# Forgot oxygen



## daughteroftheking (May 30, 2012)

I recently had a 63 year old male complaining of dizziness and nausea. Bp was found to be 190/110 and pulse 83. The pulse ox did not work, which is probably why I forgot the o2. Was this critical? I rechecked bp en route and it was 170/100 (a student took it the first time) bgl was 115. 
It was pretty hot in his office when we got there and he said he always had problems with heat. He said he also ate salmon that day which always makes him feel sick. Only medical history was hypertension which was managed by meds - he took his meds that day as well. 
Any thoughts on the benefits of o2 in this situation or possible diagnosis?


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## Veneficus (May 30, 2012)

he should probably take his meds.


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## daughteroftheking (May 30, 2012)

Sorry...I didn't make that clear. He took his meds the day of the call.


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## Martyn (May 30, 2012)

daughteroftheking said:


> I recently had a 63 year old male complaining of dizziness and nausea. Bp was found to be 190/110 and pulse 83. The pulse ox did not work, which is probably why I forgot the o2. Was this critical? I rechecked bp en route and it was 170/100 (a student took it the first time) bgl was 115.
> It was pretty hot in his office when we got there and he said he always had problems with heat. He said he also ate salmon that day which always makes him feel sick. Only medical history was hypertension which was managed by meds - he took his meds that day as well.
> Any thoughts on the benefits of o2 in this situation or possible diagnosis?


 
Sorry, but the why would the pulse ox not working make you forget the oxygen?


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## Veneficus (May 30, 2012)

There is not enough info to reasonably form a diagnosis, but with a BP that high, I am suspect if he really is taking his meds as directed or if his BP is "controlled" on his current medication regiment.

vascular occlusion, hemorrhage, HTN crisis, hyperthyroid, and neoplastic disease immediately come to mind. (in no particular order)

I don't think the lack of oxygen was a critical event.


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## Sasha (May 30, 2012)

daughteroftheking said:


> I recently had a 63 year old male complaining of dizziness and nausea. Bp was found to be 190/110 and pulse 83. The pulse ox did not work, which is probably why I forgot the o2. Was this critical? I rechecked bp en route and it was 170/100 (a student took it the first time) bgl was 115.
> It was pretty hot in his office when we got there and he said he always had problems with heat. He said he also ate salmon that day which always makes him feel sick. Only medical history was hypertension which was managed by meds - he took his meds that day as well.
> Any thoughts on the benefits of o2 in this situation or possible diagnosis?



What about this call makes you feel that oxygen was indicated?


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## NYMedic828 (May 30, 2012)

*We need to stop teaching people that every last patient needs oxygen...*

With hypertension and supposed compliance with his meds, something is off. Either he did not take them or its time to see his primary care physician. 

Excessive heat makes a lot of people dizzy/nauseated. Does not mean they need o2. Its not a respiratory problem and oxygen makes some people more nauseous. 

He ate salmon, which always makes him feel sick... Seriously? I know it makes me feel sick every time, but hey im gonna eat it anyway.

With my limited knowledge compared to a guy like ven, id say he didn't take his meds and he feels sick because of the salmon/heat.


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## EMT John (May 30, 2012)

NYMedic828 said:


> *We need to stop teaching people that every last patient needs oxygen...*
> 
> With hypertension and supposed compliance with his meds, something is off. Either he did not take them or its time to see his primary care physician.
> 
> ...




Agreed. +1

Salmon makes me sick. I think I'm going to go have some salmon. :rofl:


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## Martyn (May 30, 2012)

NYMedic828 said:


> *We need to stop teaching people that every last patient needs oxygen...*
> 
> With hypertension and supposed compliance with his meds, something is off. Either he did not take them or its time to see his primary care physician.
> 
> ...


 
I totally agree with this, however, our protocols state:


> *Cardiovascular Emergencies *
> [FONT=Arial,Arial][FONT=Arial,Arial]Stroke, CVA, TIA, Hypertensive Crisis [/FONT]
> [FONT=Arial,Arial]1. Size up the scene. [/FONT]
> [FONT=Arial,Arial]2. Formulate a General Impression. b. Begin oxygen administration (see Airway Management Protocol). [/FONT]
> ...


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## NYMedic828 (May 30, 2012)

Martyn said:


> I totally agree with this, however, our protocols state:



Unfortunately in almost all areas BLS protocols don't allow for much leniency. 

Our protocls state somewhere "these are guidelines not meant to replace good clinical judgement"

As a provider, if you feel treatment is not warranted or could even be harmful under the protocol you are supposed to follow, don't do it. But, make sure you have the knowledge to justify your actions should you come into question.


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## TatuICU (May 30, 2012)

HTN meds (especially B blockers)+ excessive heat + fish= anyone nauseated.  Excessive heat can place severe stress on your body and that stress can raise your blood pressure.  Your body is simply not as efficient a machine at certain temps which also places greater stress on the heart.

Protocol people may say something to you I guess, I see someone has already posted the monkey sheet for some reason as if it has any bearing on this particular pt.  

No difficulty breathing, no evidence of hypoxia (labored breathing, skin signs, AMS, etc).  Don't worry about it dude. No biggie. You won't forget to assess for the need next time because you know you forgot this time. Every day you will think you screwed up or will have truly screwed something up and every next day you'll be better for it. That's what being a good provider is. Self examination, experience and continuing education.


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## NYMedic828 (May 30, 2012)

TatuICU said:


> You won't forget to assess for the need next time because you know you forgot this time. Every day you will think you screwed up or will have truly screwed something up and every next day you'll be better for it. That's what being a good provider is. Self examination, experience and continuing education.



+1 Well said.

Id rather a provider who is willing to admit they did wrong and learn from it than a provider who thinks they did right, all the time.


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## TatuICU (May 30, 2012)

Martyn said:


> I totally agree with this, however, our protocols state:



protocols are guidelines which health care providers use in addition to their critical thinking skills and situational awareness to render to the best possible care to their patients given the situation.

If your protocols state for EMT-Bs to c-collar and LSB a fall from standing position (as a lot that I've seen do) in a pt with CHF who simply can't breathe in  a supine position what would you do then?

Guidelines my friend, guidelines.


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## Christopher (May 30, 2012)

Martyn said:


> I totally agree with this, however, our protocols state:



If your patient did not have a functional nose and your protocols state to place a nasal cannula on them if their SpO2 was 92-94%, would you be in trouble for not using a nasal cannula?

If your patient did not have a right arm and your back pain protocol required a blood pressure in both arms, would you be in trouble for not acquiring a right sided BP?

If your protocol insisted you punch old women on Tuesdays........well, we probably would follow that one without question.

Please, please, please do not replace sound clinical judgement with blind adherence to protocols.

And being an EMT-Basic does not mean you can't use clinical judgement to supplement protocol!

Pulse oximeters are not a measure of oxygenation, ventilation, respiration, or perfusion but rather a measure of bound hemoglobin in the peripheral capillaries (they don't even directly measure bound oxygen).

Thus the quantitative value can be used as an indirect measurement of oxygenation _IF AND ONLY IF_ it correlates with your physical examination and your clinical judgement.

If your physical exam and clinical judgement show the patient does not require supplemental oxygen...you shouldn't place them on supplemental oxygen.

Use SpO2 as a trending tool for oxygen therapy rather than a go/no-go for oxygen. You'll be doing your patients a great service.

Besides, the number of patients who actually need oxygen from EMS is shrinking as more and more studies come out showing the potential harm from hyperoxemia.

Did you miss anything or mess anything up? Absolutely not.

You were simply using clinical judgement without giving yourself credit!


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## Martyn (May 30, 2012)

Just to put away the can of worms I opened, I agree, I agree, I agree...got it? However, my original question was to do with the OP's comment:


> The pulse ox did not work, which is probably why I forgot the o2.


 
My question is just because the pulse ox was forgotten/not used, why did this make the OP 'not' use O²? Does this mean that even with cyanosis present if the pulse ox is not working you are still gonna 'forget' O²?


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## daughteroftheking (May 30, 2012)

*Reply*

Sorry! I wasn't too clear on forgetting the oxygen. In a non-respiratory emergency, I tend to judge how much o2 is needed based on pulse ox reading. There was no immediate indication for o2 on this one 
I now know that I should rely more on overall patient condition. I learned a lot from this call


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## JPINFV (May 30, 2012)

Martyn said:


> I totally agree with this, however, our protocols state:



By chance, are your protocols online, and if so can you link them?


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## JPINFV (May 30, 2012)

TatuICU said:


> protocols are guidelines which health care providers use in addition to their critical thinking skills and situational awareness to render to the best possible care to their patients given the situation.
> 
> If your protocols state for EMT-Bs to c-collar and LSB a fall from standing position (as a lot that I've seen do) in a pt with CHF who simply can't breathe in  a supine position what would you do then?
> 
> Guidelines my friend, guidelines.




Depends. I can post links to protocols that requires any deviations from the protocol to require a medical control consult. Of course this is a place where the "paramedics" are supposed to use the machine interp on 12 leads and call medical control on STEMIs since it's medical control's job to tell them to go to a hospital with a cath lab.


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## TatuICU (May 30, 2012)

JPINFV said:


> Depends. I can post links to protocols that requires any deviations from the protocol to require a medical control consult. Of course this is a place where the "paramedics" are supposed to use the machine interp on 12 leads and call medical control on STEMIs since it's medical control's job to tell them to go to a hospital with a cath lab.



Sounds like a place with very little respect for their employees.


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## JPINFV (May 30, 2012)

TatuICU said:


> Sounds like a place with very little respect for their employees.




It's a county wide protocol. It's funny because on one hand there's virtually no written BLS protocols (911 calls are always get paramedics, but since there are no private company paramedics most SNF calls are BLS) and some of their other protocols are relatively liberal (i.e. restraint policy, especially since a neighboring county requires all patients on a hold to be restrained). Yet other parts of the protocol are written in a very cook book manner, even with the current rewrite that loosened the wording a bit.


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## Martyn (May 30, 2012)

JPINFV said:


> By chance, are your protocols online, and if so can you link them?


  Sorry JP, they are available online only thru secure portal, obvoiusly can't send link but any you want to know about I can cut/paste etc (private ambulance company, need I say more?)


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## the_negro_puppy (May 30, 2012)




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## Tigger (May 30, 2012)

daughteroftheking said:


> I recently had a 63 year old male complaining of dizziness and nausea. Bp was found to be 190/110 and pulse 83. The pulse ox did not work, which is probably why I forgot the o2. Was this critical? I rechecked bp en route and it was 170/100 (a student took it the first time) bgl was 115.
> It was pretty hot in his office when we got there and he said he always had problems with heat. He said he also ate salmon that day which always makes him feel sick. Only medical history was hypertension which was managed by meds - he took his meds that day as well.
> Any thoughts on the benefits of o2 in this situation or possible diagnosis?



Not every patient needs oxygen, and odds are if you "forgot" it, they probably didn't need in the first place. Someone that needs oxygen is generally fairly obvious, and it's not going to take the reading of a pulse ox to make that decision.


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## JPINFV (May 31, 2012)

Martyn said:


> Sorry JP, they are available online only thru secure portal, obvoiusly can't send link but any you want to know about I can cut/paste etc (private ambulance company, need I say more?)




The problem is that it's a "I know it when I see it" thing. For something like this, however, what I would really be looking for is what the introduction to the protocol book says. Generally that's where you'll get whether it's written with "This is the bible of EMS that should be followed without question," vs "These generally should be followed because they're right, but you know... sometimes patients don't read the rule book." Similarly, what does the "Airway Management Protocol" say? That's what's referred to, and three times no less. I highly doubt that the protocol wants you to start oxygen therapy three separate times on the same patient.


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## bstone (May 31, 2012)

Repeat after me: O2, IV, Monitor. Those three things need to be done on basically every call. Repeat those three things and it'll become second nature.


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## JPINFV (May 31, 2012)

bstone said:


> Repeat after me: O2, IV, Monitor. Those three things need to be done on basically every call. Repeat those three things and it'll become second nature.



The only thing that has to be done on every call is an assessment. Supplemental O2, IV, and a monitor are definitely not needed on basically every call.


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## bstone (May 31, 2012)

JPINFV said:


> The only thing that has to be done on every call is an assessment. Supplemental O2, IV, and a monitor are definitely not needed on basically every call.



An assessment must be _preformed_. O2, IV, Monitor have to be _initiated_.


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## JPINFV (May 31, 2012)

bstone said:


> An assessment must be _preformed_. O2, IV, Monitor have to be _initiated_.



Why does supplemental oxygen, intravenous access, and a monitor must be "initiated" on basically every call? 

Is every patient in the ED on supplemental oxygen?

Is every patient in the ED on a cardiac monitor?

Is every patient in the ED have an IV started?

If the answer is "no" to any of those questions, what's the difference? Are EMS providers simply too stupid to decide if supplemental oxygen is needed?


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## bstone (May 31, 2012)

JPINFV said:


> Why does supplemental oxygen, intravenous access, and a monitor must be "initiated" on basically every call?
> 
> Is every patient in the ED on supplemental oxygen?
> 
> ...



Welcome to the field of Emergency Medical Services. O2, IV, Monitor are essential on basically every call. Not every call, but basically every call. Going for a ride in my ambulance? I'm going to put you on a NC, 3 lead, and start a 20 gauge.


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## adamjh3 (May 31, 2012)

bstone said:


> An assessment must be _preformed_. O2, IV, Monitor have to be _initiated_.



So the lady with isolated extremity trauma I transported today needed oxygen, an IV and a cardiac monitor?

Why?


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## bstone (May 31, 2012)

adamjh3 said:


> So the lady with isolated extremity trauma I transported today needed oxygen, an IV and a cardiac monitor?
> 
> Why?



She definitely did.


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## JPINFV (May 31, 2012)

adamjh3 said:


> So the lady with isolated extremity trauma I transported today needed oxygen, an IV and a cardiac monitor?
> 
> Why?




IV ->  Route for pain management if indicated.


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## JPINFV (May 31, 2012)

bstone said:


> Welcome to the field of Emergency Medical Services. O2, IV, Monitor are essential on basically every call. Not every call, but basically every call. Going for a ride in my ambulance? I'm going to put you on a NC, 3 lead, and start a 20 gauge.




With what medical justification? The indication for supplemental oxygen is not "ambulance." Are you saying you're incapable of determining who needs supplemental oxygen with any sort of reasonable accuracy?


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## bstone (May 31, 2012)

JPINFV said:


> With what medical justification? The indication for supplemental oxygen is not "ambulance." Are you saying you're incapable of determining who needs supplemental oxygen with any sort of reasonable accuracy?



lol:rofl:


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## adamjh3 (May 31, 2012)

Okay, lady with 2/10 pain in that isolated extremity. 

My point was that one shouldn't  perform a treatment without medical necessity. 

Bstone, you elected to answer only the first part of my question.  You've already clearly stated that every single patient you encounter gets your little blanket of treatments and skills, what's your rationale for it?


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## bstone (May 31, 2012)

adamjh3 said:


> Bstone, you elected to answer only the first part of my question.  You've already clearly stated that every single patient you encounter gets your little blanket of treatments and skills, what's your rationale for it?



If you'd like to quote me accurately then I'd be happy to reply. Until then I'll be sleeping. Goodnight.


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## adamjh3 (May 31, 2012)

Um... What? Your answer was one sentence. I want to know your justification for your answer. Avoiding the question doesn't make your argument stronger. Nor does laughing at other wholly appropriate questions make you right.


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## Tigger (May 31, 2012)

bstone said:


> Welcome to the field of Emergency Medical Services. O2, IV, Monitor are essential on basically every call. Not every call, but basically every call. Going for a ride in my ambulance? I'm going to put you on a NC, 3 lead, and start a 20 gauge.



How is EMS supposed to become a profession when this attitude is employed? Using these sort of blanket treatments is not a good way for providers to prove that they are capable of making sound and independent clinical decisions. 

As an aside, when I was transported in an ILS ambulance over the winter with suspected lumbar fractures following a significant fall I was given none of these, as none could possibly be construed as indicated. My vitals were fine and I was in no respiratory distress. If you had tried to initiate any of the above three I would have protested mightily since a) they would not do anything to help me b) they require manipulation of the patient, and when you're in pain sometimes all you want to do is lie there and c) they cost money. 

Unless you're giving a medication or fluid I see no reason to start an IV unless you have a significant worry that the patient is going to rapidly become unstable.


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## the_negro_puppy (May 31, 2012)

What Grade A baloney. Treatment and interventions should be based on assessment and clinical judgement. I don't start IVs unless I am going to give something through it, or have a likely need to do so. Many procedures come with their own risks and performing them on every patient exposes people to them unnecessarily.  While many of my patients get a 3 lead ECG, I wont be doing one on a 15 y.o with an isolated colles fracture. Our oxygen protocols have changed in so that we don't even give it to anyone with Sp02 > 93% bar a few circumstances.

The sooner EMS moves away from cookbook pre-hospital care the better.


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## Doczilla (May 31, 2012)

But I.V's save lives!  :sad:

Not knocking intermediates, but I think a lot of people who have such a minimally expanded scope try to excercise it as much as possible. And they get away with it, because its hard to ding someone if it isn't truly harmful to the patient. You can always use your "I was airing on the side of benefit to the patient" get out of jail free card.


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## Notown (May 31, 2012)

According to my instructor, even if a patient does not necessarily need the O2, the placebo effect may make them "feel better" and help calm the situation. I'm not in the field yet but I've never really understood how that could be true. I would think that some patients would get more worked up and wonder why they need O2.:censored:


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## Sasha (May 31, 2012)

Notown said:


> According to my instructor, even if a patient does not necessarily need the O2, the placebo effect may make them "feel better" and help calm the situation. I'm not in the field yet but I've never really understood how that could be true. I would think that some patients would get more worked up and wonder why they need O2.:censored:



You'll find out that's a load of bull. A nasal cannula is not comfortable and it doesn't make a lick of difference half the time.


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## Christopher (May 31, 2012)

Notown said:


> According to my instructor, even if a patient does not necessarily need the O2, the placebo effect may make them "feel better" and help calm the situation. I'm not in the field yet but I've never really understood how that could be true. I would think that some patients would get more worked up and wonder why they need O2.:censored:



I'd like to quote Dr. Paul Matera (who may be quoting somebody else):



> _Don't just do something, stand there!_



Just because you can doesn't mean you should. That being said, sometimes your patient just needs a little T.L.C. which may comprise of, _"dear, I'm going to put this oxygen on your nose to make you feel better; so you're a little bit more comfortable for the ride. How many kids did you say you have again?"_


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## Sasha (May 31, 2012)

O2 IV and monitor for every transport is bad medicine and anyone who employs that should be ashamed that they're not capable of making decisions using their clinical judgement


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## Christopher (May 31, 2012)

Sasha said:


> You'll find out that's a load of bull. A nasal cannula is not comfortable and it doesn't make a lick of difference half the time.



It certainly doesn't at less than 2 L/min 

22% FiO2 at 2 L/min...20.8% in the air they're breathin', hmmm.


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## NYMedic828 (May 31, 2012)

Notown said:


> According to my instructor, even if a patient does not necessarily need the O2, the placebo effect may make them "feel better" and help calm the situation. I'm not in the field yet but I've never really understood how that could be true. I would think that some patients would get more worked up and wonder why they need O2.:censored:



This is where the problem lies.

We have all these instructors with no clinical judgement or decision making capability of their own telling people to operate like robots, just because they can.

If I have a patient with no respiratory complaints and an O2 sat of 98%+ , what am I achieving? Its impossible to break 100% O2 sat, there is no going the extra mile. (granted o2 sat is not a definitive measure of oxygenation, just using it as an example)

Oxygen also tends to dry out the mucus membranes and makes a lot of people uncomfortable. Other people don't like having a mask on their face or something in their nose.

Doing it just to do it is stupid.

Lack of oxygen is rarely the problem your patient is going to be experiencing. COPD/Asthma/APE these are oxygenation issues. Abdominal pain and injuries are not.


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## Aidey (May 31, 2012)

I have been on a nasal cannula before, due to being consciously sedated. It was on 2lpm, and it smelled disgusting and was annoying as all heck. There was nothing comforting about it.


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## mycrofft (May 31, 2012)

OP, the issue is you forgot something you were supposed to bring. Next time it's the EKG? (Naw, not after going through this on EMTLIFE!).
:deadhorse:

I have taught for an unnamed company which also markets oxygen equipment. Want to bet they tell clients in class to use O2 whenever?

I think in most instances it is an unnecessary expense and maybe clinically unnecessary, but essentially harmless. The length of time ambulance patients in urban/suburban situations are on it is not very long, and if it was that harmful we'd have dead people stacking up next to the piles for the victims of rubber and peanut allergies.

The issues are why protocols are not written to reflect reality as we have it now, and why EMS people are seen as being stupid enough to require lowest common denominator protocols?

PS: I think bstone's initial thrust was to BRING the triad because they are  OFTEN necessary and going back for them is bad form, especially if the pt has just coded. Also, in his system and experience maybe most of the pts DID or DO require O2, and not so many owes etc.


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## TatuICU (May 31, 2012)

Doczilla said:


> But I.V's save lives!  :sad:
> 
> Not knocking intermediates, but I think a lot of people who have such a minimally expanded scope try to excercise it as much as possible. And they get away with it, because its hard to ding someone if it isn't truly harmful to the patient. You can always use your "I was airing on the side of benefit to the patient" get out of jail free card.



Same can be said for every level if provider. That's why we recently fired someone for pushing atropine on a patient with an inferior wall MI with a rate of 45 with a 95/ 52 blood pressure. 

Sometimes the best thing to do with your hands is sit on them.


As far as the every call getting o2, blah blah blah, that's garbage and just bad medicine, however that's how some companies bill apparently.


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## Christopher (May 31, 2012)

NYMedic828 said:


> If I have a patient with no respiratory complaints and an O2 sat of 98%+ , what am I achieving? Its impossible to break 100% O2 sat, there is no going the extra mile. (granted o2 sat is not a definitive measure of oxygenation, just using it as an example)



While you cannot break 100% saturation of hemoglobin, you can continue to increase the PaO2!

Which brings us to the cornerstone of _effective use of pulse oximetry_: understanding the *Oxyhemoglobin Dissociation Curve*. Basically, as you increase the partial pressures of dissolved O2 in the blood, your Hgb holds onto O2 more tightly. As you decrease the partial pressures of dissolved O2 in the blood, your Hgb more readily releases O2.







All you know (assuming no shift in the Hgb-O2 curve) with 100% SpO2 is that you have a PaO2 of at least 100 mmHg...you don't know where on the curve you are.

This is what has been shown to be harmful to your cardiac and stroke patients! You could have a PaO2 of 100, 150, 200 mmHg or even higher, you just don't know. Oxidative stress is going to increase the wider the gap is between metabolic demand and available oxygen. Going beyond ~98% (outside of preoxygenation for a procedure) isn't helpful, because you no longer know where you are on the curve.

But with say an SpO2 of 90%, again assuming no shift, you have a PaO2 of around 60 mmHg and now you're in danger of "falling off the cliff" as the curve is very steep. Partial pressures of oxygen in that range will allow the oxygen to more readily dissociate from Hgb. States like acidosis or hyperthermia will also cause your patient to shed bound-O2 more readily, even at higher SpO2's! Oops, I'm rockin' a tangent here.

Coming full circle: no respiratory complaint or distress? No need for O2.


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## TatuICU (May 31, 2012)

Aidey said:


> I have been on a nasal cannula before, due to being consciously sedated. It was on 2lpm, and it smelled disgusting and was annoying as all heck. There was nothing comforting about it.



Same here while getting a chest tube.  Was itchy and really distracted me from enjoying my versed and fent.


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## Christopher (May 31, 2012)

TatuICU said:


> Same can be said for every level if provider. That's why we recently fired someone for pushing atropine on a patient with an inferior wall MI with a rate of 45 with a 95/ 52 blood pressure.



If they blindly pushed the atropine because, "HEART RATE LOW! PARAMEDIC SMASH!!", then yeah...remediate/fire whatever.

Contrary to what most were taught, atropine is not contraindicated in higher degree blocks and often can be _useful_ in an inferior wall MI. Again, tangent...my bad.


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## Christopher (May 31, 2012)

mycrofft said:


> OP, the issue is you forgot something you were supposed to bring. Next time it's the EKG? (Naw, not after going through this on EMTLIFE!).



Not bringing everything to the patient's side eventually means you're missing something important, usually when it's the least awesome to be missing it


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## Doczilla (May 31, 2012)

This is why there were talks of ' cardiac arrest tanks' that has lower %o2. Anyone ever heard of that?


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## Doczilla (May 31, 2012)

TatuICU said:


> Same here while getting a chest tube.  Was itchy and really distracted me from enjoying my versed and fent.



That's why I would have put you in a K-hole.


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## Sasha (May 31, 2012)

Christopher said:


> If they blindly pushed the atropine because, *"HEART RATE LOW! PARAMEDIC SMASH!!"*, then yeah...remediate/fire whatever.
> 
> Contrary to what most were taught, atropine is not contraindicated in higher degree blocks and often can be _useful_ in an inferior wall MI. Again, tangent...my bad.



This made me lol.


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## TatuICU (May 31, 2012)

Christopher said:


> If they blindly pushed the atropine because, "HEART RATE LOW! PARAMEDIC SMASH!!", then yeah...remediate/fire whatever.
> 
> Contrary to what most were taught, atropine is not contraindicated in higher degree blocks and often can be _useful_ in an inferior wall MI. Again, tangent...my bad.



Why in the world would you increase the oxygen demand on an infarcting heart with a stable blood pressure? Most oftentimes the drop in rate is a protective mechanism. 

Besides, if one has a good understanding of the pharmacokinetics of atropine and a good understanding of high degree infranodal blocks, the next question would be, why would you bother pushing it?

But you're right, this is tangential and not relevant to the thread.  Happy to continue the discussion via pm or another thread.


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## TatuICU (May 31, 2012)

Doczilla said:


> That's why I would have put you in a K-hole.



Next bike race spot, Ft. Riley, KS


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## JPINFV (May 31, 2012)

Notown said:


> According to my instructor, even if a patient does not necessarily need the O2, the placebo effect may make them "feel better" and help calm the situation. I'm not in the field yet but I've never really understood how that could be true. I would think that some patients would get more worked up and wonder why they need O2.:censored:




1. Placebo effects are generally not considered ethical.

2. How would you like it if, using the set rate for one of the local counties, I charged you $80 (PDF) for a 10 minute placebo effect?


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## EpiEMS (May 31, 2012)

JPINFV said:


> 2. How would you like it if, using the set rate for one of the local counties, I charged you $80 (PDF) for a 10 minute placebo effect?



I'm kind of a fan of that whole "charging for what we do" thing. Might make some folks think twice about putting O2 on pts who don't need it.


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## bstone (May 31, 2012)

I will reply once I get things in order. Just a moment please.


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## bstone (May 31, 2012)

Clearly not every patient needs O2/IV/Monitor. Some patients need one of them, some needs two of them, some need all three of them. If someone is in an ambulance and there is an emergency then it is likely they will get one of the three. The sicker and more injured they are the more like it is they will get all three.


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## JPINFV (May 31, 2012)

Wait a minute. So you're backtracking from "Items 1, 2, and 3 are needed on basically every call and almost all of my patients gets them" to "Well, at least 1 of the three are likely to be used, the more serious the patient the more likely they'll get all three, and the provision that there's an "emergency" present"?

So, yes, I agree that the sicker the patient is the more likely they are to get at least one of those three, and more likely all three of them. That, however, bears no resemblence to your original claim and doesn't address at all the fact that EMS abuses oxygen more than Rush Limbaugh abuses OxyContin.


----------



## bstone (May 31, 2012)

JPINFV said:


> Wait a minute. So you're backtracking from "Items 1, 2, and 3 are needed on basically every call and almost all of my patients gets them" to "Well, at least 1 of the three are likely to be used, the more serious the patient the more likely they'll get all three, and the provision that there's an "emergency" present"?
> 
> So, yes, I agree that the sicker the patient is the more likely they are to get at least one of those three, and more likely all three of them. That, however, bears no resemblence to your original claim and doesn't address at all the fact that EMS abuses oxygen more than Rush Limbaugh abuses OxyContin.



I was watching Emergency! while making that posting and Johnny and Roy were starting an IV while a patient was on O2 and a monitor.


----------



## JPINFV (May 31, 2012)

bstone said:


> I was watching Emergency! while making that posting and Johnny and Roy were starting an IV while a patient was on O2 and a monitor.


 

They also used IVs, monitors, and oxygen a lot on NBC's Trauma. What does Trauma and Emergency! have in common? They're fiction.


----------



## bstone (May 31, 2012)

JPINFV said:


> They also used IVs, monitors, and oxygen a lot on NBC's Trauma. What does Trauma and Emergency! have in common? They're fiction.



Never seen an episode of Trauma. Johnny and Roy are not fiction!


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## NYMedic828 (May 31, 2012)

While on the subject... most patients don't truly need a pre-hospital IV either...


----------



## the_negro_puppy (May 31, 2012)

It can't hurt?

IV Cannulation risks:

infection, phlebitis and thrombophlebitis, emboli, pain, haematoma or haemorrhage, extravasation, arterial cannulation, nerve puncture, syncope, needlestick injury.

*Oxygen?*

"Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial"

http://www.bmj.com/content/341/bmj.c5462.full

*Results* In an intention to treat analysis, the risk of death was significantly lower in the titrated oxygen arm compared with the high flow oxygen arm for all patients


----------



## Doczilla (May 31, 2012)

A little knowledge is a dangerous thing.


----------



## ffemt8978 (Jun 1, 2012)

Doczilla said:


> A little knowledge is a dangerous thing.



It is even more dangerous when paired with good intentions.


----------



## 18G (Jun 1, 2012)

emt john said:


> salmon makes me sick. I think i'm going to go have some salmon. :rofl:



lol !


----------



## Chris07 (Jun 1, 2012)

EpiEMS said:


> I'm kind of a fan of that whole "charging for what we do" thing. Might make some folks think twice about putting O2 on pts who don't need it.



I really don't think those folks even care about their pt.'s bill...if they are even aware that every little thing they mark on their run sheet gets a thorough look-over by the billing department.


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## Sasha (Jun 1, 2012)

Chris07 said:


> I really don't think those folks even care about their pt.'s bill...if they are even aware that every little thing they mark on their run sheet gets a thorough look-over by the billing department.



I do care actually. It is irresponsible of me as a patient advocate to perform a service the patient doesn't need when I know they will struggle or not be able to pay the bill. 

I strongly feel those that throw their patient on oxygen regardless of the need are either seriously needing further education or need to step out of the profession.


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## 18G (Jun 1, 2012)

sasha said:


> i do care actually. It is irresponsible of me as a patient advocate to perform a service the patient doesn't need when i know they will struggle or not be able to pay the bill.
> 
> I strongly feel those that throw their patient on oxygen regardless of the need are either seriously needing further education or need to step out of the profession.



+20


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## HMartinho (Jun 1, 2012)

I really can't see why O2 is important in this patient...


----------



## EMTFozzy (Jun 1, 2012)

O2 and go use to be the base of EMT-B Programs! Hopefully they start teaching the importance of not overing oxygenating your patient!


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## NYMedic828 (Jun 1, 2012)

HMartinho said:


> I really can't see why O2 is important in this patient...



Im not sure where you are going with this one...

Is the sarcasm airing on the side of GIVING his patient oxygen?

If thats case, then you have kind of misread the entire thread...


----------



## FLdoc2011 (Jun 1, 2012)

Sasha said:


> I do care actually. It is irresponsible of me as a patient advocate to perform a service the patient doesn't need when I know they will struggle or not be able to pay the bill.
> 
> I strongly feel those that throw their patient on oxygen regardless of the need are either seriously needing further education or need to step out of the profession.



We have the same problem with patients in the hospital being on oxygen for no reason.   I think it's one of those psychological things that just makes the pt feel like we're doing something and makes the nurse feel better.  But if not needed (which it isn't most cases usually) it's one of the first things I D/C.   Even sometimes have to walk the patient with pulse ox or check room air ABG just to prove to them that they don't need the oxygen if they put up a fight.


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## HMartinho (Jun 2, 2012)

@NYMedic828

Sorry, but in my opinion, this patient did not need oxygen.

I know that I was not there to access him , but according to the info given, he had no respiratory distress, SOB, altered state of consciousness,altered circulation, politrauma, chest pain, hypovolemia or other clinical signs/symptoms that require O2, so this patient do not need O2.

The theory of giving oxygen to all patients its really annoying. Ok, can have a placebo effect? Perhaps, but it is waste of money and resources.


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## NYMedic828 (Jun 2, 2012)

HMartinho said:


> @NYMedic828
> 
> Sorry, but in my opinion, this patient did not need oxygen.
> 
> ...



You stated

"I really can't see why O2 is important in this patient..."

I thought you were portraying that sarcastically in the direction of they should have had oxygen based on symptoms.

My apologies.


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## HMartinho (Jun 2, 2012)

NYMedic828 said:


> You stated
> 
> "I really can't see why O2 is important in this patient..."
> 
> ...




No problem.

I think the problem is also my bad English. Anyway, I believe I can still improve, and read this forum has helped me a lot.


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## Bullets (Jun 2, 2012)

daughteroftheking said:


> Sorry! I wasn't too clear on forgetting the oxygen. In a non-respiratory emergency, I tend to judge how much o2 is needed based on pulse ox reading. There was no immediate indication for o2 on this one
> I now know that I should rely more on overall patient condition. I learned a lot from this call



Ok, you need to drop the pulse ox. You can palpate a radial pulse, and you have eyes to see a patient. If they are hypoxic then you will be able to see it. Look at how the patient is presenting. No tool is a substitute for a quality assessment. 

Also


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## jjesusfreak01 (Jun 3, 2012)

Sasha said:


> You'll find out that's a load of bull. A nasal cannula is not comfortable and it doesn't make a lick of difference half the time.



Not disagreeing with you. Hospice patient the other day on 4L NC, no COPD history, satting 92%, reports SOB. Patient was mouthbreathing. Moving the NC to their mouth bumped SPO2 to 98%, pt no longer reported SOB.


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## Sasha (Jun 4, 2012)

jjesusfreak01 said:


> Not disagreeing with you. Hospice patient the other day on 4L NC, no COPD history, satting 92%, reports SOB. Patient was mouthbreathing. Moving the NC to their mouth bumped SPO2 to 98%, pt no longer reported SOB.



I wish we carried simple face masks for stuff like this.


----------



## Shishkabob (Jun 4, 2012)

Sasha said:


> I wish we carried simple face masks for stuff like this.



Pop the tabs out of the sides of an NRB and you're basically there.



Bullets said:


> Look at how the patient is presenting. No tool is a substitute for a quality assessment.



EKG?
EtCO2?
EEG?
MRI?
CT?


Tools are to augment your assessment for a reason.  Just because it says 90% doesn't mean you treat, just because it says 100% doesn't mean you don't treat, but to ignore its benefits are ignoring its true purpose.


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## the_negro_puppy (Jun 4, 2012)

Treat the patient AND the monitor/SP02/ECG/EtCo2


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## NYMedic828 (Jun 4, 2012)

jjesusfreak01 said:


> Not disagreeing with you. Hospice patient the other day on 4L NC, no COPD history, satting 92%, reports SOB. Patient was mouthbreathing. Moving the NC to their mouth bumped SPO2 to 98%, pt no longer reported SOB.



...moving the NC to their...mouth?

Linuss I believe Sasha was being sarcastic suggesting what in the world you would put a NC in someone's mouth for over switching to a NRB.

There's a few issues, to me, with the patient he has presented us besides the oral NC.

Regardless of the delivery device used, a hospice patient in my eyes is not really fair to include with the general population of patients. This is a person with chronic end stage multi-system dysfunction. There body doesn't work nearly the same as a regular patient depending on what their illnesses are.

If she is blatently mouth breathing she probably is not pulling much pure o2 in from the nose/NC. A NC at 4 LpM I believe has an FiO2 of 15%+21% room air. The problem is, FiO2 is INSPIRED oxygen. The nasal canula is spraying out 100% oxygen, but without the tidal volume of room air it is nearly useless.

So she has an extra 15% o2 available to be inspired via the nose, but of course it is doing next to nothing if there is no tidal volume to take it to the alveoli.


----------



## usalsfyre (Jun 4, 2012)

NyMedic, 

I've done the NC in the mouth thing, it seems to work. Look up passive insuflation and the partial pressure concept to see why you can *oxygenate* even when the patient is apenic.


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## NYMedic828 (Jun 4, 2012)

usalsfyre said:


> NyMedic,
> 
> I've done the NC in the mouth thing, it seems to work. Look up passive insuflation and the partial pressure concept to see why you can *oxygenate* even when the patient is apenic.



I am not saying it won't work. I'm asking why would you.

If a medical director saw/heard I gave someone O2 by an oral NC, I would have a lot of explaining to do.

Oxygen is a gas, it will fill the space it is put into regardless of ventilation if nothing blocks it's path. But why would I not use a NRB for that scenario...


----------



## Christopher (Jun 4, 2012)

NYMedic828 said:


> I am not saying it won't work. I'm asking why would you.



Because a mask wasn't appropriate?


----------



## NYMedic828 (Jun 4, 2012)

Christopher said:


> Because a mask wasn't appropriate?



On a living breathing patient, other than 1/10000 scenarios how could you justify a NC in the mouth being more appropriate than a mask?


----------



## usalsfyre (Jun 4, 2012)

NYMedic828 said:


> I am not saying it won't work. I'm asking why would you.


Because the patient wouldn't tolerate a mask. 



NYMedic828 said:


> If a medical director saw/heard I gave someone O2 by an oral NC, I would have a lot of explaining to do.


Simple. "The patient exhibited signs of air hunger and hypoxia but wouldn't tolerate a mask. So we put the NC in his mouth, he showed less exertion and his sats went up". 



NYMedic828 said:


> Oxygen is a gas, it will fill the space it is put into regardless of ventilation if nothing blocks it's path. But why would I not use a NRB for that scenario.


Like I said above, a mask isn't always appropriate or tolerated.


----------



## usalsfyre (Jun 4, 2012)

NYMedic828 said:


> On a living breathing patient, other than 1/10000 scenarios how could you justify a NC in the mouth being more appropriate than a mask?



You haven't hauled a whole lot of hospice patients have you?


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## NYMedic828 (Jun 4, 2012)

NYMedic828 said:


> On a living breathing patient, other than 1/10000 scenarios how could you justify a NC in the mouth being more appropriate than a mask?





usalsfyre said:


> You haven't hauled a whole lot of hospice patients have you?



No, I have not. A few at most. I havent done an IFT in 3 years.

I am not asking in a manor to say you are wrong, I am asking to hear your reasons why, so that I may learn.


----------



## Christopher (Jun 4, 2012)

NYMedic828 said:


> On a living breathing patient, other than 1/10000 scenarios how could you justify a NC in the mouth being more appropriate than a mask?



If they're mouth breathing an NC in the mouth works great. They've provided the airway adjunct and I'm providing the blow-by.

Same with an NC over a Stoma, you can cut off one of the two prongs and it usually works way better than holding a mask over it.


----------



## usalsfyre (Jun 4, 2012)

NYMedic828 said:


> No, I have not. A few at most. I havent done an IFT in 3 years.
> 
> I am not asking in a manor to say you are wrong, I am asking to hear your reasons why, so that I may learn.



Very often they're at a baseline diminished LOC, when they get hypoxic the claustrophobia sets in and the won't tolerate a mask. An NC in the mouth works great.


----------



## AnthonyM83 (Jun 4, 2012)

Christopher said:


> Coming full circle: no respiratory complaint or distress? No need for O2.


 Really Chris? So, signs/symptoms of shock and altered (but no respiratory distress) gets no oxygen?




Christopher said:


> It certainly doesn't at less than 2 L/min
> 
> 22% FiO2 at 2 L/min...20.8% in the air they're breathin', hmmm.


That would be 29%....approximately 4% increase for every L/Min increase





Notown said:


> According to my instructor, even if a patient does not necessarily need the O2, the placebo effect may make them "feel better" and help calm the situation. I'm not in the field yet but I've never really understood how that could be true. I would think that some patients would get more worked up and wonder why they need O2.:censored:


 I won't use oxygen for comfort, but I have definitely used it for placebo effect for pain control. Placebo effect can be a very strong and if I'm in pain, my healthcare provider is welcomed to palcebo the hell out of me.

Though, as more and more literature comes out about the dangers of O2 administration, I do this very rarely nowadays.


----------



## AnthonyM83 (Jun 4, 2012)

Bullets said:


> Ok, you need to drop the pulse ox. You can palpate a radial pulse, and you have eyes to see a patient. If they are hypoxic then you will be able to see it. Look at how the patient is presenting. No tool is a substitute for a quality assessment. [/IMG]


Except, now they're giving us two standards. The signs of hypoxia which is what we looked for all along. But now we're increasing the standard to include pulse ox as well. So, patient could look fine, but could still use oxygen...so they tell us.




NYMedic828 said:


> I am not saying it won't work. I'm asking why would you.
> 
> If a medical director saw/heard I gave someone O2 by an oral NC, I would have a lot of explaining to do.



Patient is breathing through his mouth due to a stuffy nose. Chest pain. No respiratory distress, but sat is 93%. Air gets drawn in with the inhale.

Could use a mask, too...but honestly, I don't know how much I'm giving with an NRB at its lower settings (below the recommended range).



RANDOM STORY ABOUT BENEFIT OF OXYGEN:
I've had a near syncope at work before. I was sick, dehydrated, and think I vagaled myself. I dragged myself hands and knees from the bathroom to our oxygen tank with extreme weak/dizziness, sweaty, and skin felt hot/cold. Put an NRB mask on. INSTANT relief. That was the best feeling in the world right there. It was like being released from a choke hold.


----------



## Christopher (Jun 4, 2012)

AnthonyM83 said:


> Really Chris? So, signs/symptoms of shock and altered (but no respiratory distress) gets no oxygen?



Anxiety or restlessness is a subtle sign of air hunger, indicating a potential mismatch in perfusion. At this point you can add oxygen to _maybe_ improve their status...keeping in mind that hyperoxemia is not healthy either.

In patients with true shock they almost always have a derangement in their respiratory rate and quality as part of their compensatory drive. Both of these I would interpret as signs of "distress".



AnthonyM83 said:


> That would be 29%....approximately 4% increase for every L/Min increase



I guess this depends on the text, but I'll accept 29% at 2L/min. I just ask that at least 3 L/min be used if you have an indication for supplemental O2 therapy on a patient who is not normally on supplemental O2. At that rate you're guaranteed a higher concentration of oxygen being delivered than in room air.



AnthonyM83 said:


> I won't use oxygen for comfort, but I have definitely used it for placebo effect for pain control. Placebo effect can be a very strong and if I'm in pain, my healthcare provider is welcomed to palcebo the hell out of me.



I give pain medication for pain control, but I'm also ALS so it isn't necessarily a fair comparison for BLS providers. My only point is that supplemental oxygen should be given due to an indication, not just because someone is an EMT or Paramedic and feel like they should be doing something.


----------



## NYMedic828 (Jun 4, 2012)

AnthonyM83 said:


> RANDOM STORY ABOUT BENEFIT OF OXYGEN:
> I've had a near syncope at work before. I was sick, dehydrated, and think I vagaled myself. I dragged myself hands and knees from the bathroom to our oxygen tank with extreme weak/dizziness, sweaty, and skin felt hot/cold. Put an NRB mask on. INSTANT relief. That was the best feeling in the world right there. It was like being released from a choke hold.



Not so sure that reflects any TRUE benefits of oxygen. I think you may have placeboed yourself in a time of distress that probably had you a bit out of it to begin with.

Chris, would you happen to have any articles handy on hyperoxia/hyperoxemia/oxygen toxicity? (need material for a presentation)


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## Tigger (Jun 4, 2012)

AnthonyM83 said:


> I won't use oxygen for comfort, but I have definitely used it for placebo effect for pain control. Placebo effect can be a very strong and if I'm in pain, my healthcare provider is welcomed to palcebo the hell out of me.
> 
> Though, as more and more literature comes out about the dangers of O2 administration, I do this very rarely nowadays.



The less you do that, the better. Oxygen is indicated for cases of respiratory distress, not for any sort of pain control, placebo or not! You might think it's helping but odds are the patient is less comfortable (ever had an NC for extended period of time) and you are costing them more money. Never mind the whole ethics and breaching the trust of patients issue. 

There are BLS pain control measures. Proper positioning, cold and heat packs, blankets, pillows, splinting, and even holding the patient's hand are all more effective than supplementary oxygen.


----------



## Sasha (Jun 4, 2012)

I actually wasn't being sarcastic. I'd love to have a simple face mask for hospice patients who are mouth breathing but don't require the o2 flow rate for an NRB.


----------



## AnthonyM83 (Jun 4, 2012)

Tigger said:


> The less you do that, the better. Oxygen is indicated for cases of respiratory distress, not for any sort of pain control, placebo or not! You might think it's helping but odds are the patient is less comfortable (ever had an NC for extended period of time) and you are costing them more money. Never mind the whole ethics and breaching the trust of patients issue.
> 
> There are BLS pain control measures. Proper positioning, cold and heat packs, blankets, pillows, splinting, and even holding the patient's hand are all more effective than supplementary oxygen.



During the time when I did this, it was indicated for hypoxia, chest pain, respiratory distress, hypoperfusion, nausea, and others. 

As far as ethics, it was within protocol that every patient got oxygen anyway (stupid protocol). I don't feel it was a breach of trust, either. I was doing something I was required to do anyway, but told them an additional benefit. The BLS pain controls you mentioned rarely relieved the pain. I also spent a long time studying placebo, hypnotic suggestions, alternative pain relief, etc. Both on my own and under guided supervision in a formal clinical setting.

The phrases I would use would be similar to "This is going to help you, okay? Let me know when you can feel the difference." Hand holding most definitely had a strong effect too.


----------



## the_negro_puppy (Jun 4, 2012)

Sasha said:


> I actually wasn't being sarcastic. I'd love to have a simple face mask for hospice patients who are mouth breathing but don't require the o2 flow rate for an NRB.



You guys don't carry the 'Hudson" 50% masks that you can run on 4-8 L/m then?


----------



## Tigger (Jun 5, 2012)

AnthonyM83 said:


> During the time when I did this, it was indicated for hypoxia, chest pain, respiratory distress, hypoperfusion, nausea, and others.
> 
> As far as ethics, it was within protocol that every patient got oxygen anyway (stupid protocol). I don't feel it was a breach of trust, either. I was doing something I was required to do anyway, but told them an additional benefit. The BLS pain controls you mentioned rarely relieved the pain. I also spent a long time studying placebo, hypnotic suggestions, alternative pain relief, etc. Both on my own and under guided supervision in a formal clinical setting.
> 
> The phrases I would use would be similar to "This is going to help you, okay? Let me know when you can feel the difference." Hand holding most definitely had a strong effect too.



Hand holding has a strong effect and has the added benefit of not being a medication like oxygen, which despite our initial education to the contrary, does have drawbacks in its use. I'm not super choosy about who gets 02, if I think there is some sort of respiratory compromise I'll ask the patient if they would like something to help their breathing (assuming a non-serious patient). But sadly, for a truly patient in a lot of pain, there is no medication that I can give to change that and I refuse to place someone on oxygen just so that it looks like I am doing something.


----------



## Tigger (Jun 5, 2012)

the_negro_puppy said:


> You guys don't carry the 'Hudson" 50% masks that you can run on 4-8 L/m then?



I wish we did, but so far as I can tell most states do not require them to be carried, so they are not. We can take people from a facility with them already on of course.


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## AnthonyM83 (Jun 5, 2012)

Tigger said:


> I refuse to place someone on oxygen just so that it looks like I am doing something.


Agreed on that point.
Even in the placebo days, I never gave it to "shut them up" or "look good". It was for a specific intentioned purpose. My friend on the other hand was better at verbal pain control than I was. Through guided imagery and those sorts of techniques once had a femur fracture pain free. Wouldn't believe it till you saw it. He now makes a living doing alternative pain control. In other words, we were serious about giving mental suggestions to alleviate pain...not just screwing with patients...


----------



## jjesusfreak01 (Jun 17, 2012)

AnthonyM83 said:


> Agreed on that point.
> Even in the placebo days, I never gave it to "shut them up" or "look good". It was for a specific intentioned purpose. My friend on the other hand was better at verbal pain control than I was. Through guided imagery and those sorts of techniques once had a femur fracture pain free. Wouldn't believe it till you saw it. He now makes a living doing alternative pain control. In other words, we were serious about giving mental suggestions to alleviate pain...not just screwing with patients...



Ahh, the "Mentalist" method...


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## xrsm002 (Jun 26, 2012)

Treat the patient NOT the pulse ox.


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## mycrofft (Jun 26, 2012)

Especially if the pulse ox doesn't work.  :deadhorse:


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## the_negro_puppy (Jun 26, 2012)

Treat the patient AND other assessment tools including SP02, EtC02, GCS, RR, lung sounds


----------



## JPINFV (Jun 26, 2012)

the_negro_puppy said:


> Treat the patient AND other assessment tools including SP02, EtC02, GCS, RR, lung sounds


----------



## Christopher (Jun 26, 2012)

xrsm002 said:


> Treat the patient NOT the pulse ox.



The dead horse you're beating here is our credibility as providers.

Obviously you treat the the patient...this is what a clinician does. Assessment of the patient includes qualitative and quantitative measurements obtained through a history, physical assessment, and tools available to you as a provider.

Please never use that phrase again, for the sake of our profession.


----------



## Handsome Robb (Jun 27, 2012)

the_negro_puppy said:


> Treat the patient AND other assessment tools including SP02, EtC02, GCS, RR, lung sounds





Christopher said:


> The dead horse you're beating here is our credibility as providers.
> 
> Obviously you treat the the patient...this is what a clinician does. Assessment of the patient includes qualitative and quantitative measurements obtained through a history, physical assessment, and tools available to you as a provider.
> 
> Please never use that phrase again, for the sake of our profession.



Clinical correlation, say what?!?!?!?


----------



## mycrofft (Jun 27, 2012)

Which phrase, "treat the patient", or "beat the dead horse"? Or "credibility as providers"?


----------



## AnthonyM83 (Jun 29, 2012)

xrsm002 said:


> Treat the patient NOT the pulse ox.



No, treat both....


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## xrsm002 (Jul 8, 2012)

That's what my I instructor I've had for the past year has drilled into my classss head treat the patient not the devices. This was especially true during cardiology class.


----------



## xrsm002 (Jul 8, 2012)

Still of the pulse ox is reading 90% on a respiratory distress I will give oxygen.


----------



## JPINFV (Jul 8, 2012)

xrsm002 said:


> That's what my I instructor I've had for the past year has drilled into my classss head treat the patient not the devices. This was especially true during cardiology class.



So your female diabetic patient is complaining of no pain yet has ST elevation, do you treat the monitor and call it a STEMI or treat the patient and do... nothing?

Your patient doesn't have any respiratory distress, but has a SpO2 of 89, do you start supplemental oxygen or do nothing?


----------



## jwk (Jul 8, 2012)

JPINFV said:


> So your female diabetic patient is complaining of no pain yet has ST elevation, do you treat the monitor and call it a STEMI or treat the patient and do... nothing?
> 
> Your patient doesn't have any respiratory distress, but has a SpO2 of 89, do you start supplemental oxygen or do nothing?



I'd be much more concerned about the first patient than the second.

HOWEVER...

The sentiments about NOT treating the monitor/number are correct.  You have to take all the clinical informatin you have and put it altogether.  If you simply treat a number or an EKG trace, all by itself, with no other data to correlate it with, then you're foolish.


----------



## Handsome Robb (Jul 8, 2012)

xrsm002 said:


> That's what my I instructor I've had for the past year has drilled into my classss head treat the patient not the devices. This was especially true during cardiology class.



Clinical correlation. They don't give us all these tools for no reason. We use clinical findings along with quantitative and qualitative measurements to treat our patients. 

Example: patient is aysmptomatic with minor complaints yet in VT on the monitor, what do you do?


----------



## Aidey (Jul 8, 2012)

jwk said:


> I'd be much more concerned about the first patient than the second.
> 
> HOWEVER...
> 
> The sentiments about NOT treating the monitor/number are correct.  You have to take all the clinical informatin you have and put it altogether.  If you simply treat a number or an EKG trace, all by itself, with no other data to correlate it with, then you're foolish.



Arguably taking into account the pts age, past history (diabetes) and gender are clinical information you can use to interpret the test results you get.


----------



## usalsfyre (Jul 8, 2012)

jwk said:


> I'd be much more concerned about the first patient than the second.
> 
> HOWEVER...
> 
> The sentiments about NOT treating the monitor/number are correct.  You have to take all the clinical informatin you have and put it altogether.  If you simply treat a number or an EKG trace, all by itself, with no other data to correlate it with, then you're foolish.



The key word you said is correlate. Treating a single assessment tool is indeed foolish. 

However, what I've seen far too often in "I treat the patient" medics is a tendency to simply ignore electronic assessment aids that don't "fit" their impression of the patient rather than go back and reevaluate if their impression is flawed.


----------



## JPINFV (Jul 8, 2012)

jwk said:


> I'd be much more concerned about the first patient than the second.
> 
> HOWEVER...
> 
> The sentiments about NOT treating the monitor/number are correct.  You have to take all the clinical informatin you have and put it altogether.  If you simply treat a number or an EKG trace, all by itself, with no other data to correlate it with, then you're foolish.



You're equally foolish if you just disregard what your assessment tools tells you just because they're run by a battery.


----------



## JPINFV (Jul 8, 2012)

NVRob said:


> Clinical correlation. They don't give us all these tools for no reason. We use clinical findings along with quantitative and qualitative measurements to treat our patients.
> 
> Example: patient is aysmptomatic with minor complaints yet in VT on the monitor, what do you do?




According to the TV show Trauma, you check to make sure they aren't shaking a lead.


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## ZootownMedic (Jul 11, 2012)

NVRob said:


> Clinical correlation. They don't give us all these tools for no reason. We use clinical findings along with quantitative and qualitative measurements to treat our patients.
> 
> Example: patient is aysmptomatic with minor complaints yet in VT on the monitor, what do you do?



WELD EM BRO! MAX joules!  

I actually had a fire medic the other day who thought a pt was in V-fib. When we explained that the pt had palpable carotids and BY GOD radials TOO!....he still didn't care because he was seeing 'V-Fib' on the monitor. Thank god we were there for THAT pt.......


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## OzAmbo (Jul 12, 2012)

jwk said:


> I'd be much more concerned about the first patient than the second.
> 
> HOWEVER...
> 
> The sentiments about NOT treating the monitor/number are correct.  You have to take all the clinical informatin you have and put it altogether.  If you simply treat a number or an EKG trace, all by itself, with no other data to correlate it with, then you're foolish.


Are you advocating ignoring a half of your assessent to concentrate on the other half of your assessment?

Either way its a half arsed assessent :blush: 

No one its saying ignore you assessment tools, everyone is saying perform a thorough assessment using all the tools available and then make a clinical decision. No one here, ( and ive seen qiute a few of the people in this thread over in EMT city fighting the good fight for a few years now) is saying treat a single monitor

I have to ask though, if that single ECG trace did not fit the rest of the clinical picture, would you reject it?


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## KellyBracket (Jul 12, 2012)

I guess I'll treat the dead horse.

Had a medic bring in an intubated patient. His monitor had inline ETCO2, so rather than confirm lung sounds myself, I just asked him for the numbers and waveform.

He replied "You know, I think it's not working right. Couldn't get anything above 5, but the tube is in the right place, I could tell."

The ETCO2, it turns out, was working just fine. 

We have monitors, tests, and imaging precisely because our clinical skills have limits. Yeah, sometime I have to treat the monitor, because it's better than me.


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## EMTNJA (Jul 13, 2012)

*Have to agree with others.*

Any sort of Cardio/Respiratory complaints. HTN, CVA, CP, DB, SOB, all need immediate application of supplemental O2. Stable usually 2-4 lpm NC, unstable 15 lpm NRB. Vitamin O is a great drug, as well as making most pt's feel like we're doing tangible things for them. Calms them down immensely.


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## STXmedic (Jul 13, 2012)




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## NYMedic828 (Jul 13, 2012)

EMTNJA said:


> Any sort of Cardio/Respiratory complaints. HTN, CVA, CP, DB, SOB, all need immediate application of supplemental O2. Stable usually 2-4 lpm NC, unstable 15 lpm NRB. Vitamin O is a great drug, as well as making most pt's feel like we're doing tangible things for them. Calms them down immensely.








This is not the way to do things. What are you achieving by giving oxygen to someone with hypertension?

The only people I usually put on a cannula are those on one already home...


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## Medic Tim (Jul 13, 2012)

EMTNJA said:


> Any sort of Cardio/Respiratory complaints. HTN, CVA, CP, DB, SOB, all need immediate application of supplemental O2. Stable usually 2-4 lpm NC, unstable 15 lpm NRB. Vitamin O is a great drug, as well as making most pt's feel like we're doing tangible things for them. Calms them down immensely.



facepalm
I hope you aren't serious


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## EMTNJA (Jul 13, 2012)

My bad HA/DZ, not HTN. Also many providers fail to use O2 on N/V pt's. works well in most cases prior to any emesis.


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## usalsfyre (Jul 13, 2012)

EMTNJA said:


> My bad HA/DZ, not HTN. Also many providers fail to use O2 on N/V pt's. works well in most cases prior to any emesis.



I'm going to take a stab and say you haven't done much education outside your EMT class...


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## NYMedic828 (Jul 13, 2012)

EMTNJA said:


> My bad HA/DZ, not HTN. Also many providers fail to use O2 on N/V pt's. works well in most cases prior to any emesis.



Your methods are still facepalm worthy and completely in the wrong.

I have no idea what HA/DZ is an abbreviation for.

In my experience, nauseous patients get worse when put on an O2 mask and then when they need to vomit, they have a mask on their face. 

If they are vomiting odds are their problem is not the result of inadequate oxygenation or ventilation. If they were that hypoxic they probably need more than a NRB anyway.



On the other hand, learning is what we are here for so I think it's time you read through the rest of the thread.


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## Tigger (Jul 13, 2012)

NYMedic828 said:


> Your methods are still facepalm worthy and completely in the wrong.
> 
> I have no idea what HA/DZ is an abbreviation for.
> 
> ...



Well this pretty much sums up what I was going to say. The next time you've got some nausea try putting a tight fitting mask over your face with very dry air coming out and tell me if that makes you feel better?


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## NYMedic828 (Jul 13, 2012)

Tigger said:


> Well this pretty much sums up what I was going to say. The next time you've got some nausea try putting a tight fitting mask over your face with very dry air coming out and tell me if that makes you feel better?



I put all of my patients on humidified O2. (not serious)


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## medichopeful (Jul 13, 2012)

NYMedic828 said:


> I have no idea what HA/DZ is an abbreviation for.


Wikipedia (so take that for what it's worth! :rofl seems to suggest "HA" is "headache."  "DZ" from the same place is "disease," though I'm guessing here it means "dizziness" :wacko:


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## NomadicMedic (Jul 13, 2012)

NYMedic828 said:


> I put all of my patients on humidified O2. (not serious)



I use ginger flavored O2. It helps prevent nausea. Kids get bubblegum flavored O2.

Also not serious.





...but, think of how cool it would be.


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## Anjel (Jul 13, 2012)

n7lxi said:


> I use ginger flavored O2. It helps prevent nausea. Kids get bubblegum flavored O2.
> 
> Also not serious.
> 
> ...



One of the medics I worked with told a pt the o2 was infused with a pain reliever. 

Wrong on all levels. But made her feel better. I giggled.


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## JPINFV (Jul 13, 2012)

The only place supplemental oxygen shouldn't be used is near Berkeley. 


...they already have enough free radicals.


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## EpiEMS (Jul 13, 2012)

JPINFV said:


> The only place supplemental oxygen shouldn't be used is near Berkeley.
> 
> 
> ...they already have enough free radicals.



*rimshot*

But actually, that gave me a good chuckle.

And in all seriousness: if you're administering oxygen to everybody, you're doing something wrong.


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## NomadicMedic (Jul 13, 2012)

The BLS folks look at me like I'm crazy when I take the oxygen mask off of the patients. 

I just smile and tell them I'll explain later. 

Most times, when I use oxygen, its only to drive a neb or CPAP.


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## NYMedic828 (Jul 14, 2012)

My favorite is when you see people take a baseline O2 sat while the patient is on a NRB cranked up to 15 LPM.


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## AnthonyM83 (Jul 14, 2012)

So let's consider:

Say there isn't a recent studying supporting that oxygen helps with a certain medical complaint. But it's either a local standard OR they were taught to do so by an instructor or textbook. 

At what point do they stop using oxygen for that complaint? Once the study is a certain number of years old? If there is three, but not four studies on it? If only two out of the main four textbooks instruct it? Could the EMT ever be found at fault for not applying it in these circumstances?

Take the nasal cannula for oxygen. As a new EMT, I was taught it helped for nausea. There were a couple studies showing that oxygen reduced nausea. I used it for some nausea patient and a certain number of them said it reduced the nausea (no way to know how they would have felt without the oxygen). Is this EMT now wrong for continuing this process a few years later?

Now I'm a HUGE HUGE proponent of evidence based medicine. But being devil's advocate here too. Want to throw in some realism. There are a lot of things studies haven't been done on. Should a practice be discontinued completely? What if personal experience supports it, but there's no study to support/refute it?

It reminds me of that article about how now there have been no double blind randomized studies to show the effectiveness of the use of a parachute when skydiving. There is no solid evidence to promote the routine use of parachutes when skydiving. Screw experience altogether?

http://www.bmj.com/content/327/7429/1459.long

It was at least an important enough "consideration" to write a tongue in cheek article that got actually published...


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## NomadicMedic (Jul 14, 2012)

Well I think some of the problems stem from the amount of oxygen that EMTs are taught to apply. It's either 2 L via nasal cannula or 15 L on a non-rebreather. Never mind that the patient has a respiratory rate of 18, an end tidal CO2 reading of 40 and an SpO2 of 97%... If the patient expresses that they're having difficulty breathing, most EMTs put oxygen on that patient, in my experience, usually by mask at 15 L.

That patient may only be experiencing anxiety due to the situation that they're in… Not true respiratory distress. Or the patient who experienced a syncopal episode.. The majority of those patients do not require oxygen, although I see them with a mask strapped to their face every time. 

I asked the EMTs why are they on oxygen and the response is invariably, "because they need it". It's simply a matter of poor education and teaching to the test, rather than explaining the action and reasoning behind the oxygen use. 

I would bet if you took any new EMT and ask them how much oxygen a "medical" patient gets, they'll tell you 2 to 6 L via nasal cannula. Ask about a "trauma patient", they'll tell you 15 L on a mask. No if's, ands or buts. And they'll bust out the gem about how "oxygen will kill a COPD patient". 

I try to do a little reeducation when I can, and most of the BLS crews I work with now don't put oxygen on a patient and less they clinically need it. Isn't that what were striving for?


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