# Let's just take oxygen out of standing orders.



## NYMedic828 (Sep 2, 2012)

Ok I know that's completely absurd in reality but I'm sick of almost everyone I work with putting all my patients on oxygen by one method or another.

The nurse looked as us like we were mentally challenged yesterday because we had someone who was otherwise completely asympomatic on o2.

People get mad at me when we call a trauma note, they open the back doors and I have our patient on room air...

Oxygen is NOT the duct tape of EMS, when will people get it?

Atleast if you had to call a doctor for permission (which I realize is completely ridiculous in reality I'm just ranting) then there would be someone to tell the provider stop being an incompetent moron and transport...

Again I am just ranting I realize this would be a completely impractical change.


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## rennex (Sep 2, 2012)

That's because step 2 in like every protocol we have is "Administrate Oxygen" :blush:

Edit: In NYC.


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## WolfmanHarris (Sep 2, 2012)

I'm about to incriminate myself:
The Ontario BLS standards (All our delegated medical acts fall under ALS standards) still list a huge number of generic patient types requiring high concentration oxygen within two minutes of patient contact. The BLS standards haven't had a rewrite in years and are extremely dated in medicine and approach. 

BLS standards require high concentration oxygen on all chest pains despite the mounting evidence and AHA  best practice to the contrary. I decided awhile ago that i'd had enough and switched to nasal prongs titrated to SPO2. 

My approach now is that if the standard is so far behind medicine as to be irrelevant then I might as well disregard when in the best interests of my patient, medically justifiable and within my medical directives.


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## WolfmanHarris (Sep 2, 2012)

I'm about to incriminate myself:
The Ontario BLS standards (All our delegated medical acts fall under ALS standards) still list a huge number of generic patient types requiring high concentration oxygen within two minutes of patient contact. The BLS standards haven't had a rewrite in years and are extremely dated in medicine and approach. 

BLS standards require high concentration oxygen on all chest pains despite the mounting evidence and AHA  best practice to the contrary. I decided awhile ago that i'd had enough and switched to nasal prongs titrated to SPO2. 

My approach now is that if the standard is so far behind medicine as to be irrelevant then I might as well disregard when in the best interests of my patient, medically justifiable and within my medical directives.


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## bigbaldguy (Sep 2, 2012)

NYMedic828 said:


> I'm sick of almost everyone I work with putting all my patients on oxygen by one method or another.



Aren't most them technically on oxygen already


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## bigbaldguy (Sep 2, 2012)

They could just do what they did on airplanes. The highest flow rate for our O2 tanks on the plane is 4 lpm on a non re-breather. It's kind of like holding a pillow over their face  great for hyper-ventilators I suppose.


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## shfd739 (Sep 2, 2012)

Yeah Im always aggravating first responders and some of our folks when I take the O2 off their patients..Its fun to see the reactions. Then I educate them.

Most recent was a kidney stone patient @99% room air and they were putting on a cannula @ 4lpm..When asked why the crew said "well he's short of breath"..No, he is in pain- give your fentanyl and it will get better...and I took the cannula away.


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## Ridryder911 (Sep 2, 2012)

In lieu of removing it from standing orders... how about educating them right the first time?... As most fail to remember; oxygen is a drug .. and drug(s) need to be used accordingly and properly and as well..... have a physician authorization.


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## DrParasite (Sep 2, 2012)

NYMedic828 said:


> Ok I know that's completely absurd in reality but I'm sick of almost everyone I work with putting all my patients on oxygen by one method or another.


your complaint is unfair, and your anger is misplaced.  RR said it before I could:


Ridryder911 said:


> In lieu of removing it from standing orders... how about educating them right the first time?


If you tell someone that everyone needs oxygen when they are first trained, that's what will happen.  Trauma's need oxygen, medical's need oxygen, and all your protocols say apply high flow oxygen, guess what every provider will do?  and even better, if your bosses/ER doctors are going to file complaints when you don't apply oxygen, what's your defense going to be?  "I know it's in the protocol, and my medical director wants me to do it, but I know more than they so I just won't do it."  I don't think it will go over quite as well as you hope.

Please don't misunderstand, I agree that we over oxygenate people in EMS.  but changes needs to start at the top, at the medical director level, and the state protocol level, and the education level. You can't call someone stupid for following the directions of his or her state protocol, or medical director, or what what drilled into their head in school can you?


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## the_negro_puppy (Sep 2, 2012)

Our oxygen protocols have changed dramatically over the past few years. We only use it if its clinically indicated and even then its titrated for effect.

As a rule ACS and strokes don't get oxygen unless there is a problem with their oxygenation.


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## JPINFV (Sep 2, 2012)

Ridryder911 said:


> In lieu of removing it from standing orders... how about educating them right the first time?... As most fail to remember; oxygen is a drug .. and drug(s) need to be used accordingly and properly and as well..... have a physician authorization.




...because we can't have that edujmacation things in EMS... especially at the EMT level.


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## NYMedic828 (Sep 2, 2012)

DrParasite said:


> your complaint is unfair, and your anger is misplaced.  RR said it before I could:
> If you tell someone that everyone needs oxygen when they are first trained, that's what will happen.  Trauma's need oxygen, medical's need oxygen, and all your protocols say apply high flow oxygen, guess what every provider will do?  and even better, if your bosses/ER doctors are going to file complaints when you don't apply oxygen, what's your defense going to be?  "I know it's in the protocol, and my medical director wants me to do it, but I know more than they so I just won't do it."  I don't think it will go over quite as well as you hope.
> 
> Please don't misunderstand, I agree that we over oxygenate people in EMS.  but changes needs to start at the top, at the medical director level, and the state protocol level, and the education level. You can't call someone stupid for following the directions of his or her state protocol, or medical director, or what what drilled into their head in school can you?



Can I hold them accountable for doing what they were told, by other incompetent people made instructor? No.

Can I hold them accountable for not self educating to understand what is truly right. Absolutely. And I do.


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## Anonymous (Sep 2, 2012)

WolfmanHarris said:


> BLS standards require high concentration oxygen on all chest pains despite the mounting evidence and AHA  best practice to the contrary.



Can you elaborate a little on this? Still learning here.


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## NYMedic828 (Sep 2, 2012)

Anonymous said:


> Can you elaborate a little on this? Still learning here.



AHA i believe suggests there is no immediate need for supplemental oxygen at O2 saturations of 94% or greater in the absence of respiratory distress.


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## mycrofft (Sep 2, 2012)

rennex said:


> That's because step 2 in like every protocol we have is "Administrate Oxygen" :blush:
> 
> Edit: In NYC.



There you go. Anyone with the educational level to order "administrate oxygen" ...sort of like "getting orientated" (oriented). 

I teach for a company that also sells oxygen and I am required to teach them to start O2 no matter what. Fixed at six liters, nonetheless....


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## mycrofft (Sep 2, 2012)

Ridryder911 said:


> In lieu of removing it from standing orders... how about educating them right the first time?... As most fail to remember; oxygen is a drug .. and drug(s) need to be used accordingly and properly and as well..... have a physician authorization.



Yes that! A tool is a tool, whether it is oxygen or the "administrationater".


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## the_negro_puppy (Sep 2, 2012)

Our protocols lol


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## mycrofft (Sep 2, 2012)

How is "SpO2" measured in the field? (Pulse Ox I assume. Never know what you folk downundah are going to be doing next).


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## the_negro_puppy (Sep 3, 2012)

mycrofft said:


> How is "SpO2" measured in the field? (Pulse Ox I assume. Never know what you folk downundah are going to be doing next).



Yeah pulse ox


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## mycrofft (Sep 3, 2012)

We actually had for a short time a  device that read haemoglobin on a reagent strip like a urine dipstick. Pre-pulse ox


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## Ridryder911 (Sep 3, 2012)

Part of the problem of not only EMS but medicine... treat the patient *NOT* the protocols!!! How many times have we seen medics (all levels) categorize the patient to _fit_ their local protocols in lieu of treating accordingly? 

The new trend is less oxygen... even AHA is finally recognizing this. Again, treat the patient *NOT* the monitor.. numbers.... or protocols!! 

Why knowing and understanding good, accurate patient assessment is so essential... no matter what level you are!


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## Anonymous (Sep 3, 2012)

The problem is the second anything goes wrong and protocol was not followed (patient placed on high flow O2, or c-spine as in other threads) the provider is usually screwed. Fear of litigation has taken autonomy away from a lot of us. Also, would kind of be nice if basics were able to utilize the ever so invasive pulse ox.


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## firecoins (Sep 3, 2012)

I put my patients on room air o2 if they aren't s.o.b.


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## NYMedic828 (Sep 3, 2012)

Anonymous said:


> The problem is the second anything goes wrong and protocol was not followed (patient placed on high flow O2, or c-spine as in other threads) the provider is usually screwed. Fear of litigation has taken autonomy away from a lot of us. Also, would kind of be nice if basics were able to utilize the ever so invasive pulse ox.



Find me a documented case where a lawsuit was opened yet alone lost because oxygen was not administered when it wasn't indicated or a patient was not long boarded. (good luck)

Pulse-oximetry is a non invasive form of quantitative monitoring. Not all places have it for BLS. In NY it is optional for BLS mandatory for ALS. 

Pulse-oximetry is also not a completey reliable vital sign. It is heavily affected by many outside factors from nail polish to movement. It is also at a delay from what is really going on in the body. But, it is absolute useful for establishing baselines and titrating/evaluating your treatment.

My favorite is when people assess SpO2 AFTER starting oxygen therapy. Sigh.


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## Veneficus (Sep 3, 2012)

Ridryder911 said:


> Part of the problem of not only EMS but medicine... treat the patient *NOT* the protocols!!! How many times have we seen medics (all levels) categorize the patient to _fit_ their local protocols in lieu of treating accordingly?
> 
> The new trend is less oxygen... even AHA is finally recognizing this. Again, treat the patient *NOT* the monitor.. numbers.... or protocols!!
> 
> Why knowing and understanding good, accurate patient assessment is so essential... no matter what level you are!



It is very good to see you still hanging around.

Unfortunately, the trend more and more in EMS education I have noticed is to follow the protocols without deviation or thought.

Telling people to treat the patient, not the monitor or protocol is akin to telling me to use my judgement while wrenching on a Russian spacecraft. I just don't know how to do it to begin with.


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## NYMedic828 (Sep 3, 2012)

Veneficus said:


> It is very good to see you still hanging around.
> 
> Unfortunately, the trend more and more in EMS education I have noticed is to follow the protocols without deviation or thought.
> 
> Telling people to treat the patient, not the monitor or protocol is akin to telling me to use my judgement while wrenching on a Russian spacecraft. I just don't know how to do it to begin with.



This factor probably plays one of the biggest roles in why EMS providers interested in providing real medical care often move on to a more progressive field. It is unfortunate as EMS does have potential for greatness but it will never be achieved in this country. Never. (hope one day I am proven wrong)


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## Veneficus (Sep 3, 2012)

NYMedic828 said:


> This factor probably plays one of the biggest roles in why EMS providers interested in providing real medical care often move on to a more progressive field. It is unfortunate as EMS does have potential for greatness but it will never be achieved in this country. Never. (hope one day I am proven wrong)



A couple of years ago I suggested nursing take it over. The idea was not well recieved despite being how it is done in several advanced systems around the world. 

EMS follows the standard path of evolution, evolve or become a curio for archaeologists.


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## mycrofft (Sep 3, 2012)

*Vocab Nazi comment*



mycrofft said:


> There you go. Anyone with the educational level to order "administrate oxygen" ...sort of like "getting orientated" (oriented).
> 
> I teach for a company that also sells oxygen and I am required to teach them to start O2 no matter what. Fixed at six liters, nonetheless....



rennex showed me the citation for use of the word "adminstrate" being equivalent to "administer". Point taken, point granted, and the material seems sound, so I'll roll up my proofreading rug and steal away. (aweigh?)

However, it will now dwell alongside "irregardless" (double negative), "gone south"* (the original is "gone west"), "underway" (properly, "underweigh") and "oral exams" (not being done by a dentist, it means VERBAL exams) ; adopted by common usage, but still redheaded stepkids to me.

*If something "went South" from New Zealand, it would not have far to go before it would be going North again, right?


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## DrParasite (Sep 3, 2012)

NYMedic828 said:


> Can I hold them accountable for doing what they were told, by other incompetent people made instructor? No.
> 
> Can I hold them accountable for not self educating to understand what is truly right. Absolutely. And I do.


ACLS has been shown to not affect whether or not a cardiac arrest patient will walk out of the hospital.  does that mean you are no longer going to follow the protocol on your next cardiac arrest patient?

Please don't think I think we should overoxygenate everyone, but for change to happen, it needs to start with the medical directors, ER doctors, EMT curriculum writers, and everyone who writes protocols.  you can't fault an ignorant crew for following what they were taught and what their protocols say to do, regardless of if it's wrong or not.





Ridryder911 said:


> The new trend is less oxygen... even AHA is finally recognizing this. Again, treat the patient *NOT* the monitor.. numbers.... or protocols!!


I have heard this before... so if I pick up grandma who is complaining of feeling sick, and has a pulse ox of 74, I shouldn't put her on supplemental oxygen?

You can't just treat the numbers, but use them to formulate a treatment plan.


NYMedic828 said:


> Find me a documented case where a lawsuit was opened yet alone lost because oxygen was not administered when it wasn't indicated or a patient was not long boarded. (good luck)


According to current standards/protocols, oxygen is always indicated.  until the standards and protocols are changed, failing to administer oxygen is failing to do your job according to current standards, which can be cause for termination.  You might be right but until the governing body catches up, it's going to be an uphill battle winning that fight.

I do know of people who were disciplined for not C-spining people, and people who were not disciplined for over c-spining people.


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## NYMedic828 (Sep 3, 2012)

You are without a doubt the most irritating person on the forum to debate with...

AHA doesn't recommend oxygenation unless symptoms of respiratory distress are present and or an SpO2 of <94%. If grandmas sat is 74, she is administered o2, titrated to 94-100%.

ACLS is a standard utilized by ALL levels of medical provider in the country. Oxygenating every last patient is only done by EMS. Maybe there is a reason no one else does it? Does every arrest need 5mg of epi, no and it hasn't been proven to do anything at all but other aspects of ACLS do in fact work. ACLS in and of itself is an ongoing study of trials and error, as it is designed to be.

And my protocols in NYC have a section stating that "these protocols are guidelines not to be used in place of good clinical judgement." Basically, it is saying that the protocols exist as they do so that even the
 most incompetent of providers can't do too much wrong.


And being "disciplined" for c-spine criteria at an agency level is FAR different from a lawsuit. Odds are the person doing the disciplining wasn't much more competent than the persons getting a talking to. If a provider is proficient in there abilities, being disciplined should not worry them unless they know they truly did wrong. Always be able to justify your actions and you will remain safe.


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## mycrofft (Sep 3, 2012)

_Reductio ad absurdum_ threads (take away oxygen, get rid of EMT's) invite wide-swinging arguments.


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## Veneficus (Sep 3, 2012)

mycrofft said:


> _Reductio ad absurdum_ threads (take away oxygen, get rid of EMT's) invite wide-swinging arguments.



I actually have considerable reservations about eliminating tools from the box as a means of compensating for poor quality providers.

It has not worked in the past and I don't see anything that would suggest doing it now would have any different of an outcome.


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## Aprz (Sep 3, 2012)

NYMedic828 said:


> Find me a documented case where a lawsuit was opened yet alone lost because oxygen was not administered when it wasn't indicated or a patient was not long boarded. (good luck)
> 
> Pulse-oximetry is a non invasive form of quantitative monitoring. Not all places have it for BLS. In NY it is optional for BLS mandatory for ALS.
> 
> ...


I think he was being sarcastic about the pulse ox.


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## Sandog (Sep 3, 2012)

NYMedic828 said:


> Find me a documented case where a lawsuit was opened yet alone lost because oxygen was not administered when it wasn't indicated or a patient was not long boarded. (good luck)
> 
> .



Failure to C-spine

*FANG v. UNITED STATES*
UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT
Nos. 96-56800 97-55028
March 31, 1998

Fang's mother, plaintiff Pearl Bei Fei Fang, brought this wrongful death action which, in part, alleged the negligent failure of National Park Service ("NPS") employees to (1) *properly stabilize Fang's spine prior to treatment;* (2) administer to Fang proper CPR; (3) carry all of the equipment necessary to Fang's treatment with them to the accident site.


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## JPINFV (Sep 3, 2012)

Sandog said:


> Failure to C-spine
> 
> *FANG v. UNITED STATES*
> UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT
> ...




...and the only thing we know is that there was a case (granted, that was all that NYMedic asked for), not what the final decision in the case was.


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## DrankTheKoolaid (Sep 3, 2012)

Just read that case summary.  

Interesting read actually and not quite applicable as the equipment was not on hand at the time of the incident.


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## JPINFV (Sep 3, 2012)

Corky said:


> Just read that case summary.
> 
> Interesting read actually and not quite applicable as the equipment was not on hand at the time of the incident.



Plus the appeals court case dealt only with the argument that the government has immunity against the claims, not whether the claims were successful. That issue was sent back down to the trial court to be heard.


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## mycrofft (Sep 3, 2012)

http://classweb.gmu.edu/erodger1/prls560/content/fang.htm

Description of incident:

After requesting additional medical personnel and supplies through dispatch, the two EMTs grabbed their emergency medical kits, a radio, and a partially full portable oxygen tank with delivery system and went down the hill. Upon finding Fang, the EMTs cleared her airway and administered oxygen _without attempting to move her_*. No immediate attempt was made to stabilize her spine. Approximately fifteen minutes after the accident, Fang stopped breathing. Cavanna and Boes, with the assistance of another of the car's passengers,_ then began to administer cardiopulmonary resuscitation_* ("CPR").

After the arrival of additional medical support and equipment, Fang was placed in a cervical collar and strapped to a backboard. _Then, using climbing ropes, the EMTs transported her up the mountain. This process took approximately fifty-five minutes, during which CPR was continuously administered.*_ Unfortunately, Fang was pronounced dead upon her arrival at the top of the hill. The cause of death was listed as "cervical fracture."
Basis of the claim:

"...wrongful death action which, in part, alleged the negligent failure of National Park Service ("NPS") employees to (1) properly stabilize Fang's spine prior to treatment; (2) administer to Fang proper CPR; (3) carry all of the equipment necessary to Fang's treatment with them to the accident site".


Plaintiff lost, then appealed. Findings of the appeals court:

"The appeals court, therefore, concluded that the Fang's equipment claim is precluded by the discretionary function exception. As a result, the appeals court affirmed the district court's dismissal of this claim.

Having found that Fang's spine stabilization and CPR claims against the United States were not precluded by the discretionary function exception, the appeals court reversed the summary judgment in favor of the United States and remanded (i.e., sent back) these two claims to the district court for further proceedings. In so doing, the appeals court expressed "no opinion on the facts underlying these claims or their outcome" at a future trial in the district court.

So it was the usual clustermug a multiple victim MVA in the middle of nowhere turns into, then they did CPR continuously while ascending a 45 deg angle hill for 210 feet (was that 210 vertical or linear?)/55 minutes. The final finding (I wonder if it is still going on?) was "no" to part, and "maybe, try again" to another part.

PS: MOI note: ejected from car during the accident. Other passengers ok enough to help.


* emphasis added by Mycrofft


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## DrankTheKoolaid (Sep 3, 2012)

Family looking for a payout after the victims own negiligence caused the ejection in the first place (no seatbelt use).  These cases really should not even make it into the court system, absolute shame.


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## JPINFV (Sep 3, 2012)

mycrofft said:


> Plaintiff lost, then appealed. Findings of the appeals court:




That's the rub. The case looks like it was dismissed erronously by the trial court. As such, it's hard to discuss the applicablity of this case because no actual ruling to the basis of the specific claim is discussed in the appeals court ruling. It looks like it was dismissed prior to going to trial.


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## Aidey (Sep 3, 2012)

Here is a case in which a patient was taken out of c-spine precautions at the hospital, and later became paralyzed. The court found in favor of the defendants and basically told the kid if he hadn't been a drunk obnoxious jackass then maybe everyone else could have done their job.


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## Aidey (Sep 3, 2012)

Here is a case in which the defendant was found 35% responsible for damages after a patient sustained neurological damage during a move in the hospital. The pt had a confirmed back injury the IFT company didn't know about, and they used sheet to slide him, resulting in injury. There was testimony that a back board would have been the only proper way to move him, however it all happened in 1976 and I think a couple good expert witnesses could have argued that the log roll to get him onto the back board would have been just as likely to cause the injury as the sheet slide.


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## mycrofft (Sep 3, 2012)

Corky said:


> Family looking for a payout after the victims own negiligence caused the ejection in the first place (no seatbelt use).  These cases really should not even make it into the court system, absolute shame.



1. Driver is also negligent. At least in Calif.

2. That was immaterial to the basis of the suit. I threw it in because I thought it was ironic.

The lessons I got form it were not to claim you are doing adequate CPR while moving a subject up a steep incline, etc. Like I tell my cat, whem you take a dump on linoleum, acting like you are covering it up makes it no better.


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## mycrofft (Sep 4, 2012)

Aidey said:


> Here is a case in which the defendant was found 35% responsible for damages after a patient sustained neurological damage during a move in the hospital. The pt had a confirmed back injury the IFT company didn't know about, and they used sheet to slide him, resulting in injury. There was testimony that a back board would have been the only proper way to move him, however it all happened in 1976 and I think a couple good expert witnesses could have argued that the log roll to get him onto the back board would have been just as likely to cause the injury as the sheet slide.



The lesson is when you transport, get an order about how. Spineboard is not actually something you do as an EMT during an IFT unless the pt fell there and was going to a hospital; it is not customary nor likely to have to re-spineboard someone for an IFT. I think the court got tangled up in the service and wanted to make sure SOMEONE paid the patient SOMETHING.


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## Aidey (Sep 4, 2012)

From what I could understand the company was found 35% at fault not really because the of the lack of backboard, but because they didn't get a good enough report and failed to know about the back injury. 

Frankly the vast majority of the cases I found against EMS were patients that were placed in spinal motion restriction and were paralyzed anyway. Lots of suits claiming it wasn't done fast enough, or right or the patient was moved incorrectly after. And lots of judgements in favor of the defendants.


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## leoemt (Sep 4, 2012)

Regarding Oxygenation, they teach us to always oxygenate and in class it is always a 15lpm NRB. 

Being new, I am probably guilty of over oxygenating my patients at times. My clinical skills aren't as developed as other providers and I am still learning. I do make a point to research conditions as much as possible so that I can better understand for future calls. 

However, I disagree with minimizing oxygen delivery. In a pre-hospital setting it is unlikely that over oxygenation is going to cause any ill effects. Yes, Oxygen is a drug and should be treated as such. However, one of its benefits is it does provide a calming effect. 

I am not allowed to withold oxygen. If they want it they get it. The problem with oxygen is many underlying conditions can affect its delivery. That is starting to get into diagnostic territory which is not my job. 

Oxygen was one of the most confusing parts of my EMT class because there are no clear cut answers. When do you use an NC or an NRB? What about medium concentration vs high? CPAP? BiPap?

Even doctors screw this up. I treat my patients and I do my best to provide appropriate treatment and as my clinical skills develop, my oxygen use is going down. However, I err on the side of caution and they get O2 if they need it or if I am not sure.


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## Veneficus (Sep 4, 2012)

leoemt said:


> However, I disagree with minimizing oxygen delivery. In a pre-hospital setting it is unlikely that over oxygenation is going to cause any ill effects.



How do you know this? 



leoemt said:


> That is starting to get into diagnostic territory which is not my job.



Do basics in your area give ntg? That is diagnostic
Do they use a glucometer? That is diagnostic
Pulse oximeter? Diagnostic
physical exam and history? Diagnostic



leoemt said:


> there are no clear cut answers. When do you use an NC or an NRB? What about medium concentration vs high? CPAP? BiPap?



Welcome to medicine 



leoemt said:


> Even doctors screw this up. I treat my patients and I do my best to provide appropriate treatment and as my clinical skills develop, my oxygen use is going down. However, I err on the side of caution and they get O2 if they need it or if I am not sure.



Fair and reasonable.

I don't like it, but it is.


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## mycrofft (Sep 4, 2012)

Jumping clear now. Have a good day.


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## JPINFV (Sep 4, 2012)

leoemt said:


> However, I disagree with minimizing oxygen delivery. In a pre-hospital setting it is unlikely that over oxygenation is going to cause any ill effects. Yes, Oxygen is a drug and should be treated as such. However, one of its benefits is it does provide a calming effect.



So because something doesn't hurt in your time horizon, the risk shouldn't be considered? What ill effects are you looking for? If generating unneeded free radicals affects the final outcome, why would the patient need to immediately get worse with the administration of supplemental oxygen?


> I am not allowed to withold oxygen. If they want it they get it. The problem with oxygen is many underlying conditions can affect its delivery. That is starting to get into diagnostic territory which is not my job.



I agree... EMS shouldn't withhold oxygen. That's a good way to kill patients. 

Now withholding *supplemental *oxygen is a different issue altogether. Are you suggesting that EMTs are not trained or educated to determine when one of their primary interventions aren't needed? If I can't trust an EMT to provide good judgement on whether supplemental oxygen is needed, why should I trust them with any other judgement call? 

Finally, if diagnostics isn't your job, why do a history and physical? I'm serious, if you aren't supposed to come to some sort of conclusion based off of your history and physical, and use that to guide your treatments, why even perform a history and physical? 



> However, I err on the side of caution and they get O2 if they need it or if I am not sure.


How is over treatment erring on the side of caution?


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## Sandog (Sep 4, 2012)

So how often are Reactive oxygen an issue, what condition? Does not the body have anti-oxidants to counter this. Just curious. I do know radical oxygen is making my skin age. :sad:

To put it another way, when would oxygen be contraindicated for worry of radicals?


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## JPINFV (Sep 4, 2012)

Sandog said:


> So how often are Reactive oxygen an issue, what condition? Does not the body have anti-oxidants to counter this. Just curious. I do know radical oxygen is making my skin age. :sad:



The body is set up to handle 21% oxygen, not 100% oxygen. Are there ways to handle reactive oxygen species? Sure. The problem is that sometimes those defenses are compromised, and even when they're not they're not designed to protect against 100% oxygen continuously. 



> To put it another way, when would oxygen be contraindicated for worry of radicals?



I think "contraindicated" is too strong of a word. There's very few times that oxygen is truly "contraindicated" in a patient who actually needs oxygen. The problem is that EMS more often administers oxygen to patients where oxygen isn't indicated outside of the indication of "ambulance."


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## leoemt (Sep 4, 2012)

JPINFV said:


> So because something doesn't hurt in your time horizon, the risk shouldn't be considered? What ill effects are you looking for? If generating unneeded free radicals affects the final outcome, why would the patient need to immediately get worse with the administration of supplemental oxygen?
> 
> 
> I agree... EMS shouldn't withhold oxygen. That's a good way to kill patients.
> ...



On the 911 side, I am with a patient for about 15 mins. Obviously some calls take longer than others, but we have a luxury of having hospitals close by. 

As a Basic I cannot give NTG. I CAN assist a patient with it after obtaining Medical Control Authorization. In this state we are allowed to do glucometry (though some counties consider it an ALS skill). What is your point? How is that a Diagnosis? Hypoglycemia or Hyperglycemia is a symptom that I can address. However I don't diagnose the condition. Does Hypoglycemia automatically mean they are Diabetic? No it doesn't. 

It takes initials after your name to make a clinical Diagnosis. I MAY know what is going wrong, I MAY know what their treatment will be but that doesn't mean it is definitive. Is every cancer patient going to receive Chemo? Does every Diabetic patient receive Insulin. 

There is a big difference in making a diagnosis and having a reasonable suspicion as to what is wrong. If you are ever called to court for your treatment you better be able to articulate the two. 

There is a lot I can do for a patient and even more a Paramedic can do. However we are not the definitive care. 

Concerning over oxygenation not every person gets15lpm via NRB. Just because I give O2 doesn't mean they are getting the same level of O2. Room air is 21% oxygen. Depending on delivery methods, supplemental oxygen can be anywhere from 24% - 100%. Just because there is 100% O2 in the tank doesn't mean the patient is being saturated with 100%. 

There are a lot of benefits to oxygen. I am not advocating giving oxygen to every patient, but in the pre-hospital setting the benefits far outweigh the risks. I have never seen a medic or a basic withhold supplemental o2. 

Until my doctors change the protocols, I will continue to give O2 as necessary.

This is the article I have been reading, even before this thread was started. It is an interesting read. Even though it states the risks of over oxygenation, it typically takes around 72 hours for those risks to become apparent. That is LONG after we have turned them over to the ER. http://www.jems.com/behind-the-mask

As my clinical abilities improve I am less likely to jump to O2, and if I do I don't always do the 15lpm NRB. I think many people confuse the prehospital setting with long term oxygen use. 

Again, education is key but don't be afraid of giving the O2. If in doubt there is always Medical control.


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## NYMedic828 (Sep 4, 2012)

leoemt said:


> On the 911 side, I am with a patient for about 15 mins. Obviously some calls take longer than others, but we have a luxury of having hospitals close by.
> 
> As a Basic I cannot give NTG. I CAN assist a patient with it after obtaining Medical Control Authorization. In this state we are allowed to do glucometry (though some counties consider it an ALS skill). What is your point? How is that a Diagnosis? Hypoglycemia or Hyperglycemia is a symptom that I can address. However I don't diagnose the condition. Does Hypoglycemia automatically mean they are Diabetic? No it doesn't.
> 
> ...



Without being at a computer it is difficult to properly address your entire post but right off the bat I can tell you 99% of the above could not be further from the truth.

Also, hypoglycemia IS a diagnosis secondary to a disease, diabetes. Altered mentation, diaphoresis, skin temperature/color changes are sings/symptoms.


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## Tigger (Sep 4, 2012)

leoemt said:


> Regarding Oxygenation, they teach us to always oxygenate and in class it is always a 15lpm NRB.
> 
> Being new, I am probably guilty of over oxygenating my patients at times. My clinical skills aren't as developed as other providers and I am still learning. I do make a point to research conditions as much as possible so that I can better understand for future calls.



Maybe I was just lucky with my class, but that was never really emphasized. If it is clinically indicated to give oxygen, provide in the proper manner. The key of course is to know when it is in fact clinically indicated...


> However, I disagree with minimizing oxygen delivery. In a pre-hospital setting it is unlikely that over oxygenation is going to cause any ill effects. Yes, Oxygen is a drug and should be treated as such. However, one of its benefits is it does provide a calming effect.


Do you have any evidence beyond personal anecdote to back up oxygen's calming properties? I have not found much. It is not a mystery drug, it helps with respiratory distress and that's about it. Many patients of mine report that oxygen agitates them instead. I too might be a bit agitated too with plastic prongs jammed in my nose or mask pressed to my face blasting a very dry gas. An NRB makes talking and listening to your patient much more difficult as well.



> I am not allowed to withold oxygen. If they want it they get it. The problem with oxygen is many underlying conditions can affect its delivery. That is starting to get into diagnostic territory which is not my job.
> 
> Oxygen was one of the most confusing parts of my EMT class because there are no clear cut answers. When do you use an NC or an NRB? What about medium concentration vs high? CPAP? BiPap?



You can certainly withhold oxygen to a patient if there is no clinical indication for its use. Now if my patient says that they would like some (COPD etc) then sure they can have some even if my assessment doesn't indicate it. But if the patient says they don't want it and it's not indicated, then you aren't withholding it. 

If you aren't comfortable with "diagnosing" a patient that's fine, but realize that you need to base your treatments off of your clinical impression. Based upon such an impression you should have a lot better idea on how to administer oxygen.


I've said it once I'll say it a million times. We don't give everyone oral glucose, so why does everyone get oxygen?


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## Sandog (Sep 4, 2012)

leoemt said:


> On the 911 side, I am with a patient for about 15 mins. Obviously some calls take longer than others, but we have a luxury of having hospitals close by.
> 
> As a Basic I cannot give NTG. I CAN assist a patient with it after obtaining Medical Control Authorization. In this state we are allowed to do glucometry (though some counties consider it an ALS skill). *What is your point? How is that a Diagnosis? Hypoglycemia or Hyperglycemia is a symptom that I can address.* However I don't diagnose the condition. Does Hypoglycemia automatically mean they are Diabetic? No it doesn't.
> 
> ...




Looks like I can't just respond in the quotes, so here is blah blah.


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## JPINFV (Sep 4, 2012)

leoemt said:


> On the 911 side, I am with a patient for about 15 mins. Obviously some calls take longer than others, but we have a luxury of having hospitals close by.
> 
> As a Basic I cannot give NTG. I CAN assist a patient with it after obtaining Medical Control Authorization. In this state we are allowed to do glucometry (though some counties consider it an ALS skill). What is your point? How is that a Diagnosis? Hypoglycemia or Hyperglycemia is a symptom that I can address. However I don't diagnose the condition. Does Hypoglycemia automatically mean they are Diabetic? No it doesn't.



Actually, hypoglycemia is very much a diagnosis. 


> *2012 ICD-9-CM Diagnosis Code 251.2*
> 
> *Hypoglycemia, unspecified*
> 
> ...



http://www.icd9data.com/2012/Volume1/240-279/249-259/251/251.2.htm

It's just like any other issue with blood concentrations, like hypo/hyper-calcemia, kalemia, natremia. Just because it's often caused by diabetes and can be caused by other diseases doesn't mean that it, itself, is not a diagnosis. 


> It takes initials after your name to make a clinical Diagnosis. I MAY know what is going wrong, I MAY know what their treatment will be but that doesn't mean it is definitive. Is every cancer patient going to receive Chemo? Does every Diabetic patient receive Insulin.



As someone over halfway to getting those magical initials, there's nothing special about making a diagnosis. I swear, we don't get a decoder ring, or some sort of special hand shake, or even a cape (thankfully)


> There is a big difference in making a diagnosis and having a reasonable suspicion as to what is wrong. If you are ever called to court for your treatment you better be able to articulate the two.



You mean like the difference between a working *diagnosis*, a differential *diagnosis*, and a discharge *diagnosis*? Yep, there's a difference between them. Wanna guess what the common theme is between them?



> There is a lot I can do for a patient and even more a Paramedic can do. However we are not the definitive care.



Cool beans. No one is saying  you are definitive care. Wanna know a little secret? When the emergency physician admits a patient to the internal medicine team or surgery or some other specialty, they aren't definitive care either. Do you think that emergency physicians don't diagnose? Do you think that the admission diagnosis always matches the discharge diagnosis, especially in anything that isn't completely textbook? 


> Concerning over oxygenation not every person gets15lpm via NRB. Just because I give O2 doesn't mean they are getting the same level of O2. Room air is 21% oxygen. Depending on delivery methods, supplemental oxygen can be anywhere from 24% - 100%. Just because there is 100% O2 in the tank doesn't mean the patient is being saturated with 100%.
> 
> There are a lot of benefits to oxygen. I am not advocating giving oxygen to every patient, but in the pre-hospital setting the benefits far outweigh the risks. I have never seen a medic or a basic withhold supplemental o2.



What benefits are there for oxygen in patients who are eupneic with a normal SpO2? "Look, we did something"? 


> Until my doctors change the protocols, I will continue to give O2 as necessary.



I guess I'm just lucky that the strictest protocols for oxygen use I've ever worked under as an EMT used the words, "as clinically indicated." Not indicated, not given. 


> This is the article I have been reading, even before this thread was started. It is an interesting read. Even though it states the risks of over oxygenation, it typically takes around 72 hours for those risks to become apparent. That is LONG after we have turned them over to the ER. http://www.jems.com/behind-the-mask



Um, that 72 hours related directly to mortality in animals administered 100% oxygen, not the other complications like damage from reactive oxygen species. Additionally, just because there's a latent period between removing the insult and the onset of complications doesn't mean that the insult doesn't cause the complications. 



> As my clinical abilities improve I am less likely to jump to O2, and if I do I don't always do the 15lpm NRB. I think many people confuse the prehospital setting with long term oxygen use.



I think many people in EMS, including unfortunately many educators, think that oxygen is some sort of wonder drug. It isn't Paracetamoxyfrusebendroneomycin.


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## Sandog (Sep 4, 2012)

> I think many people in EMS, including unfortunately many educators, think that oxygen is some sort of wonder drug. It isn't Paracetamoxyfrusebendroneomycin.



Don't use words you can't pronounce.


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## Sandog (Sep 5, 2012)

JPINFV said:


> The body is set up to handle 21% oxygen, not 100% oxygen. Are there ways to handle reactive oxygen species? Sure. The problem is that sometimes those defenses are compromised, and even when they're not they're not designed to protect against 100% oxygen continuously.
> 
> 
> 
> I think "contraindicated" is too strong of a word. There's very few times that oxygen is truly "contraindicated" in a patient who actually needs oxygen. The problem is that EMS more often administers oxygen to patients where oxygen isn't indicated outside of the indication of "ambulance."



Based on what you say, I would think the best we can do is understand airway management, base our findings on current level of training, use visual indicators such as difficulty in breathing, perhaps vitals for further diagnostics, even pinch the nail for perfusion. Use the tools we have been given, and then follow our protocols. I think the protocols are pretty clear as to when O2 is indicated. I am unclear as to what you mean "when not indicated". Surely the protocols do not indicate O2 for a broken arm, but they do indicate for shortness of breath and blue lips.

Not trying to be a wise guy, rather, seek enlightenment.


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## Veneficus (Sep 5, 2012)

Sandog said:


> Based on what you say, I would think the best we can do is understand airway management, base our findings on current level of training, use visual indicators such as difficulty in breathing, perhaps vitals for further diagnostics, even pinch the nail for perfusion. Use the tools we have been given, and then follow our protocols. I think the protocols are pretty clear as to when O2 is indicated. I am unclear as to what you mean "when not indicated". Surely the protocols do not indicate O2 for a broken arm, but they do indicate for shortness of breath and blue lips.
> 
> Not trying to be a wise guy, rather, seek enlightenment.



I think this is where the misconception is.

This is an obsolete view of airway management. It is from an era when it was assumed they could all be grouped into 1 simple task and if it wasn't working it was was for greater minds to figure out.

It is not possible to deflect lack of knowledge or "just following orders" and claim professionalism or demend respect from others in the healthcare community as a healthcare team member.

Ventilation, oxygenation and respiration are all seperate processes. The pathologies that result from them cannot always be treated simply by giving oxygen.  

Take for one example hemorrhage, with loss of both blood volume, and heme, you have lost 2 of the 3 parts of oxygen delivery. Adding more oxygen isn't going to really matter.

Think of it like a train, oxygen delivery requires intact vascular volume (tracks) Heme (train cars) and cardiac output (the engine) Oxygen is the cargo. 

No tracks, no cars, and you can add all the cargo in the world and go nowhere with it. But sooner or later it will break somebody's back.

Sure somebody might argue that by raising the Po2, then you maintain heme saturation, but the problem isn't that there is not enough to saturatate, the problem is similar to anemia, there isn't enough blood to carry that oxygen.

As JP said, when you over oxygenate, you cause harm. Perhaps not perceptable by you in your short time. But it is like lighting dynamite and running away, you might not see the destruction, but you certainly caused it. 

That leaves the people you drop the patient off at to clean up your mess. (At least try to)

You might even take years off of the end of life and not this acute event. 

You can induce pulmonary damage, which may form scar. You can induce renal damage, which may not heal, you can even induce liver damage. (did you know lliver damage from tylenol OD is actually from free radical formation?) Which means Your oxygen might ultimately make things worse.

Now let's say you lose 1% of your lung function forever and/or 0.5% renal function from a short event of 100% o2 by NRB. It probably won't show up clinically or even on a lab. But then what if you do this to a person 5 times throughout their life. Plus the loss of function from the normal process of aging, plus any other acute or chronic pathology you add?

That 0.5 or 1% might be the difference between quality of life or total life down the road for that person. 

How do you look at a patient and say "I might take a few years of your life away from you , but it makes me comfortable to take the risk and do this to you today."

What if your patient is truly critical? O2- (superoxide) is one of the things your immune cells use to protect you, it is also what your body uses to kill some of its own cells. It works like a bomb, it doesn't matter what it hits. 

So lets say your patient has neutrophils getting filtered in the lung, because they get filtered by in the lung and kidneys .(Everytime epinepherine is released into your system, your circulating neutrophils increase by 50%) some of these will degranulate and cause damage most likely in the lung and kidney. (with superoxide) Now you come along and add more oxygen to it. Amplifying the damage.  2 days later the patient is in the ICU with ARDS. Did you make it worse? Did you incite it? Truthfully we will not ever know. But we do know you did what can incite it or make it worse.

So much for "do no harm."

Now the argument becomes "why was it written into protocol?" Because it was written by people who had no idea of this stuff at the time or simply didn't care because they thought just like you do. "As long as they don't die here, then we didn't kill them."

Today's standards of care take far more evidence to change than they did to implement. (I know cause I try to change them all the time.) If anyone will even let you gather the evidence or change them even in the face of overwhelming evidence. 

I don't think it is reasonable for an EMT-B to know and understand this level of pathophysiology while drinking coffee at starbucks, but I think it is very reasonable to demand that the same EMT-B understand that not every patient they see should be given high doses of a drug because it might harm in the long term.

I will never give professional acknowledgement or respect to any individual who hides behind "just following orders" to make up for lack of knowledge or deflect responsibility. 

That is not the behavior of a professional.

Accepting responsibility, educating oneself, and promoting change based on new information are things professionals do.

You can no longer claim ignorance. I just explained it to you...

For free.

Considerably more than your EMT instructor probably ever told you.


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## Veneficus (Sep 5, 2012)

*correction of error*

Circulating neutrophils increase 100%.

I meant to say they double and for some reason typed 50%.

Sorry.

My fault.


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## NYMedic828 (Sep 5, 2012)

Veneficus said:


> Circulating neutrophils increase 100%.
> 
> *I meant to say they double and for some reason typed 50%.
> *
> ...



Entire post is now invalid. You are going to have to explain it all over again.





On a more serious note thanks for that, very informative as always.

Unfortunately, the lowest common denominator, even the mid-range common denominator is often far too set in their ways to change. The second problem is the information you posted will never reach them because those who instruct, often instruct wrongly.

In my experience, the people I work with are quite honestly a lost cause. (both volunteer and paid) There are those few great people who enjoy reading journals and forums but for the rest it is just a paycheck. They think because they can already perform the skill, it makes them as good as a doctor who can do the same. They don't care to understand why or how it works they just want to be told they are awesome because they can do it.

The standards of EMS quite honestly seem to get lower and lower. (I believe it is actually the only form of medical provider that can physically administer real treatments that does not require a single college credit in many areas) 

I don't like picking on people, but the posts in this thread by "leoemt" are a prime example of how low EMS is falling. Someone comes into a thread, states blatantly that they are new and learning and then writes an essay length response to justify the fact that they are right, and we are wrong because their inexperienced and incompetent EMT class instructor told them otherwise. The "i know everything" mindset is too widespread in EMS at this point to be reversed.

As I have said before, EMS will die. Not today, not tomorrow, but eventually. Some would say this is a harsh statement but I see it as a completely plausible reality evidenced by the fact that healthcare costs continue to rise, EMS services are costing municipalities money instead of profiting in many areas and the biggest factor being that the medical world is advancing at speeds far beyond that which is fathomable by the base level EMS provider to keep up with. Once it all comes crumbling down, and it will, we can rebuild with an entirely new set of plans all together.


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## the_negro_puppy (Sep 5, 2012)

See the problem lies with Clinical freedom. A few pages back I posted out protocols for Oxygen therapy. If we don't follow that chart and can justify why, management are happy as long as there is a clinical reason behind it. From what I read here, failing to follow 'protocols' exactly in other services could lead to your termination. When I first started nearly 3 years ago, we used oxygen more; on all chest pains etc. Now it is rarely used. The last 2 times I have used it were on COPD patients, one with a LRTI leading to exacerbation that required supplemental 02. Even then it was titrated to effect.The other was for a severely hypoxaemicCOPD pt with influenza A and losing the battle.


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## RocketMedic (Sep 5, 2012)

Veneficus, how do you feel about supplemental oxygen in hyperventilation  with associated hypocarbia?


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## Veneficus (Sep 5, 2012)

Rocketmedic40 said:


> Veneficus, how do you feel about supplemental oxygen in hyperventilation  with associated hypocarbia?



I am not sure what to think of it actually. 

I see mixed results in the trauma studies I saw.

Edit: but I do favor the studies that claim hyperventilation would likely induce brain ischemia. There are 2 logical mechanisms for that I can think of.


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## NYMedic828 (Sep 5, 2012)

Veneficus said:


> I am not sure what to think of it actually.
> 
> I see mixed results in the trauma studies I saw.
> 
> Edit: but I do favor the studies that claim hyperventilation would likely induce brain ischemia. There are 2 logical mechanisms for that I can think of.



I assume the first mechanism is cerebral vasoconstriction from hypocapnia?

What's the second reason if you don't mind explaining?


Also, has a nonrebreather been shown at all too help with reinhalation of CO2, regardless of it being a "non" rebreather? I imagine O2 cranked to 15 liters would quickly displace exhaled CO2 but maybe titrated to a specific flow rate would provide a happy medium?


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## Veneficus (Sep 5, 2012)

NYMedic828 said:


> I assume the first mechanism is cerebral vasoconstriction from hypocapnia?



That is the first.





NYMedic828 said:


> What's the second reason if you don't mind explaining?



Alveolar vascoconstriction comes immediately to mind.

I could probably make a pretty good case for hemolysis and bradycardia too.




NYMedic828 said:


> Also, has a nonrebreather been shown at all too help with reinhalation of CO2, regardless of it being a "non" rebreather? I imagine O2 cranked to 15 liters would quickly displace exhaled CO2 but maybe titrated to a specific flow rate would provide a happy medium?



Shown?

Not that I know of, but it stands to reason if you put a piece of plastic over somebody's mouth and nose, they probably will not inhale or exhale much. 

In TBI and other neurosurg, hypercapnia to some degree is demonstrated as theraputic, so I really don't know what anyone would hope to acheive doing exactly the opposite.

temporary hyperventilation can reduce ICP, but that does not stipulate hyper oxygenation.

I also read 2 studies on this today that show this hyperventilation is less effective than both mannitol and craniotomy.


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## NYMedic828 (Sep 5, 2012)

Veneficus said:


> That is the first.
> 
> 
> 
> ...



A few people have told me that hyperventilation is not truly that effective in reducing ICP and you are better off just effectively managing the airway and providing whatever other treatments that may be indicated.


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## Veneficus (Sep 6, 2012)

NYMedic828 said:


> A few people have told me that hyperventilation is not truly that effective in reducing ICP and you are better off just effectively managing the airway and providing whatever other treatments that may be indicated.



The reduction is temporary, for a few minutes.

It was meant to be a presurgical procedure, not a prehospital one.


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## Sandog (Sep 6, 2012)

> Now the argument becomes "why was it written into protocol?" Because it was written by people who had no idea of this stuff at the time or simply didn't care because they thought just like you do. "As long as they don't die here, then we didn't kill them."



Don't presume to know what I think. I asked my question to gain understanding.


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## Veneficus (Sep 6, 2012)

Sandog said:


> Don't presume to know what I think. I asked my question to gain understanding.



Sorry, 

I have heard that argument so many times over the years, I figured I would just pre-empt it.


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## Sandog (Sep 6, 2012)

Veneficus said:


> Sorry,
> 
> I have heard that argument so many times over the years, I figured I would just pre-empt it.



No worries, I was not making an argument, rather I presented my level of understanding and requested JP to elaborate in order to improve my knowledge.


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## JPINFV (Sep 6, 2012)

Sandog said:


> Based on what you say, I would think the best we can do is understand airway management, base our findings on current level of training, use visual indicators such as difficulty in breathing, perhaps vitals for further diagnostics, even pinch the nail for perfusion. Use the tools we have been given, and then follow our protocols. I think the protocols are pretty clear as to when O2 is indicated. I am unclear as to what you mean "when not indicated". Surely the protocols do not indicate O2 for a broken arm, but they do indicate for shortness of breath and blue lips.
> 
> Not trying to be a wise guy, rather, seek enlightenment.



Shortness of breath and blue lips? Sure. The problem is that many students are taught, and is reinforced by the NREMT medical practical, that the indication for supplemental oxygen is "ambulance." Furthermore, a lack of understanding on the difference between ischemia and hypoxia. Hyperoxygenating blood isn't going to relieve ischemia since the oxygen/blood isn't reaching the tissue anyways (think stroke and ACS). Compound this with a lack of understanding of how oxygen is transported, and the issues involved with oxygen (i.e. reactive oxygen species, vasoconstriction, etc) and you get the "give everyone oxygen for any complaint because it "can't hurt" lie. 


Now, yes, oxygen is relatively safe to give when not indicated, and if there was some over use then it really wouldn't be an issue (think narcan as a comma cocktail when everything that can be ruled out is ruled out... like hypoglycemia). The problem is that oxygen is the EMS equivalent of duck tape in frequency of use, with the efficacy of using chewed gum as an adhesive the vast majority of the time.


As an aside, I once did have someone post a protocol that called for oxygen for every single patient... period. I never saved the link and that was years ago.


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## Sandog (Sep 6, 2012)

Copy that, and thanks.


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## Undaedalus (Sep 7, 2012)

I'm just dropping through to post an observation, relevant or otherwise, that I have made in regards to one Mr. leoemt and his arguments concerning EMT field diagnosis and O2 administration.  

The tired rubric that EMTs do not diagnose in the field is as worn as the concept of universal O2 administration irrespective of clinical impression.  Both ideas are dogma perpetuated by lazy EMS instructors who would rather pass along dated ideas for the sake of ease, than teach concepts like titrate to effect, and judgement.  EMTs make diagnoses in the field every damn day.  Whether you are diagnosing the symptom or the cause is a separate issue, and apparently one that is lost on some.  The observation of signs/symptoms and use of diagnostic tools, along with the accumulation of as good of a Hx as possible leads a _clinician_ towards a diagnosis of the cause of the complaint, and hopefully some kind of care plan.  This is the biggest step a progressing EMT makes.. moving away from cookbook/checklist protocol and towards experiential field judgement.


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## Veneficus (Sep 7, 2012)

Undaedalus said:


> Both ideas are dogma perpetuated by lazy EMS instructors who would rather pass along dated ideas for the sake of ease, than teach concepts like titrate to effect, and judgement..



I would just like to point out that most EMS instructors can't teach these concepts because they do not know them.

Many, I would say "most" EMS instructors are simply teaching what they were taught and what they do. 

One of the things being developed for the recent curriculum changes by publishers specifically marketed at instructors is pre-made lessons on subjects that were formerly not part of the paramedic curriculum.

The ones I have seen actually have handouts to give students with the instructor copy having a few words on each bullet explaining why it is relevant to EMS.
(You know it is going to go horribly wrong when the teacher needs to be told why something is relevant next to the bullet point they are teaching)

I have even seen teachers hand out these documents and then tell students that they need to know the information for registry but it is not useful in the field. Then go right into a lecture about the usefulness of the coma cocktail in the USA in 2011.

Educated, knowledgable instructors are in the vast minority. Just as rare are ones who will admit they don't know something and get a content expert or consult their medical director as to why something is important enough to teach.

This same problem is repeated during field training. Many FTOs are promoted to such by seniority, not ability or education. This practice further perpetuates old practices. If you deviate from the FTO, you are considered insufficent and may face termination. 

Some agencies don't even have formal field interships. They just put you with a senior member (usually one that has espoused the very values of agency tradition) who arbitrarily decides if you are fit for duty or not. (Usually decided favorably if you do what they do) 

The problems of US EMS education are many and not easily solved.

I agree it will probably have to be redone from scratch. I still advocate it would be better served by being absorbed by nursing.


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## JMorin95 (Sep 13, 2012)

In the state Maine our EMS protocols state that we only have to titrate for an SPO2 of 95% better. Most likely if a patient is in between 95-100 we will not administer oxygen. If the pt. has COPD then the number to try and get is 85% or better, if a pt is on home oxygen at 2 lpm and is at 85% oxygen will not usually be administered unless there is stroke or severe hemorrage/shock of any kind.


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