# Shouting at Elderly?



## Noctis Lucis Caelum (Dec 31, 2008)

You are called to the house of a 85 year old female. As you approach, you hear the patient begin to moan. You learn from the patients daughter that her mother was cleaning a kitchen cabinet and had slipped. In order to get a chief complaint, you ask the patient if she feels any pain anywhere. The patient responds with a moan. Of the following, which is not an appropriate coarse of action in dealing with this patient?

A. Apply supplemental oxygen to the patient.
B. Prepare for spinal immobilization via a backboard.
C. Obtain baseline vital signs.
D. Shout your question louder because most elderly are hard of hearing

The answer is (D)

I was taught never to shout at geriatrics


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## akflightmedic (Dec 31, 2008)

Noctis Lucis Caelum said:


> You are called to the house of a 85 year old female. As you approach, you hear the patient begin to moan. You learn from the patients daughter that her mother was cleaning a kitchen cabinet and had slipped. In order to get a chief complaint, you ask the patient if she feels any pain anywhere. The patient responds with a moan. Of the following, which is  *****not******* an appropriate coarse of action in dealing with this patient?
> 
> A. Apply supplemental oxygen to the patient.
> B. Prepare for spinal immobilization via a backboard.
> ...



Of course the answer is D. Re read the question and I hope I made it easier for ya.


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## Noctis Lucis Caelum (Dec 31, 2008)

Err, sorry about that.  The answer says its A but i chose (D)


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## Sapphyre (Dec 31, 2008)

Um, was there a question here?  cause, this looks like you're just posting a test question, just to post a test question.


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## KEVD18 (Dec 31, 2008)

A. Apply supplemental oxygen to the patient. *is only appropriate if the patient actually needs oxygen. if they are satting well, exibiting no signs of resp distress, theres no need for 02.*
B. Prepare for spinal immobilization via a backboard.*  would arguably be appropriate.*
C. Obtain baseline vital signs.*  also not a bad answer.*
D. Shout your question louder because most elderly are hard of hearing*  further asses their level of conciousness. if they are responsive to painful only, you could shout at them all day and just make your throat sore.*


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## akflightmedic (Dec 31, 2008)

Only reason I agreed with A is because he is EMT and as we all know, on almost every single exam, the proper answer is high flow O2 and transport.

I chose D because you would not keep shouting at the person. My normal tone is enough for me to determine if a patient is going to answer or not, no further yelling required.

I do agree with KEV's explanations.


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## stephenrb81 (Dec 31, 2008)

EDIT:  I missed the *NOT*, makes my whole post obsolete lol


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## rhan101277 (Dec 31, 2008)

Unless indicated (i.e. respiratory distress) our protocols say give 4L via nasal cannula


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## FF894 (Dec 31, 2008)

rhan101277 said:


> Unless indicated (i.e. respiratory distress) our protocols say give 4L via nasal cannula



Meaning you would go NRB if resp distress?  Almost makes it sound as if you would withold oxygen if there was resp distress:wacko:


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## JPINFV (Dec 31, 2008)

I dislike the use of the verb "shout" in this question. I don't shout or yell at patients I'm standing next to. I will, though, if need be talk with a higher volume for assessment and/or disability reasons (ex. hard of hearing)


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## KEVD18 (Dec 31, 2008)

so what your saying is your protocols basically want you to do this:

if the patient has *no* difficulty breathing/respiratory compromise, give them 4l n/c.

if the patient *does* have difficulty breathing/respiratory compromise, give them high flow by mask.


so the question comes up again, why give oxygen to patients that dont need it?


and yes, im aware that the standard answer to every emt test question is high flow o2 and rapid transport to the closest appropriate facility, doesnt mean i have to agree with it.


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## marineman (Dec 31, 2008)

KEVD18 said:


> so what your saying is your protocols basically want you to do this:
> 
> if the patient has *no* difficulty breathing/respiratory compromise, give them 4l n/c.
> 
> ...



Common sense isn't covered in the 100 hour course.


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## JPINFV (Dec 31, 2008)

marineman said:


> Common sense isn't covered in the 100 hour course.




Common sense?

THIS IS EMS!


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## TexasEMTech (Jan 12, 2009)

*In my very humble opinion.*

While I was in school we was taught that a patient can always benefit from    o2.But,in this case,I'm not so sure I wouldn't grab a quick set of baseline vitals first to get a good benchmark of where the patient stands,especially airway and breathing since she was 82 yo.


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## CH47Doc (Jan 13, 2009)

rhan101277 said:


> Unless indicated (i.e. respiratory distress) our protocols say give 4L via nasal cannula



seems to me like they give you oxygen just cuz they have a big tank of it.:blink:


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## Labareda (Jan 17, 2009)

That idea of giving oxygen just for the hell of it is wrong, what if the patient is intoxicated with Paraquat? What if the patient suffers from COPD? In case of Paraquat you could actually kill the patient for giving him O2, and in the COPD you could cause him respiratory distress.


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## Epi-do (Jan 17, 2009)

Labareda said:


> That idea of giving oxygen just for the hell of it is wrong, what if the patient is intoxicated with Paraquat? What if the patient suffers from COPD? In case of Paraquat you could actually kill the patient for giving him O2, and in the COPD you could cause him respiratory distress.



First of all, I want to thank you for posting something that sent me on a search to learn more.  I wasn't familiar with Paraquat until now.  From what I have been able to find, while it is not recommended to give O2, I did read that if the patient was exhibiting signs of hypoxia that it should still be considered.  It appears that it needs to be administered cautiously, and everything states it is best to contact medical control for advice first.

Now, for the COPD myth.  If you have a patient with COPD that presents with any complaint that would indicate O2 should be administered, do not with hold it.  The short amount of time that a patient is with EMS is not enough to disrupt their respiratory drive.  It drives me nuts that this is still being taught, because it is completely false.  Heck, these patients will also receive O2 in the ER as needed.  O2 in COPD patients only becomes an issue in the long term, and even then some patients may very well end up on supplemental O2.


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## Labareda (Jan 17, 2009)

It's true what you say about COPD. The thing is, im supposed to follow the protocol. And I was told to never administer too much oxygen on a patient with this patology, and if the patient uses oxygen at home, never to give more than the amount that is prescribed by the medic. Thats why I stated it.
I was trying to give examples of situations where O2 isnt that great of a benefict, in an atempt to make him understand why the test says that the right answer was A.
About the Paraquat, intoxications with that substance are very rare. But still, just because it doesnt happen every day, doesnt mean we should not be prepared.


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## rhan101277 (Jan 20, 2009)

I went and looked over the protocols and we give 2L/min for pt's with COPD.  

4L/min as a precautionary measure for people with chest pain, stroke (beginning dose), trauma etc. 

High flow 15L/min indications for using this are bad perfusion or inadequate oxygenation.

If they are not breathing adequately, assisted ventilations are always better than just plain 02.

I wasn't meaning we slap oxygen on every patient, but if IFT are already on it we put them on what they were on.  Throughout my clinicals and now my part-time work I have never seen high flow O2 put on yet or have I seen a BVM in action.


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## JPINFV (Jan 20, 2009)

^
There's a difference between continuing an established therapy and starting/adjusting a therapy. Yea, if a patient is on continuous supplemental oxygen, then I'm not going to sit there and go under that limit. I'm free to increase that concentration during transport based off of my assessment, but that's the difference between continuing and initiating treatment. 

As far as "high flow" oxygen, the difference between 10 L/M and 15 L/M (this actually makes an interesting question, why is liters per minute abbreviated LPM and not L/M?) most of the time is how fast you're going to drain your tank. 




TexasEMTech said:


> While I was in school we was taught that a patient can always benefit from    o2.But,in this case,I'm not so sure I wouldn't grab a quick set of baseline vitals first to get a good benchmark of where the patient stands,especially airway and breathing since she was 82 yo.



If a patient can always benefit from supplemental oxygen, then why isn't every patient in the hospital on supplemental oxygen?



I'm curious, though, can anyone give me a link to one of these protocols that actually proclaim "Thou shalt give oxygen to all thy patients?"


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## EMTWintz (Jan 20, 2009)

although you are taught to never deny O2. If patient doesn't seem to need it, in you clinical judgement, ask if they would like to have a little. Most will say no thank you


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## JPINFV (Jan 20, 2009)

^
Why is the person who is supposed to be deciding on a treatment plan based off of an assessment asking a patient if they want a treatment that the assessment doesn't make? Does a paramedic ask a patient who denies having any pain if they want morphine 'just in case?' I've always been perplexed on how supplemental oxygen has gotten this reputation as being a miracle cure all.


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## MRE (Jan 21, 2009)

JPINFV said:


> ^
> Why is the person who is supposed to be deciding on a treatment plan based off of an assessment asking a patient if they want a treatment that the assessment doesn't make? Does a paramedic ask a patient who denies having any pain if they want morphine 'just in case?' I've always been perplexed on how supplemental oxygen has gotten this reputation as being a miracle cure all.



If you have a CAOx4 pt, why not make them part of their own care.  I'm not saying they should be telliing you what to do, but if you want to put them on a NC at 4L, tell them what you are doing if they have any questions or objections, talk to them about it instead of just shoving a tube under their nose.

In many cases, I think the O2 ends up being a placebo for the pt.  If you are a basic truck and have a pt who you can't do anything for except transport, a little O2 might also keep them from thinking that they would have been better off driving themselves to the hospital (admittedly not always the message we want to send).


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## JPINFV (Jan 21, 2009)

W1IM said:


> If you have a CAOx4 pt, why not make them part of their own care.  I'm not saying they should be telliing you what to do, but if you want to put them on a NC at 4L, tell them what you are doing if they have any questions or objections, talk to them about it instead of just shoving a tube under their nose.



Of course informed consent is something completely different than:


> If patient doesn't seem to need it, *in you clinical judgement*, _ask if they would like to have a little._


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## EMTinNEPA (Jan 21, 2009)

JPINFV said:


> I've always been perplexed on how supplemental oxygen has gotten this reputation as being a miracle cure all.



Because they assume that every single person on the planet who doesn't have MD, DO, PhD, RN, LPN, CNA, PHRN, or EMT-P behind their name is a complete and total moron who doesn't know how to exercise clinical judgment and make a determination as to whether or not a patient needs supplemental oxygen?


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## TexasEMTech (Jan 23, 2009)

Well JP,there's quite a bit of difference between the "hospital setting", and the "pre-hospital setting".It's always nice to know as much as you can about your patient,but as you probably know,you only get 100% of the story about 50% of the time.That's not necessarily because the patient deliberately withholds that information,but maybe he just doesn't think about everything, especially an 80 y/o person.So,when it's all said and done,it's the unknown that motivates a person,or at least that's what motivates me to take extra measures to prevent the unknown from taking hold,saying this,sometimes there are mistakes made,and sometimes there's really nothing that can be done in the pre-hosptal setting,especially by an emt-b.Do I give O2 to every patient I come in contact with? No.But ifIthink they will benefit from it I don't hesitate,or sometimes the best thing to do is simply ask them if they think oxygen would make them feel any better.Even though there is only one National Registry,some places from state to state just do things different,sometimes climate is a factor sometimes protocols take action.So until one knows how different places do things,it's really hard to criticize.


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## JPINFV (Jan 23, 2009)

TexasEMTech said:


> Well JP,there's quite a bit of difference between the "hospital setting", and the "pre-hospital setting".



So please tell me what magic quality supplemental oxygen possesses in the field that is immediately rendered useless upon moving the patient from the ambulance gurney to the hospital gurney? When the RN removes the NRB from the patient for a room air assessment and doesn't even put the patient back on oxygen you can't quite claim something as easy as lab values. 



> So,when it's all said and done,it's the unknown that motivates a person,or at least that's what motivates me to take extra measures to prevent the unknown from taking hold,



Do you call paramedics for all of your patients because of the unknowns?
Do you transport all of your patients emergently because of the unknowns? 
After all, if unneeded treatments are started 'due to unknown factors' why stop at oxygen? Why not go all the way for every patient? 




> ...or sometimes the best thing to do is simply ask them if they think oxygen would make them feel any better.Even though there is only one National Registry,some places from state to state just do things different,sometimes climate is a factor sometimes protocols take action.So until one knows how different places do things,it's really hard to criticize.


Again, why even go through class if it becomes the patient's choice on whether a treatment is needed or not (note: a patient deciding if a treatment is needed is not the same as a patient declining a treatment)? I'll ask it again, would it be appropriate for a paramedic to offer a patient who denies the presence of pain morphine (or any other narcotic) 'just in case?'

...and no, it's never hard to criticize protocols born from stupidity. As my signature says, "Tradition: Just because you've always done it that way doesn't mean it's not incredibly stupid."


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## TexasEMTech (Jan 24, 2009)

First of all,we're not talking about a strong narcotic here,it's O2.I don't give every patient oxygen.But,Let's say an emt gives every patient oxygen,what would that hurt? Until you have M.D. behind your name,don't tell me what I do is wrong,I have yet to criticize you,so quit making every person that sees your posts think you're a paragod. Not everything about about emergency medicine is a science,so you may want to quit treating it as so. I have learned that putting things that I am currently learning in school to use in the medical field without having the experience or supervision to do so can be tricky. Don't ever get in over your head,always play on the safe side.


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