous treatments or pathology reports.

The most damning flaw for the conclusion was that oxygen administered by EMS caused death in the ICU, but the ED was permitted any treatment. That is a big unaccounted for variable.

Like I siad though, this is going to be par for the course when you try to answer "what" without "why" or "how."

 

[Rialaigh]

Well, that's the conclusion of "Effect of high flow oxygen on mortality .." Austin et al. found an absolute 5% increase in in-hospital mortality (or a 42% relative) after COPD patients received high-flow oxygen during the pre-hospital phase.

As I said, I find this result out-sized and implausible, but it's out there.

Not sure how everything was controlled for but I would say that patients that are receiving high flow oxygen in the EMS phase are likely sicker patients. Sicker prior to receiving oxygen or EMS arrival. This is a perfect example of causation verse correlation....

 

[Alyzabeth]

I don't thin too much O2 for a 15 minute ride's gonna hurt anyone.

 

[Veneficus]

I don't thin too much O2 for a 15 minute ride's gonna hurt anyone.

Based on what?

 

[mycrofft]

I'll leave that sidebar for a moment since I sort of got it started...

Simplistcism...everything has to have a diagnosis, preferably no more than three words (when a hyphen is used, like Smith-Jone Disease).

As I've said before, when you start peeling the onion too far, you waste time and onions.

I like the concept of a "syndrome". Cancer used to be a diagnosis, now it's a syndrome (multiple tissue types, multiple causative pathways). Same for diabetes. AIDS still is despite the primary causative agent having been identified, and rightly so, because although HIV is the ringleader, the rest of the syndrome's manifestors are not necessarily even congeners with the primary infection; HIV is pretty clear cut, AIDS can have all sorts of twists and turns depending upon opportunistic infections and sites.

So, someone has SOB, regularly irregular and weak pulse, chest pain, prostration...hospital needs to know what to treat? Versus what does the tech need to know to get the pt back to definitive care? Tech doesn't need to know every diddle and jot, but that you do THIS to make the pt stop doing THAT and get in safe and dry; and if THIS #1 fails to work, you go for THIS #2. That way you avoid target fixation. It doesn't HAVE to be cookbooky, but just enough to meet the training and equipage.

 

[Veneficus]

I'll leave that sidebar for a moment since I sort of got it started...

Simplistcism...everything has to have a diagnosis, preferably no more than three words (when a hyphen is used, like Smith-Jone Disease).

As I've said before, when you start peeling the onion too far, you waste time and onions.

I like the concept of a "syndrome". Cancer used to be a diagnosis, now it's a syndrome (multiple tissue types, multiple causative pathways). Same for diabetes. AIDS still is despite the primary causative agent having been identified, and rightly so, because although HIV is the ringleader, the rest of the syndrome's manifestors are not necessarily even congeners with the primary infection; HIV is pretty clear cut, AIDS can have all sorts of twists and turns depending upon opportunistic infections and sites.

So, someone has SOB, regularly irregular and weak pulse, chest pain, prostration...hospital needs to know what to treat? Versus what does the tech need to know to get the pt back to definitive care? Tech doesn't need to know every diddle and jot, but that you do THIS to make the pt stop doing THAT and get in safe and dry; and if THIS #1 fails to work, you go for THIS #2. That way you avoid target fixation. It doesn't HAVE to be cookbooky, but just enough to meet the training and equipage.

This is where I think the great disconnect is.

We currently live in the age of disease as defined by biochemistry and molecular biology. All of those little nit-picky bits are what leads to the treatment that brings not only the most symptomatic releif the fastest, but also effectively controls the disease process the best.

That changes everything from morbidity and mortality to days in the hospital, quality of life, etc.

Also in this age, we see more exacerbations of chronic disease than we see acute onset. (most of the acute onset of yesterday is now understood to be chronic subclinical)

The idea of US EMS was to train some simple tech skills for common emergencies that could help without requiring a bunch of knowledge or diagnostics.

It works ok. But as demonstrated in other nations, by adding the knowledgable provider with decison making capacity, better and cheaper results are the outcome. Along with a more efficent system. As we are also seeing in other first world nations, even in limited cases, putting the doctor back into the field is making a positive difference as well.

Until the US gets away from the quick tech provider mentality for EMS, it will continue to promote a less effective and economically inefficent system.

I use the example of the EM specialty. Both my friends and detractors who are EMs universally agree, the main benefit of an EM is proper dispostion. They even have studies demonstrating how well they do this.

But when you look at the treatment modalities, they are very similar to paramedics. (obviously there are a few more advanced skills and treatments, but relatively less used or needed)

So what inhibits moving the EM to the ambulance so they can dispo these patients to the best place without the need or cost of the ED?

Some will say lack of physicians, but you could change that in a year. Just add residency spots.

What really is the reason is the reimbursement for service. Financial interest holds the whole system back.

 

[mycrofft]

The US has trouble finding enough educated smart young people because societally we sell and espouse hedonism even before the time/age we can get a credit card. Black kids deride and bully their better-performing peers by telling them to "stop acting so white". My favorite sound bite of 2003: when asked what she wanted to to be someday, a high school (caucasian) senior said "I want to be hot!". :sad: Students who do want more do not take the hard courses, sometimes they can't even find them.

We have people who want to move up the ladder from the field to PA or MD or an allied professional (radiologist, lab director) but there is a heavy thick glass ceiling of grades and money.

Well, let's kick it up a notch.

1. Take that "nit-picky" knowledge, find out from the receiving hospitals what they need field techs to do and then train the techs, write protocols, and review them every five years. Take it away from NHTSA or populate their framework with MD's, top to bottom. (Has this already been done?).

2. Scholarships for generalist and primary care, family care, emergency MD's etc., but only IF they stay with it for at least five years. Then they can go to LA and become a liposuction king or whatever.

3. Starting when they are in elementary school, begin inculcating kids with a sense of personal worth beyond sex appeal; to defer gratification; to make plans and see them pay off. And STOP pandering to anti- scientists.

 

[Clipper1]

Based on what?

Can you assure all EMTs and Paramedics that withholding oxygen from someone with declining cardiac statuus and poor tissue perfusion will not be harmed? Not all patients will be obvious and not all patients with an SpO2 > than 94% with be hyperoxygenated.

Until the studies, which most are done on patients requiring many different pharmaceutical interventions and advanced ventilatory/oxygenation techniques over more than 24 hours, are conclusive it it really good to advise someone to go again their protocols? What will they use to defend themselves to the physician at the ER or their medical director? Veneficus an annoymous EMT or Paramedic on EMTlife told them not to give oxygen.

When the patients are mentioned as being on high flow in the studies, they in a hosptial and a NRB is not considered to be high flow. When disputed in the literature, several researchers have had their work invalidated by misuse of terms and assumptions made about the actual oxygen delivery of what is essentially a low flow device.

 

[Clipper1]

What really is the reason is the reimbursement for service. Financial interest holds the whole system back.

Do you work for free? Hospitals and ambulances can not exist giving their services away for free. Higher labor costs are also a a factor. People want to get paid. EMTs with only a little over 100 hours of training are expecting the same pay as someone with several years of education and experience in health care. If you as an EMT or Paramedic would like to be paid well, why shouldn't others also be paid. Technology and advanced services come with a hefty price tag.

As for the quick service of an ambulance, just how long do you want the EMTs and Paramedics to stay on scene? Doesn't that raise costs also if more EMTs and Paramedics need to be hired and more trucks so that an EMT or Paramedic can spend a couple hours on scene for every patient before transporting.

Doctors also don't want to work for free but some have had to when reimbursement was cut. Look at MediCal and a few state insurers in other places. When doctors and employees in healthcare don't get paid, the move on and leave an area or limit their practice. Do you really think they should lose their homes and families just because of your opinions about financial interests? Get a clue about how the whole health system works. You and Mycroft run this forum and argue against anyone else who has an opinion different than yours even if others have expressed more experience and knowledge.

I still encourage those who want to learn more and be part of a less one sided conversation to join other forums, many of which are closed to prevent anonymous bs and are more respectful.

 

[Veneficus]

2. Scholarships for generalist and primary care, family care, emergency MD's etc., but only IF they stay with it for at least five years. Then they can go to LA and become a liposuction king or whatever.

This has been done, it doesn't work.

The scholarships are so low it is still better to not accept them.

The other issue isthat primary care basically does nothing but add a uneeded level of care and is only open when the people who most bebefit are at work.

What is worse is that in a private pay system, the people who benefit from primary care can only actually afford to go to the doctor when they "are sick."

It is a broken system. Until the system is changed, we can only expect more of the same.

 

[Veneficus]

Ventmedic, you are really starting to bug me

Can you assure all EMTs and Paramedics that withholding oxygen from someone with declining cardiac statuus and poor tissue perfusion will not be harmed? Not all patients will be obvious and not all patients with an SpO2 > than 94% with be hyperoxygenated.

It has been covered several times here by multiple people that there is a difference between withholding a treatment and not giving a treatment that is not indicated.

You should stop trying to intitiate arguments for the sake of arguing. It doesn't make you sound smart.

Until the studies, which most are done on patients requiring many different pharmaceutical interventions and advanced ventilatory/oxygenation techniques over more than 24 hours, are conclusive it it really good to advise someone to go again their protocols?

Nobody has advised anyone to go against their protocols, you are very adept at fabrication to support your position. Nobody is fooled by it.

What will they use to defend themselves to the physician at the ER or their medical director? Veneficus an annoymous EMT or Paramedic on EMTlife told them not to give oxygen.

I appreciate your demoting me to EMT now, very clever. Despite my ability to change my screen name and my educational credentials listed, I like them just fine how they are. A screenname to give present and past employers some minor level of plausible deniability for my opinions is not the same as anonymous. I am rather confident that actually posting my picture in my profile has pretty much eliminated much of my anonymity, the same cannot be said for you.

I also have never been banned from a forum for my misbehavior before.

When the patients are mentioned as being on high flow in the studies, they in a hosptial and a NRB is not considered to be high flow. When disputed in the literature, several researchers have had their work invalidated by misuse of terms and assumptions made about the actual oxygen delivery of what is essentially a low flow device.

What has this got to do with anything discussed here? Oxygen free radical formation in any environment known to man has been estabilshed. Just because some studies made erroneous assumptions does not change basic chemical reactions just because they happen in a body instead of a lab.

Do you work for free? Hospitals and ambulances can not exist giving their services away for free. Higher labor costs are also a a factor. People want to get paid. EMTs with only a little over 100 hours of training are expecting the same pay as someone with several years of education and experience in health care. If you as an EMT or Paramedic would like to be paid well, why shouldn't others also be paid. Technology and advanced services come with a hefty price tag.

Again I appreciate the attempted insult, but I will qualify that there is a difference between being paid and being paid disproportionately because of overhead from price gouging.

Charging disproportionately high amounts of money for anything is generally referred to as greed, and the desire to be greedy does not change the moral implications.

As for the quick service of an ambulance, just how long do you want the EMTs and Paramedics to stay on scene? Doesn't that raise costs also if more EMTs and Paramedics need to be hired and more trucks so that an EMT or Paramedic can spend a couple hours on scene for every patient before transporting.

Do you think so little of people here that they do not see the difference in operations between a physician based ambulance and a transport only EMS system?

I am not sure if you are being purposefully disingenious or just simple-minded.

Doctors also don't want to work for free but some have had to when reimbursement was cut. Look at MediCal and a few state insurers in other places. When doctors and employees in healthcare don't get paid, the move on and leave an area or limit their practice. Do you really think they should lose their homes and families just because of your opinions about financial interests?

The things that cause financial probelms for doctors are much more complex than reimbursement rates. Like the loan payments and malpractice insurance rates. There are also other difficulties in attracting patients. People who seek medical attention generally want it soon, lke going to McDonalds. Not having in house lab, radiology, or other diagnostics causes patients to seek places that do. Purchasing these items for private practice has also become prohibitive. Perhaps if you were a physician you would understand better?

Get a clue about how the whole health system works. You and Mycroft run this forum and argue against anyone else who has an opinion different than yours even if others have expressed more experience and knowledge..

If you are referring to yourself, while you may have lots of the same experience, I find your knowledge suspect and your insight lacking. Nobody runs this forum as you may believe other than the mods. If you do not understand forums, generally people who have been around a while contribute disproportionately more than newer people. I have not encountered one forum that doesn't work this way.

Isn't the point of academic discussion to argue your opinion?

If you are referring to others, I am open to divergent opinions, but I will not accept them blindly. I may also decide to disagree.

As many here can attest, sometime I ask questions so I can see the thought process behind the written opinion.

I still encourage those who want to learn more and be part of a less one sided conversation to join other forums, many of which are closed to prevent anonymous bs and are more respectful.

I hear flightweb is good, never been there myself.

I signed up for 2 physician only forums, but they are all business, and nonshop talk is discouraged. As is posting Memes and other such pictures. Very sophisticated though.

But alas, i am disinclined to argue anymore schitzophrenic posts of inciteful, strawmen, and fabricated arguments.

I shall add this personality to the ignore list which is exclusive to you. I can only hope the moderators will take a tougher stance against you in the future. I would suggested banning your whole ISP.

Good luck tech.

 

[Clipper1]

But alas, i am disinclined to argue anymore schitzophrenic posts of inciteful, strawmen, and fabricated arguments.

You seem to avoid answering direct questions with responses like this.

I signed up for 2 physician only forums, but they are all business, and nonshop talk is discouraged. As is posting Memes and other such pictures. Very sophisticated though.

Which physician only forums are you on? Are you a Medical Doctor?

Have you been on the U of Washington forum?

 

[mycrofft]

Do you work for free? Hospitals and ambulances can not exist giving their services away for free.

Have you seen the rates of compensation hospital administrators get? How much all that impressive landscaping so many hospitals have costs to install and keep up? The cost of any item marketed and bought as "medical"? That large medical consortiums are investing in real estate and other venues? (At least they are around here, and that specifically includes some "non-profits").

 

[KellyBracket]

Have you seen the rates of compensation hospital administrators get? How much all that impressive landscaping so many hospitals have costs to install and keep up? The cost of any item marketed and bought as "medical"? That large medical consortiums are investing in real estate and other venues? (At least they are around here, and that specifically includes some "non-profits").

I take it you read the article in Time?

It's ironic - at a time when hospitals in CT are looking at a huge drop in revenue from the state (used to compensate for uninsured care), we're being described as hugely profitable. What a sticky subject...

Anyway, it's a long way from the relatively straight forward topic of oxygen toxicity!

 

[ShockableAsystole]

Can you assure all EMTs and Paramedics that withholding oxygen from someone with declining cardiac statuus and poor tissue perfusion will not be harmed? Not all patients will be obvious and not all patients with an SpO2 > than 94% with be hyperoxygenated.

But adequate EMS education means not all patients need to be obvious. No, most patients > 94% SpO2 aren't hyperoxygenated. That's the point, it takes some clinical decision making. Haemodynamically unstable patients with subtle signs is when you should be utilizing someone with the knowledge and skills to decide oxygen will be needed. Guidelines allow for that. 94% SpO2 is a guideline to aid decision making. But, it's guideance, not protocol.

Until the studies, which most are done on patients requiring many different pharmaceutical interventions and advanced ventilatory/oxygenation techniques over more than 24 hours, are conclusive it it really good to advise someone to go again their protocols? What will they use to defend themselves to the physician at the ER or their medical director? Veneficus an annoymous EMT or Paramedic on EMTlife told them not to give oxygen.

Perhaps then, you should fight for greater autonomy as a health care professional. Wait, this still means more education. I should be clear, it probably isn't the education that limits this, its the system itself. But education we can change.

I don't want to sound like a stuck record but perhaps a quick scan of this may shed light on this issue? At least on what evidence there is and quality of the evidence. Its a good few years out of date but there are a number of revisions to keep up with new evidence as it comes out; all saying similar things.

 

[Meursault]

conclusive it it really good to advise someone to go again their protocols?

"Conclusive" is an easy goalpost to move.

The larger issue here, and it's not specific to this thread, is that I can't think of an instance when posters here have advised members to disregard their protocols. There are a lot of discussions that point out that existing protocols are harmful and/or inadequate, and a lot of discussions about the uselessness of inflexible recipes for treatment, but that's not the same thing.

Knowing that there are risks doesn't mean that "nothing is true, everything is permitted". It's every provider's responsibility to determine how they apply protocol to reality; to my knowledge, no state has produced a set of protocols for treating every possible person who makes contact with EMS. Are you arguing that the good of the patient shouldn't be a factor in that decision, or that providers should actively blind themselves to potential problems in order to simplify the task of finding the nearest match among their recipe cards? You're also ignoring that protocols are created things, and they are changeable; we should have the strongest reasons to want better protocols.

In any case, my experience with my coworkers and even the userbase here leads me to believe that a lot of people are willing to do things they know to be risky or harmful in order to avoid deviating from explicit instructions. I just can't stand seeing them lie about it.

 

[Clipper1]

I don't want to sound like a stuck record but perhaps a quick scan of this may shed light on this issue? At least on what evidence there is and quality of the evidence. Its a good few years out of date but there are a number of revisions to keep up with new evidence as it comes out; all saying similar things.

Thank you for that link. The US also has a similar organization with the ATS.


This appears on your link on the first page in the Emergency section.

For critically ill patients, high concentration
oxygen should be administered immediately
(table 1 and fig 1) and this should be recorded
afterwards in the patient’s health record.

I do like the way it states high concentration rather than high flow.

The next section is

Oxygen should be prescribed to achieve a target
saturation of 94–98% for most acutely ill
patients or 88–92% for those at risk of
hypercapnic respiratory failure

In the British literature that is not much written about NIV as rescue which was one of the failing of the "prehospital oxygen and associated mortality article". But also note it says hypercapnic respiratory failure and not just CO2 retainer. On the other hand, respiratory failure from fatique when trying to maintaining one's oxygenation level is also a factor and should be consider. When you are dealing with acutely ill patients, there really is not a one protocol to fit all situations as some seem to want.

The Thorax article does a decent job of describing several situations including a Pulse Oximeter may not give the picture and blood work is still needed.

However, the only give 24 - 28% to a COPD patient may not be appropriate for all acute situations. COPD might be only the underlying and exacerbated by an acute disease process requiring more oxygen. There are also many COPD patients who are on much higher concentrations in home care and long term situations. Sometimes it is a cardiac issue or pulmonary hypertension which has dictated oxygen for the long term rather than the dx of COPD. Some patients also have multiple conditions which determine the best course. I will restate again there is not just one protocol to fit all and you should see that from just reading the Thorax article.

Are you arguing that the good of the patient shouldn't be a factor in that decision, or that providers should actively blind themselves to potential problems in order to simplify the task of finding the nearest match among their recipe cards? You're also ignoring that protocols are created things, and they are changeable; we should have the strongest reasons to want better protocols.

On this forum it appears you have many very young EMTs who are probably around 18 y/o who have just finished a 3 month EMT class. When someone who has numerous posts and some defend him since he claims to be a doctor, some might take that to heart and even influence their care but without the education or critical thinking skills to back up their decision except for this forum. Some may not know the risks they are assuming in providing patient care and their medical directors have written protocols which are generic but can be applied to most situations for a short time. If you laid out all the protocols for EMTs and Paramedics, you will see a similarity in them which gets the provider through most situations. Given the educational standards in the US protocols must be written carefully even if they seem over simplified to some in other countries or in more progressive agencies such as here in Washington. But then there is the difference in the amount of education given to the provider.

My main point is that some information taken here should be discussed with one's own medical director or FTO before trying it on a patient. Some of the stuff stated on these anonymous forums is exactly how urban legends and mistruths get started in EMS.

 

[Clipper1]

Have you seen the rates of compensation hospital administrators get? How much all that impressive landscaping so many hospitals have costs to install and keep up? The cost of any item marketed and bought as "medical"? That large medical consortiums are investing in real estate and other venues? (At least they are around here, and that specifically includes some "non-profits").

This sounds more like disgruntled bar talk.

The compensation most hospital administrators get is not nearly enough for all the head aches.

If hospitals look like dumps, they will have a difficult time attracting patients who can pay their bill.

You need to understand the term non-profit. It does not mean the employees work for free. Health care is a business.

 

[mycrofft]

I apologize for taking this off track.

And into an "EMT LIFE BLACK HOLE"

 

[Veneficus]

"Conclusive" is an easy goalpost to move.

The larger issue here, and it's not specific to this thread, is that I can't think of an instance when posters here have advised members to disregard their protocols. There are a lot of discussions that point out that existing protocols are harmful and/or inadequate, and a lot of discussions about the uselessness of inflexible recipes for treatment, but that's not the same thing.

Knowing that there are risks doesn't mean that "nothing is true, everything is permitted". It's every provider's responsibility to determine how they apply protocol to reality; to my knowledge, no state has produced a set of protocols for treating every possible person who makes contact with EMS. Are you arguing that the good of the patient shouldn't be a factor in that decision, or that providers should actively blind themselves to potential problems in order to simplify the task of finding the nearest match among their recipe cards? You're also ignoring that protocols are created things, and they are changeable; we should have the strongest reasons to want better protocols.

In any case, my experience with my coworkers and even the userbase here leads me to believe that a lot of people are willing to do things they know to be risky or harmful in order to avoid deviating from explicit instructions. I just can't stand seeing them lie about it.

:nosoupfortroll: