# Skills Final



## pargir (May 15, 2013)

I am at SJCC and just passed my EMT written final. Now I have the skills final on Thursday. The ones I am worried about is the medical and trauma scenerios and what they will throw at us. Any advice?


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## DesertMedic66 (May 15, 2013)

Memorize the NREMT skill sheets


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## teedubbyaw (May 15, 2013)

Biggest mistake I see is people rushing. I can't remember the time on those, 10-15 minutes? Either way, you have a copious amount of time. Take a deep breath and take your time. 

Don't forget your ABC's


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## DesertMedic66 (May 15, 2013)

teedubbyaw said:


> Biggest mistake I see is people rushing. I can't remember the time on those, 10-15 minutes? Either way, you have a copious amount of time. Take a deep breath and take your time.
> 
> Don't forget your ABC's



You get 10 minutes for trauma assessment and 10 minutes for backboarding. I think for medical it's 10-15 minutes.


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## nwhitney (May 15, 2013)

Medical is 15 minutes and I agree with slowing down and taking your time. Of course don't go so slow that you run out of time.  Remember that you can't move down the skill sheet till you fix your life threats. Also everyone gets O2 (talking testing here not real life) via the appropriate means whether it be BVM or NRB. Good luck


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## hogwiley (May 15, 2013)

Some common things I've seen. 

Memorize the skill sheets, which should have been obvious by now.

Remember to address any problems that pop up with ABCs instantly. They tell you someone is bleeding then control it, someones airway is compromised, address it. Dont move on until you know the problem is either fixed, or as good as you can make it for the moment. You can probably ask the proctor if it fixed the problem. Maybe they'll just say yes, or maybe theyll just describe what the result is and you have to figure out if its fixed. 

Remember if a patient has altered mental status to check their BGL. You get dispatched to a drunk patient or someone having a stroke, check their BGL. A patient having seizures, check their BGL, even if the cause seems obvious and nothing to do with BGL, its not going to hurt to say youd check it and ask what it is.


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## DesertMedic66 (May 15, 2013)

hogwiley said:


> Some common things I've seen.
> 
> Memorize the skill sheets, which should have been obvious by now.
> 
> ...



Not all basics are able to check BGL.


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## Jim37F (May 15, 2013)

hogwiley said:


> Some common things I've seen.
> 
> Memorize the skill sheets, which should have been obvious by now.
> 
> ...



All patients with an Altered Mental Status get oxygen, at least that's what I was taught for skills testing.


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## Mariemt (May 15, 2013)

I didn't put oxygen on my patients during all my skills during testing. One of mine was a cardiac patient for medical. I was evaluating and then asked the evaluator for o2 level. They stated it was 94%. I then stated I considered o2 but am not going to give o2 at this time but will continuously monitor level. 

All you have to do is consider it and talk through it. I did apply o2 for my shock patient.  I did not for my trauma. Etc in our state we titrate our o2. Each station I asked for a sat level and went from there


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## hogwiley (May 15, 2013)

Mariemt said:


> I didn't put oxygen on my patients during all my skills during testing. One of mine was a cardiac patient for medical. I was evaluating and then asked the evaluator for o2 level. They stated it was 94%. I then stated I considered o2 but am not going to give o2 at this time but will continuously monitor level.
> 
> All you have to do is consider it and talk through it. I did apply o2 for my shock patient.  I did not for my trauma. Etc in our state we titrate our o2. Each station I asked for a sat level and went from there



I would always give o2 for testing purposes, especially on a cardiac patient. I suppose if you knew the person testing yous thoughts on the matter you could hold off, but otherwise give them o2 for chest pain. As someone pointed out to me some basics cant check glucose, which is right, and some Basics cant check spo2 either.

I would still mention that I would consider the possibility of hypoglycemia in an altered mental status patient, and would state I would check BGL if my protocols allowed, because if that patient scenario is someone who is hypoglycemic and you never mentioned it, I think you would fail. Someone else mentioned to give o2 for altered mental status, but I assumed that went without mentioning, and youd still consider hypoglycemia and check for it if able.


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## AtlasFlyer (May 15, 2013)

The first practice practical session during my class that we practiced medical assessments I failed MISERABLY! I rushed, got flustered and forgot EVERYTHING.

For me, the key to passing medical & trauma assessments during the practical (which I passed on the first try) was to SLOW DOWN. You have 10 minutes to run down the list. Memorize the list, know it IN ORDER. As you're doing your assessments, just go down the lists. Slowly, methodically, logically. Stop and think a moment if you need to. At one point in my medical assessment I stopped and paused for a good 15 seconds, just thinking, going over the sheets in my head, then methodically continued. 

10 minutes is a long time. Slow down, take your time, think through it.


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## Mariemt (May 16, 2013)

hogwiley said:


> I would always give o2 for testing purposes, especially on a cardiac patient. I suppose if you knew the person testing yous thoughts on the matter you could hold off, but otherwise give them o2 for chest pain. As someone pointed out to me some basics cant check glucose, which is right, and some Basics cant check spo2 either.
> 
> I would still mention that I would consider the possibility of hypoglycemia in an altered mental status patient, and would state I would check BGL if my protocols allowed, because if that patient scenario is someone who is hypoglycemic and you never mentioned it, I think you would fail. Someone else mentioned to give o2 for altered mental status, but I assumed that went without mentioning, and youd still consider hypoglycemia and check for it if able.


Giving o2 to a cardiac patient with spo2 of 94 and above is a no no. O2 is not good for everyone .
I did not know any of my evaluators. However I passed all 7 of my stations first try..
Since bgl is a local protocol,  unlikely they will run into testing on that. 
You do not have to give everyone o2, just mention it.


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## hogwiley (May 16, 2013)

Mariemt said:


> Giving o2 to a cardiac patient with spo2 of 94 and above is a no no. O2 is not good for everyone .
> I did not know any of my evaluators. However I passed all 7 of my stations first try..
> Since bgl is a local protocol,  unlikely they will run into testing on that.
> You do not have to give everyone o2, just mention it.



Why is it a big no no? Where did you hear this? I understand o2 is not the answer to everything, but for testing purposes at the EMT level the rule of thumb is everyone gets o2. 

If you explain WHY you wouldnt give o2 you would probably be ok. But I dont think Ive heard of anyone failing because they gave o2, or even too much o2. People DO fail because they didnt give someone o2. If they are a COPDer maybe its a gray area that would require you to explain why you are dialing back the o2, but for chest pain not giving them o2 if they are sating below a certain level sounds more like a local protocol than something youd do on a NREMT exam. 

Hypoglycemia is a scenario Ive seen at NREMT skill stations, so dont know where you got the notion it wouldnt be on a medical assessment station, are you in a state that uses the NREMT? Would you still pass if you never addressed the hypoglycemia? Probably not in most cases( managing the patient as a competent EMT being critical criteria). If you ask the person testing what the patients blood sugar is, they will either give you a number, or they will say you dont know or cant test. If you cant do a BGL check then I guess you treat them if they are symptomatic, dont meet any contraindications, and there is a reason to suspect it.


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## chaz90 (May 16, 2013)

hogwiley said:


> Why is it a big no no? Where did you hear this? I understand o2 is not the answer to everything, but for testing purposes at the EMT level the rule of thumb is everyone gets o2.
> 
> If you explain WHY you wouldnt give o2 you would probably be ok. But I dont think Ive heard of anyone failing because they gave o2, or even too much o2. People DO fail because they didnt give someone o2. If they are a COPDer maybe its a gray area that would require you to explain why you are dialing back the o2, but for chest pain not giving them o2 if they are sating below a certain level sounds more like a local protocol than something youd do on a NREMT exam.



I think she's referring more to real life than for NREMT testing purposes. Yes, we all know the skill proctors seem to want everyone on 15 LPM by NRB, but in reality current research is leading us away from routine oxygen administration, particularly in ACS or stroke patients. Also, we should really, really move away from jabbering on about the hypoxic drive in COPD patients.


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## Mariemt (May 16, 2013)

hogwiley said:


> Why is it a big no no? Where did you hear this? I understand o2 is not the answer to everything, but for testing purposes at the EMT level the rule of thumb is everyone gets o2.
> 
> If you explain WHY you wouldnt give o2 you would probably be ok. But I dont think Ive heard of anyone failing because they gave o2, or even too much o2. People DO fail because they didnt give someone o2. If they are a COPDer maybe its a gray area that would require you to explain why you are dialing back the o2, but for chest pain not giving them o2 if they are sating below a certain level sounds more like a local protocol than something youd do on a NREMT exam.
> 
> Hypoglycemia is a scenario Ive seen at NREMT skill stations, so dont know where you got the notion it wouldnt be on a medical assessment station, are you in a state that uses the NREMT? Would you still pass if you never addressed the hypoglycemia? Probably not in most cases( managing the patient as a competent EMT being critical criteria). If you ask the person testing what the patients blood sugar is, they will either give you a number, or they will say you dont know or cant test. If you cant do a BGL check then I guess you treat them if they are symptomatic, dont meet any contraindications, and there is a reason to suspect it.


Checking blood glucose has more recently been taken out of the EMT curriculum. If the patient seems to have a diabetic issue, give them glucose they say. It is now a local protocol , my service does bgl. 
One thing a lot of people don't always realize is the skills stations are set up more for state.  My niece recently took her nremt and had 5 stations, I had 7. She had hers in a different state than I.  
As for not putting o2 on a cardiac patient with oxygen  >94. This is now  a national registry skill and should have trickled down through the curriculum even though the books have not been reprinted thus far. It is worth asking the instructor about. 
Yes I am in a national registry state. I have also become an evaluator. .O2 is to be considered . The candidate does not have to use o2 in all circumstances.


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## Mariemt (May 16, 2013)

chaz90 said:


> I think she's referring more to real life than for NREMT testing purposes. Yes, we all know the skill proctors seem to want everyone on 15 LPM by NRB, but in reality current research is leading us away from routine oxygen administration, particularly in ACS or stroke patients. Also, we should really, really move away from jabbering on about the hypoxic drive in COPD patients.


 lol you know how many COPD patients I've seen on O2 at night that never mysteriously quit breathing?


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## Mariemt (May 16, 2013)

hogwiley said:


> Why is it a big no no? Where did you hear this? I understand o2 is not the answer to everything, but for testing purposes at the EMT level the rule of thumb is everyone gets o2.
> 
> If you explain WHY you wouldnt give o2 you would probably be ok. But I dont think Ive heard of anyone failing because they gave o2, or even too much o2. People DO fail because they didnt give someone o2. If they are a COPDer maybe its a gray area that would require you to explain why you are dialing back the o2, but for chest pain not giving them o2 if they are sating below a certain level sounds more like a local protocol than something youd do on a NREMT exam.
> 
> Hypoglycemia is a scenario Ive seen at NREMT skill stations, so dont know where you got the notion it wouldnt be on a medical assessment station, are you in a state that uses the eNREMT? Would you still pass if you never addressed the hypoglycemia? Probably not in most cases( managing the patient as a competent EMT being critical criteria). If you ask the person testing what the patients blood sugar is, they will either give you a number, or they will say you dont know or cant test. If you cant do a BGL check then I guess you treat them if they are symptomatic, dont meet any contraindications, and there is a reason to suspect it.


This is the nremt page itself explaining the new aha guidelines.  It does mention o2 with cardiac.  Changes took place in 2012 

https://www.nremt.org/nremt/about/2010_aha_guidelines.asp


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## gw812 (May 16, 2013)

To the OP - verbalize EVERYTHING - say it as you do it. Forces you to slow up. Every time you rush you fail. I bombed my dynamic cardio because of it - nervous so I started doing things too fast and missed rhythms.. Second time I recited the sheet. Got it. It helps.


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## Sandog (May 16, 2013)

Mariemt said:


> I didn't put oxygen on my patients during all my skills during testing. One of mine was a cardiac patient for medical. I was evaluating and then asked the evaluator for o2 level. They stated it was 94%. I then stated I considered o2 but am not going to give o2 at this time but will continuously monitor level.
> 
> All you have to do is consider it and talk through it. I did apply o2 for my shock patient.  I did not for my trauma. Etc in our state we titrate our o2. Each station I asked for a sat level and went from there



What state is this? Pulse Ox is not always reliable.


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## Handsome Robb (May 16, 2013)

Sandog said:


> What state is this? Pulse Ox is not always reliable.



While true. It's not always unreliable either. People make it seem like pulse oximeters are always wrong.


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## chaz90 (May 16, 2013)

Sandog said:


> What state is this? Pulse Ox is not always reliable.



Don't overthink the NR. For testing purposes, the SpO2 is what they say it is.


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## Mariemt (May 16, 2013)

Sandog said:


> What state is this? Pulse Ox is not always reliable.


then treat the patients symptoms. This is elementary basic EMT stuff. During testing you can ask for a pulse ox reading.


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## Sandog (May 17, 2013)

Mariemt said:


> then treat the patients symptoms. This is elementary basic EMT stuff. During testing you can ask for a pulse ox reading.



In the previous post that I quoted, you alluded that in your state, you determine your O2 therapy based on SPO2 readings. If this is the case it is a bad practice at best.
Your thinking explains why SPO2 monitoring is not in the scope of basic in many states.


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## Mariemt (May 17, 2013)

Sandog said:


> In the previous post that I quoted, you alluded that in your state, you determine your O2 therapy based on SPO2 readings. If this is the case it is a bad practice at best.
> Your thinking explains why SPO2 monitoring is not in the scope of basic in many states.



Our state (Iowa) does titrate oxygen levels based on patient need and spo2 readings.
What is bad practice is throwing o2 on every patient. O2 is a drug.


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## Mariemt (May 17, 2013)

Sandog said:


> In the previous post that I quoted, you alluded that in your state, you determine your O2 therapy based on SPO2 readings. If this is the case it is a bad practice at best.
> Your thinking explains why SPO2 monitoring is not in the scope of basic in many states.


Titrating o2 is also standard in AHA curriculum and is now in the nremt registry bank of questioning. Bad practice? Your opinion


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## Sandog (May 17, 2013)

Just my opinion perhaps. I think more harm can be done from withholding O2 due to erroneous SPO2 readings than can arise from needless administration of O2.  



> Although pulse oximeters are nearly ubiquitous in health care, some users may question which patients should be monitored, and how often. Unless clinicians both understand and follow established guidelines, pulse oximetry can be misused or overused, further straining resources.3, 4





> Several studies show that there's a knowledge deficit about pulse oximetry among medical and nursing staff.5-7 In one study, researchers administered a 17-question survey on pulse oximetry to 442 nurses, physicians, and respiratory therapists; the respondents' mean score was just 66%.6 Another study of 50 nursing and medical staff found "an alarming deficit" in their understanding of pulse oximetry.7



http://www.nursingcenter.com/lnc/CE...906000-00037&Journal_ID=54030&Issue_ID=863636


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## Mariemt (May 17, 2013)

Sandog said:


> Just my opinion perhaps. I think more harm can be done from withholding O2 due to erroneous SPO2 readings than can arise from needless administration of O2.
> 
> 
> 
> ...


Read my last post carefully... base on patient NEED and spo2 reading. 
If your pulse ox is reading 99 but your patient is cyanotic, let's rethink this.

There are many, many studies out there supporting o2 titration.  It is now being taught in all classes, EMR and above. Too much o2 can be just as dangerous as not enough, but you can't tell if you're giving too much, only not enough. 
 You have signs of low o2. Dusky nails etc. 
I can put all sorts of links supporting this, but I already did for the one that applied to the thread. I link the nremt site.
You can argue this one until you are blue in the face, I will give you o2 then. . 
We put a pulse ox on our patient, but also assess their lips, nails etc etc. .
The pulse ox is a tool,  a tool in our assessment, not a diagnosis.  Its reading is considered with o2 therapy. 
To say titrating o2 is bad practice is irresponsible of you. To put o2, a drug on all patients is equally irresponsible.


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## hogwiley (May 18, 2013)

Mariemt said:


> Titrating o2 is also standard in AHA curriculum and is now in the nremt registry bank of questioning. Bad practice? Your opinion



It was explained to me by a medical director that the potentially harmful effects of giving o2, or too much o2 prehospital when its not really needed usually pale in comparison to the effects of even mild hypoxia, and a pre hospital environment is such that its not always possible to continuously ensure the person isn't suffering from hypoxia. 

I understand its kind of taken as a badge of sophistication among EMS personnel to complain about excessive o2 administration, and SOME of the people doing the complaining may even have some understanding of the physiological processes that underpin these arguments. I suspect most probably don't, and some of these people can possibly do more harm than good by withholding o2.

If some systems don't trust EMTs to check blood sugar, why would they trust them to titrate o2 administration on patients experiencing a medical emergency, based on possibly unreliable spo2 readings?


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## chaz90 (May 18, 2013)

hogwiley said:


> If some systems don't trust EMTs to check blood sugar, why would they trust them to titrate o2 administration on patients experiencing a medical emergency, based on possibly unreliable spo2 readings?



Poor practices and policies in one area doesn't justify ignorance in another. As mentioned previously in this thread, oxygen is not withheld just due to SpO2 values. Pulse oximetry is a tool that, when correlated with clinical findings, allows us to judiciously administer O2 to those who need it. Slapping oxygen on every patient you transport because "Hey, hypoxia is bad and sometimes patients are hypoxic" is as bad as giving 4 mg of Zofran to every patient because sometimes people are nauseous. Changing research and culture that teaches us previously held beliefs about the complete safety and benefits of O2 are wrong leads to changes in medicine.


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## Mariemt (May 18, 2013)

hogwiley said:


> It was explained to me by a medical director that the potentially harmful effects of giving o2, or too much o2 prehospital when its not really needed usually pale in comparison to the effects of even mild hypoxia, and a pre hospital environment is such that its not always possible to continuously ensure the person isn't suffering from hypoxia.
> 
> I understand its kind of taken as a badge of sophistication among EMS personnel to complain about excessive o2 administration, and SOME of the people doing the complaining may even have some understanding of the physiological processes that underpin these arguments. I suspect most probably don't, and some of these people can possibly do more harm than good by withholding o2.
> 
> If some systems don't trust EMTs to check blood sugar, why would they trust them to titrate o2 administration on patients experiencing a medical emergency, based on possibly unreliable spo2 readings?


you also didn't read where I stated spo2 is tool. It is not just a badge of sophistication, the state wants to know why o2 is being used. State is looking at use of o2. O2 is over used and can be harmful. Your spo2 looks normal but the patient's nails look dusky?  Use o2. O2 titration is now in the nremt testing and skills. There is a reason for this argument .


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## Mariemt (May 18, 2013)

hogwiley said:


> It was explained to me by a medical director that the potentially harmful effects of giving o2, or too much o2 prehospital when its not really needed usually pale in comparison to the effects of even mild hypoxia, and a pre hospital environment is such that its not always possible to continuously ensure the person isn't suffering from hypoxia.
> 
> I understand its kind of taken as a badge of sophistication among EMS personnel to complain about excessive o2 administration, and SOME of the people doing the complaining may even have some understanding of the physiological processes that underpin these arguments. I suspect most probably don't, and some of these people can possibly do more harm than good by withholding o2.
> 
> If some systems don't trust EMTs to check blood sugar, why would they trust them to titrate o2 administration on patients experiencing a medical emergency, based on possibly unreliable spo2 readings?


 the systems don't trust EMTs to take blood sugar? Or they find it unnecessary? 
Our system we take blood sugars, a lot!  On diabetics, stroke like symptoms, all altered status... you wouldn't believe how many people presenting as strokes are hypoglycemic. 
I do know it is taught that if they altered but alert enough for glucose to go ahead and give oral glucose in systems that don't check bgl


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## Mariemt (May 18, 2013)

chaz90 said:


> Poor practices and policies in one area doesn't justify ignorance in another. As mentioned previously in this thread, oxygen is not withheld just due to SpO2 values. Pulse oximetry is a tool that, when correlated with clinical findings, allows us to judiciously administer O2 to those who need it. Slapping oxygen on every patient you transport because "Hey, hypoxia is bad and sometimes patients are hypoxic" is as bad as giving 4 mg of Zofran to every patient because sometimes people are nauseous. Changing research and culture that teaches us previously held beliefs about the complete safety and benefits of O2 are wrong leads to changes in medicine.


 I love this post.


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## hogwiley (May 19, 2013)

chaz90 said:


> Poor practices and policies in one area doesn't justify ignorance in another. As mentioned previously in this thread, oxygen is not withheld just due to SpO2 values. Pulse oximetry is a tool that, when correlated with clinical findings, allows us to judiciously administer O2 to those who need it. Slapping oxygen on every patient you transport because "Hey, hypoxia is bad and sometimes patients are hypoxic" is as bad as giving 4 mg of Zofran to every patient because sometimes people are nauseous. Changing research and culture that teaches us previously held beliefs about the complete safety and benefits of O2 are wrong leads to changes in medicine.



I understand and even agree with these points. I also have seen patients brought into the ER with no oxygen on or a couple liters NC, and their spo2 is checked and its like low 80s or high 70s. It can make for an ugly scene when the Paramedic or EMT then has to explain why this is the case. 

A recent example was a patient having seizures brought in. The medic was asked what her o2 was and he looked at his partner and asked....his partner says uuuh, it was like 93. Well, it wasnt 93 when they brought her in, it was 83. He was being judicious in his use of 02, meanwhile his patient is hypoxic while hes focusing on all this other stuff like starting a line etc, which is probably a good example of why so many of these crazy board certified emergency room physicians who write EMT books keep saying be generous with the o2 til you get em into the ER.


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## chaz90 (May 19, 2013)

hogwiley said:


> A recent example was a patient having seizures brought in. The medic was asked what her o2 was and he looked at his partner and asked....his partner says uuuh, it was like 93. Well, it wasnt 93 when they brought her in, it was 83. He was being judicious in his use of 02, meanwhile his patient is hypoxic while hes focusing on all this other stuff like starting a line etc, which is probably a good example of why so many of these crazy board certified emergency room physicians who write EMT books keep saying be generous with the o2 til you get em into the ER.



Was the patient truly hypoxic though? Pulse oximetry swings both ways. Don't assume high sats are accurate until evaluated, and definitely don't assume low sats truly are low until evaluated as well. I do typically put post-ictal patients on 2 LPM O2, but just because their SpO2 was showing 83% doesn't mean it truly is. If the patient was fully alert, not complaining of any SOB, had normal skin color and was complaint free, I would troubleshoot the heck out of my pulse ox before assuming they were that hypoxic. Did the patient have poor peripheral circulation? Did she have nail polish on? This could have been an error by the medic too of course, but I'm just playing Devil's advocate.


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## Mariemt (May 19, 2013)

hogwiley said:


> I understand and even agree with these points. I also have seen patients brought into the ER with no oxygen on or a couple liters NC, and their spo2 is checked and its like low 80s or high 70s. It can make for an ugly scene when the Paramedic or EMT then has to explain why this is the case.
> 
> A recent example was a patient having seizures brought in. The medic was asked what her o2 was and he looked at his partner and asked....his partner says uuuh, it was like 93. Well, it wasnt 93 when they brought her in, it was 83. He was being judicious in his use of 02, meanwhile his patient is hypoxic while hes focusing on all this other stuff like starting a line etc, which is probably a good example of why so many of these crazy board certified emergency room physicians who write EMT books keep saying be generous with the o2 til you get em into the ER.


That's not titrating o2 that's not paying attention.. sorry you have bad medics. 
Actually you will see a change in the EMT books. In 2012 changes were made to the EMT curriculum to begin titrating o2 and have affected the nremt testing and AHA guidelines as I have mentioned earlier.
Books are catching up and amendments are being made in classes to reflect it. So your crazy board certified phycisians have changed their minds, a long time ago.


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## Mariemt (May 19, 2013)

chaz90 said:


> Was the patient truly hypoxic though? Pulse oximetry swings both ways. Don't assume high sats are accurate until evaluated, and definitely don't assume low sats truly are low until evaluated as well. I do typically put post-ictal patients on 2 LPM O2, but just because their SpO2 was showing 83% doesn't mean it truly is. If the patient was fully alert, not complaining of any SOB, had normal skin color and was complaint free, I would troubleshoot the heck out of my pulse ox before assuming they were that hypoxic. Did the patient have poor peripheral circulation? Did she have nail polish on? This could have been an error by the medic too of course, but I'm just playing Devil's advocate.


 when he said one medic looked at the other and said "uh" I believed it had nothing to do with titrating o2.

M


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## hogwiley (May 19, 2013)

chaz90 said:


> Was the patient truly hypoxic though? Pulse oximetry swings both ways. Don't assume high sats are accurate until evaluated, and definitely don't assume low sats truly are low until evaluated as well. I do typically put post-ictal patients on 2 LPM O2, but just because their SpO2 was showing 83% doesn't mean it truly is. If the patient was fully alert, not complaining of any SOB, had normal skin color and was complaint free, I would troubleshoot the heck out of my pulse ox before assuming they were that hypoxic. Did the patient have poor peripheral circulation? Did she have nail polish on? This could have been an error by the medic too of course, but I'm just playing Devil's advocate.



The patient did have an altered LOC, but that could have been the case regardless of whether they were hypoxic. They didn't look well, but not flat out cyanotic. They did have nail polish on, spo2 was rechecked using the ear lobe and it was still low. 

I think part of the reluctance to do away with the liberal application of o2 is  the worry that it could then result in pressure to not give it, or a general loss of concern over the consequences of not using it when it should be used. You will have EMTs erring on the side of not giving it, and then getting distracted with other things or getting tunnel vision, as was likely the case with the example I gave.  

Really, I have no dog in the fight, if there even is a fight, I just see that there is a potential downside to discouraging the use of o2 too much.


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## Mariemt (May 19, 2013)

hogwiley said:


> The patient did have an altered LOC, but that could have been the case regardless of whether they were hypoxic. They didn't look well, but not flat out cyanotic. They did have nail polish on, spo2 was rechecked using the ear lobe and it was still low.
> 
> I think part of the reluctance to do away with the liberal application of o2 is  the worry that it could then result in pressure to not give it, or a general loss of concern over the consequences of not using it when it should be used. You will have EMTs erring on the side of not giving it, and then getting distracted with other things or getting tunnel vision, as was likely the case with the example I gave.
> 
> Really, I have no dog in the fight, if there even is a fight, I just see that there is a potential downside to discouraging the use of o2 too much.


well as with any assessment,  a patient who is unstable will likely need o2 and assessments should be done every 5 minutes or less. Checking lips, nail beds, spo2 etc should be part of every assessment whether it be 5, 10 or 15 minutes. Tunnel vision shouldn't be an excuse. The reason o2 use is being looked at is because of the damage that's being found. All of us know the dangers of o2 over use in a newborn and young infant.. the danger is in all ages .. maybe I have just been further educated in it as I run with ALS units and its been a topic of many of our continued education, but I do work a lot with our classes for EMT and it is now being taught. So I dunno. I've seen the research. I understand it and I know how to treat my patient based on my assessment,  along with the pulse ox tool provided. Not alone in itself.


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## Sandog (May 19, 2013)

Mariemt said:


> you also didn't read where I stated spo2 is tool. It is not just a badge of sophistication, the state wants to know why o2 is being used. State is looking at use of o2. O2 is over used and can be harmful. Your spo2 looks normal but the patient's nails look dusky?  Use o2. O2 titration is now in the nremt testing and skills. There is a reason for this argument .



Are you a medic, or basic? I just retook my skills testing for my 2 year recert, and we use NREMT skills guidelines for testing. Nowhere was titration even mentioned.

I may only be a basic but I have a good deal of molecular biology background to understand what O2 titration entails, sounds neat and is a good idea, but the advantages are just not justified in comparison to the rare, very rare occasion that someone is harmed by O2.

I would love to see some real data showing all this harm that O2 has done, and I mean over a large sample, not a few out of a million. Can you show that?


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## Mariemt (May 20, 2013)

Mariemt said:


> This is the nremt page itself explaining the new aha guidelines.  It does mention o2 with cardiac.  Changes took place in 2012
> 
> https://www.nremt.org/nremt/about/2010_aha_guidelines.asp


Here's the nremt page about it.


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## Handsome Robb (May 20, 2013)

That's a tall order to ask for. These patients that o2 can be harmful too generally have so many comorbidities and other variables attached to them that it's hard to isolate hyperoxygenation as the cause of their poor outcome.

Just like its tough to do a study on transport times in HEMS affecting outcomes because the crew brings so much more to the table how do you decide if their clinical knowledge and skills or the transport time is what made the difference?


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## Mariemt (May 20, 2013)

Sandog said:


> Are you a medic, or basic? I just retook my skills testing for my 2 year recert, and we use NREMT skills guidelines for testing. Nowhere was titration even mentioned.
> 
> I may only be a basic but I have a good deal of molecular biology background to understand what O2 titration entails, sounds neat and is a good idea, but the advantages are just not justified in comparison to the rare, very rare occasion that someone is harmed by O2.
> 
> I would love to see some real data showing all this harm that O2 has done, and I mean over a large sample, not a few out of a million. Can you show that?


 How many links would make you happy? 10? 20? 500? I don't think anything will. So why waste my time? I linked above where the NREMT does test and has added o2 titration for cardiac emergencies as of 2012. . Even though you haven't heard anything about it and this was for all levels in 2012. Medics were earlier.
It is now coming down to all problems especially cardiac and stroke . Don't want too much o2 on anyone. 

Now someone in shock, has cyanosis,  inadequate breathing etc. You bet I'll throw a nr on them, but most I have had great success with just a few LPM and a nasal cannula even tho that book in basic wanted 15 LPM nr on everyone


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## Sandog (May 20, 2013)

Mariemt said:


> Here's the nremt page about it.



Can you show me where in that link that it is a BLS task? From what I have read it is a ALS function.
That is why I asked if your a medic.


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## DesertMedic66 (May 20, 2013)

Well this thread has gotten a big off topic. If it is NREMT skills all you have to do to pass the skills is just remember the NREMT sheets. If the SpO2 reading is low then the patient gets O2. For NREMT it's as simple as that.


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## Sandog (May 20, 2013)

DesertEMT66 said:


> Well this thread has gotten a big off topic. If it is NREMT skills all you have to do to pass the skills is just remember the NREMT sheets. If the SpO2 reading is low then the patient gets O2. For NREMT it's as simple as that.



We always got the thread on military time to fall back on...^_^


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## DesertMedic66 (May 20, 2013)

Sandog said:


> We always got the thread on military time to fall back on...^_^



I see what you did there


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## pargir (Jun 3, 2013)

Well thanks everyone for the help. And extra info! I passed my skills final and graduated and now I have national registry tomorrow. yikes!


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## CPRinProgress (Jun 9, 2013)

Everyone keeps talking about studies showing the "negative effects of o2" but what exactly are those.  The COPD hypoxic drive argument I have heard debunked by several people who say it won't affect them unless you are going on hours long transfers.  But what other side effects are other?


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## chaz90 (Jun 9, 2013)

CPRinProgress said:


> Everyone keeps talking about studies showing the "negative effects of o2" but what exactly are those.  The COPD hypoxic drive argument I have heard debunked by several people who say it won't affect them unless you are going on hours long transfers.  But what other side effects are other?



Nothing to do with the hypoxic drive. Reperfusion injury due to hyperoxemia, free radical damage, oxidative stress, exacerbation of the inflammatory response. The list goes on and on...


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## CPRinProgress (Jun 9, 2013)

chaz90 said:


> Nothing to do with the hypoxic drive. Reperfusion injury due to hyperoxemia, free radical damage, oxidative stress, exacerbation of the inflammatory response. The list goes on and on...


Have they been shown to be caused by o2 for the 30 mins to the emergency room.


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## chaz90 (Jun 9, 2013)

It would be really hard to set up a prospective study for that kind of information. As far as I know, one has not yet been completed on outcomes during ambulance transport. Data has come out of in hospital studies for mortality and outcome, so we're trying to apply that information to our practices.


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## AnthonyM83 (Jun 12, 2013)

Come on guys...

http://www.ems1.com/columnists/mike-mcevoy/articles/1308955-Can-oxygen-hurt/

Spread this around please...


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## epikmonolith (Jun 14, 2013)

my best advice is to practice practice practice.

i practiced with my classmates and focused a lot on assessments.

you can run through everything verbally over a cup of coffee, etc.


as long as you don't miss any critical criteria you'll be good!


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## ChanelCinq (Jul 26, 2013)

Mariemt said:


> the systems don't trust EMTs to take blood sugar? Or they find it unnecessary?
> Our system we take blood sugars, a lot!  On diabetics, stroke like symptoms, all altered status... you wouldn't believe how many people presenting as strokes are hypoglycemic.
> I do know it is taught that if they altered but alert enough for glucose to go ahead and give oral glucose in systems that don't check bgl



Mariemt in CA our protocols do not allow to check BGL.  If the patient has their own BGL monitor we can ask them to use it on themselves but that's it.  I think it probably has something to do with being exposed to blood but I am not sure.


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