# NRB over NC



## Bullets (May 7, 2011)

not you regular NC v NRB question. I am at my squad and one of my fellow EMT's said he got in a discussion with another EMT and he was told that as Basics, if we put patients on a NC instead of a NRB we are making a diagnosis and thats not allowed. He says we were only taught to put on a NC if the pt couldnt tolerate the NRB. I dont have my EMT book nearby so i cant look this up, but it doesnt seem right. Thoughts, opinions?


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## JPINFV (May 7, 2011)

Bullets said:


> not you regular NC v NRB question. I am at my squad and one of my fellow EMT's said he got in a discussion with another EMT and he was told that as Basics, if we put patients on a NC instead of a NRB we are making a diagnosis and thats not allowed. He says we were only taught to put on a NC if the pt couldnt tolerate the NRB. I dont have my EMT book nearby so i cant look this up, but it doesnt seem right. Thoughts, opinions?




Thoughts?

NRB is what is taught, what is in the books, and what is on the test. EMTs are taught that they don't make diagnosis. 

Both, independent of each other, makes for terrible patient care. If you don't make a diagnosis, what exactly are you treating? 

Everyone gets a non-rebreather mask makes as much sense as everyone is transported with lights and sirens.


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## Anjel (May 7, 2011)

I in working and on my paramedic clinicals have never placed or seen a NRB.

I have placed a pt on a NC quiet a few times though.

For testing purposes yes NRB all the way. Real life... TREAT YOUR PT


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## LucidResq (May 7, 2011)

How is providing appropriate care based on the situation "making a diagnosis" or wrong? 

That is pretty much the silliest thing I've ever heard. There are many instances in which a NC is very appropriate. They make it much easier to get a good history, for example.


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## Shishkabob (May 7, 2011)

Next time someone tells you an EMT or Paramedic don't diagnose, ask them what they would call angulated bones sticking out of a leg... and if they say it's broken tell them they just diagnosed.

I sure as hell HOPE you diagnose someone with something every time you go to give a drug... otherwise you're just giving a drug blidnly which is stupid.





I can count on one hand the amount of patients I've put on an NRB in the past year... and each one ended up getting intubated.


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## Bullets (May 7, 2011)

Thats pretty much what i said. if you decide to put a patient on a NRB, isnt that a diagnosis? and the whole high flow for everyone is bad pt care. Thanks guys


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## MrBrown (May 7, 2011)

As Ambulance Officers it is required both provisional and differential diagnoses be made.

98% of people will not require oxygen, and of the 2% that those that 1.9% will require like two litres on an NC


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## Amycus (May 7, 2011)

For testing purposes, NRB on everyone.

In real life, the only ones that get it are those in SEVERE distress. Blatent hypoxia, unresponsiveness, asthma (although we can do BLS albuterol), etc. etc.

In the CAOx4 chest pain/lightheadedness/minor respiratory distress/diabetic etc, they get a NC every time.


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## Frozennoodle (May 7, 2011)

In my basic class I was taught to treat the patient, the different stages of shock, the signs of hypoxia, and how to titrate oxygen to effect.  MI? I was told to consider supplemental O2 but not to over due it if the patient was profusing because oxygen can be detrimental to some types of cardiac events and you didn't have the tools or knowledge to identify them.  I was showed the difference between situations where high flow O2 was required and where 2LPM would be a better option.  I was taught to think.  I don't understand how people can teach cookbook medicine and no one have a problem with it.  My instructors are huge on understanding pathology and A&P and constantly challenge us to think about eitologies and what physiological processes cause the symptoms we are treating.  If we have a question about the way something works they challenge us to try and figure it out on our own before explaining how it works.  These schools are trash.


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## Anjel (May 8, 2011)

Frozennoodle said:


> In my basic class I was taught to treat the patient, the different stages of shock, the signs of hypoxia, and how to titrate oxygen to effect.  MI? I was told to consider supplemental O2 but not to over due it if the patient was profusing because oxygen can be detrimental to some types of cardiac events and you didn't have the tools or knowledge to identify them.  I was showed the difference between situations where high flow O2 was required and where 2LPM would be a better option.  I was taught to think.  I don't understand how people can teach cookbook medicine and no one have a problem with it.  My instructors are huge on understanding pathology and A&P and constantly challenge us to think about eitologies and what physiological processes cause the symptoms we are treating.  If we have a question about the way something works they challenge us to try and figure it out on our own before explaining how it works.  These schools are trash.



Good post.

I want those people that are always saying "well the book says" to show me a pt that has ever presented EXACTLY like the book says. It isn't a perfect world folks.


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## DesertMedic66 (May 8, 2011)

Linuss said:


> Next time someone tells you an EMT or Paramedic don't diagnose, ask them what they would call angulated bones sticking out of a leg... and if they say it's broken tell them they just diagnosed.
> 
> I sure as hell HOPE you diagnose someone with something every time you go to give a drug... otherwise you're just giving a drug blidnly which is stupid.
> 
> ...



That's the thing I hate. We actually have to say it's a "possible open fracture". I understand not diagnosing somethings. But if it's completely odvious then we should be able to "diagnose". Had a femer fracture the other day with deformity (obviously fractured) but still had to call it in to the hospital as a "possible fracture". :glare:


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## DrParasite (May 8, 2011)

Anjel1030 said:


> I in working and on my paramedic clinicals have never placed or seen a NRB.
> 
> I have placed a pt on a NC quiet a few times though.
> 
> For testing purposes yes NRB all the way. Real life... TREAT YOUR PT


ummm, how long have you been in EMS?  6 months?  a year maybe?  Are you taking a "Zero to Hero" paramedic program?

I probably have put on more NRB's than I should have in my career.  but if you are in your paramedic clinicals, and have never ever put a patient on an NRB?  never had a bad diff breather?  never had a lady with a pulse ox of 80 (and who was turning blue)?  or an asthmatic who you gave an NRB with a Neb treatment?

If you haven't, than wow.  

BTW, the book does say NRB for everyone. I don't agree with it, but that is the standard of care for BLS (or rather, the educated standard).  and you have documentation to support it as well.  I don't agree with it, it is over kill, but that will be the standard you are both taught to and will be held to if you are asked to defend your actions.


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## usafmedic45 (May 13, 2011)

Bullets said:


> not you regular NC v NRB question. I am at my squad and one of my fellow EMT's said he got in a discussion with another EMT and he was told that as Basics, if we put patients on a NC instead of a NRB we are making a diagnosis and thats not allowed. He says we were only taught to put on a NC if the pt couldnt tolerate the NRB. I dont have my EMT book nearby so i cant look this up, but it doesnt seem right. Thoughts, opinions?



You mean beyond the fact that your fellow EMT is a :censored::censored::censored::censored:ing retard?


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## usafmedic45 (May 13, 2011)

> but that will be the standard you are both taught to and will be held to if you are asked to defend your actions.



Well, more likely they would pull out the local protocols since that's the standard you are supposed to be practicing to, not some half-baked national "standard". Just my two cents as an expert witness.  If they were going after the medical director and they had a very low quality attorney, they might try to trot that out the EMS textbook to inquire why the protocols aren't matching the aforementioned "standard".


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## systemet (May 13, 2011)

Linuss said:


> I can count on one hand the amount of patients I've put on an NRB in the past year... and each one ended up getting intubated.



And this is one of the major reasons to use a NRB.  It's a good device for providing a high FiO2, if you're preoxygenating a patient in preparation for RSI / sedation-facilitated intubation, or if you have some reason to expect they're going to suddenly become apneic.

As far as I see it, the other is in the presence of clinical signs of hypoxia when a nasal cannula is not raising the SpO2 and bringing relief.


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## Bullets (May 13, 2011)

usafmedic45 said:


> You mean beyond the fact that your fellow EMT is a :censored::censored::censored::censored:ing retard?



that's what I said, but he challenged me to prove it


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## usafmedic45 (May 13, 2011)

Bullets said:


> that's what I said, but he challenged me to prove it


That's when you respond with, "Ah, I see you believe in the scientific principle of reproducibility.  Excellent!"


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## nwhitney (May 13, 2011)

We were taught in class that everyone gets O2.  When I did my ride along I learned that while it was a lot like the text book it was also nothing like the book.  Not everyone got O2, I think of the 9 pt's we had only 3 got O2 and of those 3 only 1 got a NRB.  Even it the pt's O2 is at 100% on room air couldn't giving them O2 help or at least make them think they are getting help?  The placebo effect?


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## usafmedic45 (May 13, 2011)

> We were taught in class that everyone gets O2.



You were taught wrong.



> Even it the pt's O2 is at 100% on room air couldn't giving them O2 help or at least make them think they are getting help? The placebo effect?



Do a search about the strong negative effects of oxygen therapy and you'll see what that's not a good idea.  It's actually been documented to increase mortality in some patient populations when used in absence of clinically demonstrable hypoxia.


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## nwhitney (May 13, 2011)

usafmedic45 said:


> You were taught wrong.
> 
> 
> 
> Do a search about the strong negative effects of oxygen therapy and you'll see what that's not a good idea.  It's actually been documented to increase mortality in some patient populations when used in absence of clinically demonstrable hypoxia.



Our text book has us giving everyone O2 unless I read it wrong which may have happened.  

I've heard that O2 therapy over a period of time (not sure how lung) can have negative affects but I thought short term use (during transport) was not as a big concern.  Sounds like I got some research to do.   Thanks for the info I find respiratory therapy fascinating.


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## usafmedic45 (May 13, 2011)

> Our text book has us giving everyone O2 unless I read it wrong which may have happened.



Yeah, the book is simply outdated.



> Thanks for the info I find respiratory therapy fascinating.



That makes one of us.  LOL  After a point, it's just a job.


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## systemet (May 13, 2011)

nwhitney said:


> Even it the pt's O2 is at 100% on room air couldn't giving them O2 help or at least make them think they are getting help?  The placebo effect?



The answer to this involves a little math, and a little physiology.  It's a little beyond what's covered in an average EMT-B class.  It's something that should be covered in medic school.

Oxygen is carried in the circulation in two forms (1) bound to hemoglobin, (2) dissolved in the plasma.  We can actually calculate the amount of oxygen carried in arterial blood.  This is called the arterial oxygen content or CaO2, and is defined as:

CaO2 = (1.34 * hgb * SaO2) + (0.003 * PaO2)

Where hgb is the hemoglobin concentration in g / dL (normal male about 14-18, female 12-16), SaO2 is the saturation percentage expressed as a decimal (i.e. 100% saturation = 1.00, 98% saturation = 0.98).  The PaO2 is a measure of how much oxygen is dissolved in the plasma, as this is a dissolved gas, it's a partial pressure, measured in mmHg.  [I've omitted some of the units from this equation, but the end value for CaO2 is expressed in ml 02 per dl arterial blood).

So for the hypothetical situation of an individual who has a 100% oxygen saturation, breathing room air, we can infer that their PaO2 is going to be around 100mmHg.  We get this from the oxyhemoglobin dissociation curve, which you can see illustrated here: http://en.wikipedia.org/wiki/Oxygen–haemoglobin_dissociation_curve or better yet, in a good physiology text.  It can also be measured with an arterial blood gas.

If we assume this person is a male with a hemoglobin of 16 g/dl, we can fill in the other values, and calculate (1) the amount of oxygen carried on hemoglobin, (2) the amount of oxygen dissolved in the blood, (3) the total arterial oxygen content.

So, first, the hemoglobin bound hemoglobin

= 1.34 * hgb * SaO2 = 1.34 ml /g  * 16 g/dl * 1.00 = 21.44 ml

Then the dissolved oxygen in the plasma

= 0.003 * 100 = 0.3 ml.

For a total oxygen content of 21.74 ml, of which 98.6% is hemoglobin bound, and 1.4% is dissolved in the plasma.

So, when we look at this, the first thing we get, is, hey, the vast, vast majority of oxygen is transported as hemoglobin.  

Now, of course, our patient is breathing room air, this is diffusing across the alveoli to give us an arterial PaO2 of about 100 mmHg.  If we assume we're at sea level, ambient air pressure is about 760 mmHg.  21% of the ambient air gives a partial pressure of about 160 mmHg. This is what we're breathing in  This is getting reduced as air in the lungs gets humidified, there's a little bit of shunting -- for a whole lot of reasons this ends up as around 100 mmHg in the arterial blood.  

If we give around 100% oxygen, we end up increasing the amount of oxygen in the ambient air from 100 to 760.  And we'll end up raising the PaO2, the amount of oxygen dissolved in the plasma.  We're not going to raise it anywhere near 760 mmHg, but it's going to increase.  

But not by much.

For every 50 mmHg we are able to raise the PaO2, the oxygen content is only going to go up by 0.15 ml.  This is an increase of 0.7%.

The point, that I'm finally getting to, is that once the hemoglobin is fully saturated, increasing supplemental oxygen is going to have minimal effects on total arterial oxygen content.

The situations where this may be more relevant, would include

(1) the presence of dysfunctional hemoglobin, e.g. CO-hemoglobin, methemoglobin, where the oxygen saturation is falsely raised.

(2) When the patient is severely anemic, e.g. hemorrhagic shock, when less hemoglobin is present.  But even in this case, if the available hemoglobin is fully saturated, additional dissolved oxygen in the plasma is only going to have a small effect.


Please understand, I'm not trying to talk down to you, or be condescending. I will happily explain more, if I can.  All the best.


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## medichopeful (May 13, 2011)

nwhitney said:


> Even it the pt's O2 is at 100% on room air couldn't giving them O2 help or at least make them think they are getting help?  The placebo effect?



Via the placebo effect, possibly.  But that is something you have to be VERY careful with.

If the patient has a 100% O2 saturation and doesn't show any signs of hypoxia, what good will giving them oxygen do?  Oxygen isn't a wonder drug! (Penicillin has that honor )

Remember at sea level, air is only made up of approximately 20-21% O2.  If you give the patient more than this (which is what you're doing in most if not all cases of oxygen therapy), that's not something the body is used to.


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## medichopeful (May 13, 2011)

nwhitney said:


> Our text book has us giving everyone O2 unless I read it wrong which may have happened.



You didn't.  Sadly :sad:



> I've heard that O2 therapy over a period of time (not sure how lung) can have negative affects but I thought short term use (during transport) was not as a big concern.  Sounds like I got some research to do.   Thanks for the info I find respiratory therapy fascinating.



Take a look at this.  It's an excellent site!
http://www.ccmtutorials.com/rs/index.htm


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## systemet (May 13, 2011)

Also, regarding the placebo effect:

Yes, giving a patient oxygen and telling them the pain in their compound fracture will improve works.  It does.  So does telling them:

- wearing a green crystal around their neck will improve nausea
- going to a chiropractor will improve their subjective symptoms of diabetes
- giving them a homeopathetic dilution of ground up pieces of the Berlin wall will improve their constipation
- giving a saline flush will make their chest pain better


But it's not particularly ethical.  For what it's worth, I believe a lot of the mystique of the medical profession is deliberately designed to invoke the placebo effect.  

There is now some concern that making patients hyperoxemic, i.e. providing oxygen beyond resting conditions, is going to result in the generation of free radicals and worsen existing disease processes.  This has been a concern in the management of neonates for years, and is now starting to get some attention in the treatment of adults. 

_[I am not suggesting that you should withhold oxygen from anyone with clinical signs or symptoms of hypoxia, nor am I suggesting that it would be a good idea to violate your existing protocols and try to explain to your medical director your concerns about reactive oxygen species generation]_.


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## JPINFV (May 13, 2011)

systemet said:


> *- wearing a green crystal around their neck will improve nausea*
> - going to a chiropractor will improve their subjective symptoms of diabetes
> *- giving them a homeopathetic dilution of ground up pieces of the Berlin wall will improve their constipation*
> - giving a saline flush will make their chest pain better



[YOUTUBE]http://www.youtube.com/watch?v=HMGIbOGu8q0[/YOUTUBE]


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## medichopeful (May 13, 2011)

systemet said:


> - giving them a homeopathetic dilution of ground up pieces of the Berlin wall will improve their constipation



LOL that made my day


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## systemet (May 13, 2011)

They actually do that.  I am not making that up!


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## feldy (May 13, 2011)

While i am an EMT and have been taught like everyone else out there that its NRB unless the pt cant tolerate it,  If the pt in unconscious and is in need of O2, i will put an NRB on them and if there is no improvement then the pt will be intubated other than, we use cannula to get 100% Spo2.


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## usafmedic45 (May 13, 2011)

systemet said:


> The answer to this involves a little math, and a little physiology.  It's a little beyond what's covered in an average EMT-B class.  It's something that should be covered in medic school.
> 
> Oxygen is carried in the circulation in two forms (1) bound to hemoglobin, (2) dissolved in the plasma.  We can actually calculate the amount of oxygen carried in arterial blood.  This is called the arterial oxygen content or CaO2, and is defined as:
> 
> ...



Thanks for the review of basic blood gas physiology, but you missed the major takeaway point that if the patient doesn't have a need for supplemental oxygen, they don't have a need for supplemental oxygen.  It's not an "It might be helpful" sort of equation....there's more evidence that it does harm than offers some unexpected benefit. 

EDIT: OOPS.  Should have read the rest of the thread before posting.  My apologies. 

BTW, you bring that sort of thing up to most medics and you get a blank stare so its not covered in a lot of medic courses apparently. 




> While i am an EMT and have been taught like everyone else out there that its NRB unless the pt cant tolerate it,



Was my class the only one in the mid-1990s teaching something other than NRB or nothing at all?  We were taught about NC, NRB, SFM, Venturi masks and trach collars.


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## usafmedic45 (May 13, 2011)

> But it's not particularly ethical. For what it's worth, I believe a lot of the mystique of the medical profession is deliberately designed to invoke the placebo effect.



Depends upon whom you ask.  I see no real reason to consider it blatantly unethical.  We do more or less the same thing with about 90% of albuterol treatments handed out in hospitals every day.  People feel better mostly because you're doing something to them, whether or not their underlying pathology is altered by the medication or not.


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## MrBrown (May 14, 2011)

There is nothing bloody magic about oxygen, not everybody needs oxygen, craming 15LPM NRB down every patients gob is not doing to do them any good and in some cases may be harmful.

Supraphysiological amounts of oxygen cause capillary and small arterioles to constrict which in some patients can have a negative effect - for example stroke and head injured patients.


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## systemet (May 14, 2011)

usafmedic45 said:


> Depends upon whom you ask.  I see no real reason to consider it blatantly unethical.  We do more or less the same thing with about 90% of albuterol treatments handed out in hospitals every day.  People feel better mostly because you're doing something to them, whether or not their underlying pathology is altered by the medication or not.



Hmm.  I guess it's a question of where do you draw the line?  I'd assume that the patients receiving albuterol are at least dyspneic and exhibiting signs of mild respiratory distress?  Even if the benefit may be minimal.

For example, I would have issue with someone pushing a bolus of saline and telling the patient they're receiving morphine.  Even if this is likely going to reduce their pain.


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## MrBrown (May 14, 2011)

There is sufficient evidence that supraphysiologic administration of oxygen is harmful AND if your standing orders state oxygen is to be titrated to SPO2 or level of illness (which most do) then yes, Brown thinks it is unethical to shove everybody on 15PLM NRB given that it may cause harm in some patients

Perhaps we should expand on that 100 hour wonder course and make this required reading? 

http://www.brit-thoracic.org.uk/cli...n/emergency-oxygen-use-in-adult-patients.aspx


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## usafmedic45 (May 14, 2011)

> I'd assume that the patients receiving albuterol are at least dyspneic and exhibiting signs of mild respiratory distress?



Actually most albuterol treatments (in non-ER patients) are given to folks with no immediate respiratory symptoms.  It's generally based on history and the lack of knowledge of the docs as to how to prevent an exacerbation of COPD or asthma (read as: albuterol is a piss poor preventive medication when you look at the negative effects it has on patients).  The fact that 99.9% of what I spent my time as a "regular" (not in a flight capacity) RT had zero benefit to the patient is a major reason why I finally got fed up with the field and started looking at other options.  The other reasons were lack of opportunities to advance, few choices as far as specialization goes (so says the guy who works on an air ambulance....guess I should point out the hypocrisy in that....LOL) and a few other minor piddly things.


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## MrBrown (May 14, 2011)

Gosh and here Brown was thinking that we should only give salbutamol to people who needed it :unsure:


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## alphatrauma (May 14, 2011)

MrBrown said:


> ... *Supraphysiological amounts of oxygen* cause capillary and small arterioles to constrict which in some patients *can have a negative effect* - for example stroke and head injured patients.



Especially in patients with *ACS* who are NOT HYPOXIC (SaO2 > 89%)! Hyperoxia can induce vasoconstriction in coronary blood vessels, which will inhibit oxygenation to the very areas with which you are trying to repurfuse. While the pulse oximetry may convey a nice therapeutic value, the counterproductive effects can be rather insidious.


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## usafmedic45 (May 14, 2011)

> Gosh and here Brown was thinking that we should only give salbutamol to people who needed it



We should only give it to people who need it.  The problem is that most hospitals don't follow that common sense approach to it.  Personally, once I have my PhD, I hope the US pulls its head out of its ***, approves intravenous albuterol (like most of the rest of the world has) and we let the nurses start giving it like any other medication.  There's nothing particularly specially about it being given by nebulization and in fact, even with perfect technique, the patient is lucky to receive half the prescribed dose.


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## MrBrown (May 14, 2011)

usafmedic45 said:


> I hope the US pulls its head out of its ***, approves intravenous albuterol (like most of the rest of the world has) and we let the nurses start giving it like any other medication.



Intensive Care Paramedics here have IV salbutamol, not where Brown is personally but it is here.


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## DrParasite (May 15, 2011)

usafmedic45 said:


> I hope the US pulls its head out of its ***, approves intravenous albuterol (like most of the rest of the world has) and we let the nurses start giving it like any other medication.


Point of information:  how does this work?  

I was told of a paramedic who did this in upstate NY and she was promptly banned from ever riding on an ALS truck ever again, because it was a gross violation of protocols and how the medication was supposed to be administered.  Not only that, but albuterol should be administered via the lungs (I am drawing a blank on the proper term) vs IV, because it relives the difficulty breathing and has an immediate concentrated action based on it's method of delivery.


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## usafmedic45 (May 15, 2011)

> Point of information: how does this work?


The same way as if you give it by inhalation or if you give any other sympathomimetic drug (epi, terbutaline, etc).  It's absorbed into the bloodstream and you get the desired effect (which is why it takes 10-15 minutes to get full effect from a dose; you wouldn't see that if it were locally acting).  You can also give it IM or PO and get the same effects.  



> Not only that, but albuterol should be administered via the lungs (I am drawing a blank on the proper term) vs IV, because it relives the difficulty breathing and has an immediate concentrated action based on it's method of delivery.


Ah, I see your reasoning, but it's badly flawed.  There's no substantial evidence that says it's more effective by inhalation.  It's not quicker. Works just the same and just as quick if you give it IV.  Anecdotally, I'd say it works faster (within five minutes) when given IV based on the handful of cases I've seen.  Any patient that gets "instant" relief from albuterol is exhibiting a placebo effect.  Also, you're not spraying half the dose into the air this way either when you give it IV.  



> I was told of a paramedic who did this in upstate NY and she was promptly banned from ever riding on an ALS truck ever again, because it was a gross violation of protocols and how the medication was supposed to be administered.



Because it's not packaged for IV use here in the US, not because it doesn't work if you give it that way.    It's a quirk we have here in the US that I don't fully understand but I would imagine it has something to do with keeping my colleagues in respiratory therapy employed since dosing people with albuterol is about 90-95% of the workload for about 90-95% of us.

BTW, apparently the IV formulation is approved here in the US but it just is not very common.  It's also able to use off label in that form as a tocolytic according to some anecdotal reports.


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## Hellsbells (May 15, 2011)

Hmmm, this wholesale administration of NRB's must be an American idiosyncrasy. EMT education in Canada doesn't involve any sort of stipulation that all pts get oxygen, and should also all get NRB's. This seems completely preposterous to me. 

As to the original question, I fail to see what the debate vis-à-vis NC and NRB has to do with diagnosis. If all pts get 02 then there is absolutely no diagnosis at play, no matter how its delivered.

I have heard the notion that "EMT/Paramedics" don't diagnosis. However, I can't remember ever being taught that specifically in school. In order for us to treat pts, we must diagnosis, even to a limited degree. In all reality, once the pt gets to the hospital, the physician will assess the pt and make an independent diagnosis. Its not as if what we determine in the field becomes the last word on the pts chart.


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## AMF (Jun 12, 2011)

Hellsbells said:


> Hmmm, this wholesale administration of NRB's must be an American idiosyncrasy. EMT education in Canada doesn't involve any sort of stipulation that all pts get oxygen, and should also all get NRB's. This seems completely preposterous to me.
> 
> As to the original question, I fail to see what the debate vis-à-vis NC and NRB has to do with diagnosis. If all pts get 02 then there is absolutely no diagnosis at play, no matter how its delivered.
> 
> I have heard the notion that "EMT/Paramedics" don't diagnosis. However, I can't remember ever being taught that specifically in school. In order for us to treat pts, we must diagnosis, even to a limited degree. In all reality, once the pt gets to the hospital, the physician will assess the pt and make an independent diagnosis. Its not as if what we determine in the field becomes the last word on the pts chart.



We do it backwards... the EMT/Ps assess and stabilize, doctors diagnose and treat.  the latter sounds more terminal.  I'm not sure if you're familiar with the the American populace, but we like to be right.


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## JPINFV (Jun 12, 2011)

AMF said:


> the EMT/Ps assess and stabilize, doctors diagnose and treat.



What's the difference between stabilize and treat? Are the interventions taken to stabilize the patient treatments?

What's the point of performing an assessment if you don't use the information gained to develop an idea of what is going on, or in other words, diagnose? If your patient has a blood glucose level of 30, did you not just diagnose hypoglycemia?


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## Shishkabob (Jun 12, 2011)

AMF said:


> We do it backwards... the EMT/Ps assess and stabilize, doctors diagnose and treat.  the latter sounds more terminal.  I'm not sure if you're familiar with the the American populace, but we like to be right.



No, the Paramedics diagnose.  If you treat, you've made a diagnosis.   It may not be the definitive diagnosis, but it's a diagnosis.



If you start pushing medications and doing things without having an idea as to why, you need to lose your license.


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## usalsfyre (Jun 12, 2011)

AMF said:


> We do it backwards... the EMT/Ps assess and stabilize, doctors diagnose and treat.  the latter sounds more terminal.  I'm not sure if you're familiar with the the American populace, but we like to be right.



Paramedics use history, physical exam and diagnostic test to diagnose and treat disease and injury within their scope of practice. Which is fundamentally the practice of medicine (albeit of limited scope). Honestly we are far closer in job description to a mid-level provider (NP or PA) than anything else, but we are VASTLY undereducated for the role.

Legal niceties or not, that is what we do. Some paramedics may like to say otherwise (usually because they somehow think it will shield them from liability), but it's a word game. The sooner paramedics accept this, the sooner we can move on as a profession. 

(all views above are my own)


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## Too Old To Work (Jun 13, 2011)

DrParasite said:


> I was told of a paramedic who did this in upstate NY and she was promptly banned from ever riding on an ALS truck ever again,



An anecdote, told third hand is not data, it's a war story. As others pointed out it's not used in the US because it's not approved for IV use in most cases. 



usafmedic45 said:


> Was my class the only one in the mid-1990s teaching something other than NRB or nothing at all?  We were taught about NC, NRB, SFM, Venturi masks and trach collars.



In the mid 1990s, no. By the end of the 1990s, a class taught that way would be extremely rare, if not extinct. The use a NRB on all patients BS came about with the 1994 EMT-B curriculum. I won't get into the back story on why that was done, but suffice it to say that there was pressure on the committee putting the new curriculum together to keep it at 110 hours. As a result, almost all of the medicine was taken out of the EMT-B course and it became barely distinguishable from a Boy Scout First Aid course. 

As a result, EMS at all levels became a skill set and any hope of it becoming a profession, let alone a trade, were smashed forever.

The NRB is to the EMT as the Albuterol Neb is to the RT. Most patients absolutely don't need it, but they get it anyway because too many doctors subscribe to the Chicken Soup school of medicine.


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## usafmedic45 (Jun 13, 2011)

> The use a NRB on all patients BS came about with the 1994 EMT-B curriculum.



Which is the one I was trained under when I got into the field initially.  Our training program's medical director rejected it as medically unsupportable and made sure we were aware of that fact.



> The NRB is to the EMT as the Albuterol Neb is to the RT. Most patients absolutely don't need it, but they get it anyway because too many doctors subscribe to the Chicken Soup school of medicine



It's a good analogy, but I've been much more successful in not putting NRBs on people who need them than I have in trying to talk docs out of non-essential/non-indicated albuterol treatments.



> I won't get into the back story on why that was done, but suffice it to say that there was pressure on the committee putting the new curriculum together to keep it at 110 hours



I've never seen a state that actually has a 110 hour course. Ours was 140 or 150 plus clinicals.  This is where people need to get their heads out of their asses and realize there's a difference between a guideline and a mandate.


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## Too Old To Work (Jun 13, 2011)

usafmedic45 said:


> Which is the one I was trained under when I got into the field initially.  Our training program's medical director rejected it as medically unsupportable and made sure we were aware of that fact.



He was right, but like everyone else who said that, he wasn't listened to. 



> It's a good analogy, but I've been much more successful in not putting NRBs on people who need them than I have in trying to talk docs out of non-essential/non-indicated albuterol treatments.



This seems to be a common lament among RTs. I read a couple of respiratory therapy blogs and a lot of posts are put up about stupid Albuterol orders. I ran into this when my mother was in a major teaching hospital. She had zero Hx of COPD or Asthma, but the insisted on giving her Albuterol for dyspnea. I was probably less subtle than I should have been in pointing out that she had a long standing Hx of cardiac disease and CHF and that her anginal equivalent was respiratory distress and pulmonary edema. I got the point across finally, but only because the nurse manager of the unit was the wife of a long time co worker. 



> I've never seen a state that actually has a 110 hour course. Ours was 140 or 150 plus clinicals.  This is where people need to get their heads out of their asses and realize there's a difference between a guideline and a mandate.



Although I'm sure I'll get a lot of hate mail, I will tell you that it was the volunteer services that drove the 110 hour requirement. They were afraid that if they made it too difficult, they'd lose volunteers.


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## medichopeful (Jun 13, 2011)

Too Old To Work said:


> Although I'm sure I'll get a lot of hate mail, I will tell you that it was the volunteer services that drove the 110 hour requirement. They were afraid that if they made it too difficult, they'd lose volunteers.



Don't take this the wrong way but do you have a source for this?  I'm trying to get concrete or professional data on why the hell something with so much responsibility has such a low entry requirement.  I'm hoping to get involved in changing this in the future, and I think in order to do that I need as much background as possible!

Again, not calling you out but rather looking for more information.

Thanks!
Eric


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## Too Old To Work (Jun 14, 2011)

medichopeful said:


> Don't take this the wrong way but do you have a source for this?  I'm trying to get concrete or professional data on why the hell something with so much responsibility has such a low entry requirement.  I'm hoping to get involved in changing this in the future, and I think in order to do that I need as much background as possible!
> 
> Again, not calling you out but rather looking for more information.
> 
> ...



Yes, the chair of the committee that developed the curriculum. It was at EMS Today in 1995. There was a lot of dissention in the ranks and part of the explanation for decontenting the curriculum was that the volunteer contingent (more influential then than now) insisted that they would lose members if the course was extended to the proposed 150 (I think) hours.


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## TacEMT (Jun 19, 2011)

This is a good discussion but I had a question regarding "why" to use a NC over a NRM during a cardiac related emergency. I was taught in the very last week of class to use NC on cardiac patients unless they have dyspnea, then use NRM. I can't exactly remeber why, but they said NC would be the appropriate answer for our final and on the National Registry. When I asked, one student suggested that the high flow oxygen of the NRM would make the patient more anxious and worsen the effects and I think someone else explained that it was like hyperventilating and it would cause vasoconstriction which worsen the situation as well. Can someone explain to me the reason why high flow oxygen may not be appropriate for a cardiac patient, or any other emergency? And what is titrate effect and does that somehoe play into all this? Thanks


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## Lifeguards For Life (Jun 19, 2011)

TacEMT said:


> This is a good discussion but I had a question regarding "why" to use a NC over a NRM during a cardiac related emergency. I was taught in the very last week of class to use NC on cardiac patients unless they have dyspnea, then use NRM. I can't exactly remeber why, but they said NC would be the appropriate answer for our final and on the National Registry. When I asked, one student suggested that the high flow oxygen of the NRM would make the patient more anxious and worsen the effects and I think someone else explained that it was like hyperventilating and it would cause vasoconstriction which worsen the situation as well. Can someone explain to me the reason why high flow oxygen may not be appropriate for a cardiac patient, or any other emergency? And what is titrate effect and does that somehoe play into all this? Thanks



Why would you think putting a patient and their ischemic, soon to be infarcted cells on high flow O2(read: toxic levels of free radicals) would be a good thing?

Before answeromg your question in red, consider what is really going on with a cardiac patient? At the most basic level they are suffering from some form of coronary occlusion, constriction, partial blockage, that interferes with the heart getting enough oxygen. Oxygen has no thrombolytic properties. Any blood moving past the "blockage" has plenty of oxygen. This is a perfusion problem, not a ventilation problem. (from your post i assume we are talking an uncomplicated chest pain CC)

Also as others have mentioned supraphysiologic 02 tension has been shown to cause coronary vasoconstriction in animals.

Before considering what makes high flow 02 innapropriate, tell us what makes it appropriate.

In all seriousness, research in this area is in it's infancy, so i wouldn't fret too much.
	
	



```

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 and furthermore seems to be poorly understood by field practitioners, if they are even aware of it. Any  negative implications are most likely just a tad bit on the worse side of negligible,


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## TacEMT (Jun 19, 2011)

What I was taught in class is that, for the most part, all your patients should recieve high flow oxygen with a NRM. However they said when appropriate, which it vague. Also if the person can't tolerate a NRM, you put them on a NC or have them hold the NRM in front of them to give them blow by oxygen. For testing purposes, everyone gets oxygen. As others have mentioned, if they are already at an SpO2 of 100%, then oxygen may not do them any good. However, I would not figure out their SP02 till later on in the asessment until after I have already provided them oxygen. 

The cadiac and respiratory systems are two seperate systems. It is a perfusion issue so I can see why oxygen would not help them, but how does it hurt them?

I would think high flow oxygen would be appropriate for some cardiac cases, and yea I do mean chest pains to clarify. If they are suffering from CHF, left side, couldn't that lead to pulmonary edema, which reduces the oxygen exchange? For them, if they are having difficult times breathing, I would give them high flow oxygen.


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## Lifeguards For Life (Jun 19, 2011)

TacEMT said:


> What I was taught in class is that, for the most part, all your patients should recieve high flow oxygen with a NRM. However they said when appropriate, which it vague. Also if the person can't tolerate a NRM, you put them on a NC or have them hold the NRM in front of them to give them blow by oxygen. For testing purposes, everyone gets oxygen. As others have mentioned, if they are already at an SpO2 of 100%, then oxygen may not do them any good. However, I would not figure out their SP02 till later on in the asessment until after I have already provided them oxygen.
> 
> The cadiac and respiratory systems are two seperate systems. It is a perfusion issue so I can see why oxygen would not help them, but how does it hurt them?
> 
> I would think high flow oxygen would be appropriate for some cardiac cases, and yea I do mean chest pains to clarify. If they are suffering from CHF, left side, couldn't that lead to pulmonary edema, which reduces the oxygen exchange? For them, if they are having difficult times breathing, I would give them high flow oxygen.



If you can see why it is not beneficial, why give it regardless of it's potential to harm a patient? two ways it can harm the patient were given in my last post.

CHF is definitely a possibilitym and can definitely "reduce oxygen exchange".

So imagine your cardiac patient has a clot, which is preventing his left ventricle from getting proper blood flow, and enough oxygen. The left ventricle becomes tired and can't pump effectively. It starts pumping slower, and with less force, it can not keep up with the lungs. So inter atrial pressure increases, along with the pressure in the pulmonary veins and cappiliares. this ultimately causes blood to be forced back through the pulmonary cappilaries, and back into the alveoli.

With the alveoli filling with fluids, how will high flow O2 help them? How will high flow O2 improve their "oxygen exchange"?

I don't believe it is as big a deal as some people would have you believe, nothing to get worked up about, but it is good for you to think about.


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## TacEMT (Jun 19, 2011)

Knowing the exact reason why I believe is way above the EMT-B's level, but it is good to know. I read about the oxygen toxicity and free radicals but this seems like something more for someone on high concentration oxygen for a prolonged period of time. Supposedly, though I could be wrong, that there has never been a case of a person who has stopped breathing when given oxygen because they are on hypoxic drive and getting too much oxygen. 

But I am still confused as to how it applies specifically to a cardiac patient. If a patient is suffereing from an angina, the cardiac muscle is not recieving enough oxygen, due to a clot, so wouldn't giving them more oxygen assist with that, unless its a full occlusion? I guess to be more specific, is there some type of chemical or physiological effect that high flow oxygen has on the blood that makes it harmful when given for only a short period of time?


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## usalsfyre (Jun 19, 2011)

Lifeguards For Life said:


> How will high flow O2 improve their "oxygen exchange"?/QUOTE]
> While I generally agree with what your saying, high concentration O2 will improve oxygen exchange at the alveolar level. Look up partial pressures, Dalton's Law and how gas moves across the alveolar/capillary membrane.


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## Lifeguards For Life (Jun 19, 2011)

TacEMT said:


> I read about the oxygen toxicity and free radicals but this seems like something more for someone on high concentration oxygen for a prolonged period of time.



Yes, I would generally agree with this statement, Which is why I said any ill efffects are likely just a tad worse than negligible, and this whole high flow 02 argument is not as dire as some people would like to tell you.

Even recongizing there is a discrepancy is more than I would expect from most EMT's, it is good to be thinking and questioning.




TacEMT said:


> Supposedly, though I could be wrong, that there has never been a case of a person who has stopped breathing when given oxygen because they are on hypoxic drive and getting too much oxygen.



Good.

The Hypoxic dirve theory is a piece of intellectual beauty to be sure, but it doesn't describe anything that really happens. Just like in science, if it doesn't agree with experiment it's wrong. Even though the theory is beautifully crafted, the theory is wrong and utterly useless.

Talking about theory agreeing with experiment brings us back to the high flow oxygen theory. While this theory is backed by "experiment", and the theory does hold true, it's not neccesarily applicable for EMS. To have any appreciable  cellular damage takes time that you usually won't have prehospital. And even if you did have the time, there is a strong possiblity that any injury suffered is completely recoverable.

This theory has been around since the 1950's I believe, yet EMS have still been told to give high flow 02 to everyone, I know I was in EMT school. Yet people haven't been dropping off like flies when giveh high flow O2.

It will be interesting to see where this argument goes in the future. I can see it becoming protocol to not use high flow O2 even for cardiac arrest, during some of our careers.



TacEMT said:


> But I am still confused as to how it applies specifically to a cardiac patient. If a patient is suffereing from an angina, the cardiac muscle is not recieving enough oxygen, due to a clot, so wouldn't giving them more oxygen assist with that, unless its a full occlusion?



Your blood can only carry so much oxygen. In an uncomplicated cardiac patient, the RBC's and plasma already have plenty of oxygen. It's not like you can really super-saturate their blood with oxygen to make up for poor blood flow.




TacEMT said:


> I guess to be more specific, is there some type of chemical or physiological effect that high flow oxygen has on the blood that makes it harmful when given for only a short period of time?



Sure. You already told me about Oxygen free radicals. But the damage you can cause in the short amount of time you will have the patient, is like "the smallest amount of damage you can possibly cause". These radicals are destructive to DNA, proteins, etc. But the amount of free radicals that can accumulate in a short period of time is minimal, and your body is always repairing damages, so it's negligible.

Should we really be giving all our patients high flow o2? well no.
Is it really going to cause any appreciable harm, well probably not.

However, I do think that high flow o2 in a code can infact be much more destrucive than high flow o2 than in your CP or COPD etc. patients.


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## TacEMT (Jun 20, 2011)

usalsfyre said:


> Lifeguards For Life said:
> 
> 
> > How will high flow O2 improve their "oxygen exchange"?/QUOTE]
> ...


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## usalsfyre (Jun 20, 2011)

TacEMT said:


> usalsfyre said:
> 
> 
> > So Dalton's law is about total pressue being partial pressues added together. I'm thinking it might be more toward the decomperssion sickness and barotrauma. If high flox oxygen at 100% is much more then at room air, 21%, then it would have a higher partial pressue right? Would that increase in total pressue, like in the lungs, cause the nitrogen to disolve in blood and when the pressue goes back down, the nitrogen turns back to gas and expands and causes an air embolism that could potentially block blood flow. This would be bad for someone already experiencing some type or perfusion problem due to a cardiac emergency.
> ...


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