# Transporting a SOB back to res.



## VA Transport EMT (Jan 3, 2013)

So while working my transport job, I was the driver and riding shotgun was a new hire (yikes). While transporting pt back to res from DR office, pt shows signs of sob. (shallow breaths at a rate of 40pm and 80 something SAT. Pt has a healing left leg fx with no pert. hx.) my partner puts pt on 2 lpm and releases pt back into familys care with no signs of returning to normal vitals. Pt's family refuses my offer to take to ER and we leave pt at home. 

Was this the right action of my partner? I have never heard of comfort o2 and have always diverted to ER when any of my PTs start showing signs of SOB and they tell me they want to go to hospital.

EDIT: this particular pt never requested hospital.


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## Chris07 (Jan 3, 2013)

VA Transport EMT said:


> So while working my transport job, I was the driver and riding shotgun was a new hire (yikes). While transporting pt back to res from DR office, pt shows signs of sob. (shallow breaths at a rate of 40pm and 80 something SAT. Pt has a healing left leg fx with no pert. hx.) my partner puts pt on 2 lpm and releases pt back into familys care with no signs of returning to normal vitals. Pt's family refuses my offer to take to ER and we leave pt at home.
> 
> Was this the right action of my partner? I have never heard of comfort o2 and have always diverted to ER when any of my PTs start showing signs of SOB and they tell me they want to go to hospital.
> 
> EDIT: this particular pt never requested hospital.



In my mind that's very concerning. I personally would have diverted to the closest ED. High flow 02 is definately indicated also. Low flow = useless in this case.

Hx of recent leg fx...sudden onset dyspnea...no other significant history...first thing I'm thinking is PE.
Unless the pt flat out refuses Despite explaining my concern, they're going to the ED.


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## Chris07 (Jan 3, 2013)

What were the vitals like? HR, BP? Skin color...heck, what was their medical hx?


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## TheLocalMedic (Jan 3, 2013)

Hmmmm...  So it was your partner's decision to just take them home?  In the future if you're not comfortable with that, then try talking to them, away from patient and family, to air your concerns.  

What were lung sounds?  Did patient appear short of breath or did their rate just go up?  And were their hands cold?  I can't tell you the number of times I've seen people get freaked out by a "low O2 sat" when the patient's hands were just cold.


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## leoemt (Jan 3, 2013)

VA Transport EMT said:


> So while working my transport job, I was the driver and riding shotgun was a new hire (yikes). While transporting pt back to res from DR office, pt shows signs of sob. (shallow breaths at a rate of 40pm and 80 something SAT. Pt has a healing left leg fx with no pert. hx.) my partner puts pt on 2 lpm and releases pt back into familys care with no signs of returning to normal vitals. Pt's family refuses my offer to take to ER and we leave pt at home.
> 
> Was this the right action of my partner? I have never heard of comfort o2 and have always diverted to ER when any of my PTs start showing signs of SOB and they tell me they want to go to hospital.
> 
> EDIT: this particular pt never requested hospital.




What were signs and symptoms? I have had several SOB patients who were SOB due to anxiety. Coach them in their breathing and get them down to normal. 

You said you were a driver. Did you look at this patients paperwork? Maybe this was normal for the patient and the family is well aware of how to take care of it. 

You need to look at the entire picture to determine what needs to be done, not just a little snippet. 

I have concerns that you don't want to work with a newbie and you are looking for reasons to fault them.


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## Epi-do (Jan 3, 2013)

VA Transport EMT said:


> shallow breaths at a rate of 40pm and 80 something SAT. Pt has a healing left leg fx



I find this concerning.  However, without additional information it is hard to really comment further on the situation.  It could be a PE.  It could also be countless other things - anxiety causing hyperventilation, cold hands or malfunctioning equipment.  

Do they have any sort of respiratory history?  Cardiac history?  What sort of meds do they take?  Other vital signs, particularly skin color/condition & cap refill?


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## Milla3P (Jan 3, 2013)

Chris07 said:


> High flow 02 is definately indicated also. Low flow = useless in this case.



Titrate to effect?
Can't make this decision unless you're there to assess?
High flow O2 is almost never the answer?


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## mycrofft (Jan 3, 2013)

I don't have any concerns, you're an adult and you don't report to me.


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## medichopeful (Jan 3, 2013)

Nevermind


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## VFlutter (Jan 3, 2013)

so the patient never requested to go to the hospital and they refused your offer to go to the ED? I do not see a problem as long as they were competent.

You said "signs" of SOB, what did the patient say? You said no pertinent medical history but for a COPD patient who is always tachypenic and mildly hypxoic then that might be fairly normal.

And if I had a $1 for every time someone called a RRT for a false spo2 reading I would have at least $34


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## Akulahawk (Jan 3, 2013)

Chase said:


> so the patient never requested to go to the hospital and they refused your offer to go to the ED? I do not see a problem as long as they were competent.
> 
> You said "signs" of SOB, what did the patient say? You said no pertinent medical history but for a COPD patient who is always tachypenic and mildly hypxoic then that might be fairly normal.
> 
> And if I had a $1 for every time someone called a RRT for a false spo2 reading I would have at least $34



I would wonder what that patient's baseline status is. In my case, my resting HR is in the high 40's. My wife's is in the high 90's. My RR typically is around 14. Hers? About 28. Her SpO2 is typically 98-99% on room air. Her ETCO2 is normal as well. Without knowing that's her baseline, you might get a bit too concerned and either rush her to the ED or put her on O2 that she doesn't need. In my case, you might get overly concerned and be ready to pace me because my HR is bradycardic... but I'm asymptomatic, and so is she. No complaints. 

Keep that stuff in mind. What may seem "off" to you may actually be the patient's baseline status. When in doubt, ask!


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## VA Transport EMT (Jan 3, 2013)

Chris07 said:


> In my mind that's very concerning. I personally would have diverted to the closest ED. High flow 02 is definately indicated also. Low flow = useless in this case.
> 
> Hx of recent leg fx...sudden onset dyspnea...no other significant history...first thing I'm thinking is PE.
> Unless the pt flat out refuses Despite explaining my concern, they're going to the ED.
> ...


I agree with you regarding the transport, I had a PT a few days prior with same scenario and transported to ED.

PT was a 93 year old female. Skinny, no extra fluid: you know how old people get wrinkly and stuff.

PT had a high HR around low 60's, BP (AIC didn't obtain due to short transport) skin color was fine and extremities were warm to touch.



TheLocalMedic said:


> Hmmmm...  So it was your partner's decision to just take them home?  In the future if you're not comfortable with that, then try talking to them, away from patient and family, to air your concerns.
> 
> What were lung sounds?  Did patient appear short of breath or did their rate just go up?  And were their hands cold?  I can't tell you the number of times I've seen people get freaked out by a "low O2 sat" when the patient's hands were just cold.



AIC didn't listen to lung sounds because it was just for comfort. I spoke to my partner after finishing the run and she went total defensive b/c it was her decision.

PT did have signs of SOB, shallow and fast respirations (I didn't think to count due to what was going on). PT would breath and then mutter and rinse/lather/repeat.


leoemt said:


> You said you were a driver. Did you look at this patients paperwork? Maybe this was normal for the patient and the family is well aware of how to take care of it.


It was my fifth day driving, usually I'm in the back. I don't look at paperwork because I don't want to step on my partner's toes or insult them by second-guessing them.


leoemt said:


> I have concerns that you don't want to work with a newbie and you are looking for reasons to fault them.


I see...I guess you can say that. But since I'm new to transport, I like to ask questions in case I run into a similar situation.


Epi-do said:


> Do they have any sort of respiratory history?  Cardiac history?  What sort of meds do they take?  Other vital signs, particularly skin color/condition & cap refill?


Skin was normal for her age.


Chase said:


> so the patient never requested to go to the hospital and they refused your offer to go to the ED? I do not see a problem as long as they were competent.


PT didn't request to my knowledge, but my partner did say she was having trouble breathing; hence the 2lpm via NC. When we arrived to residence, I spoke with PT's family about what my partner did and they decided the PT would be better off at home because she was normal.

We were a BLS truck.


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## VFlutter (Jan 3, 2013)

VA Transport EMT said:


> *they decided the PT would be better off at home because she was normal.*



There you go. So what makes you question the decision? I am not convinced she has "no medical history"


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## VA Transport EMT (Jan 3, 2013)

alright, I was worried about the reported respiratory rate and the use of o2, I was taught if you think they are bad enough to get it then they are bad enough to transport. I didn't read the paperwork to get history, sorry.

edit: PT was not on home o2


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## Uclabruin103 (Jan 3, 2013)

VA Transport EMT said:


> alright, I was worried about the reported respiratory rate and the use of o2, I was taught if you think they are bad enough to get it then they are bad enough to transport. I didn't read the paperwork to get history, sorry.
> 
> edit: PT was not on home o2



It's hard when it's not your normal partner, but never feel like you're stepping on someone's toes by listening in on a report or asking to see the paperwork.  Just because you're the driver, doesn't mean you wont be pulled in as being sharing responsibility for something that happens.  

My partners and I would always be right there for histories and reports so that we could make sure that neither of us missed something.  And it never hurts to have another person to bounce ideas off of.  "Hey, she seems pretty tachypneic doesn't she?"  "I saw on her H&P that all her vitals had a respiratory rate of 40."


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## MidTech (Jan 3, 2013)

Similarly I am looking for an opinion on a related matter. I had a morbidly obese F pt, became SOB with minimal exertion who does not have prescribed o2 at home. Upon being discharged my driver said I cannot give her o2 because we are not allowed to discontinue a treatment unless we do so at an ER.  However, i simply said, "I will not hold back o2 if she needs it." After a little bickering we took her and left.

Anyway, our ALS unit backed us up on the lift assist into appt and sure enough she became SOB due to the exertion.  Our medics simply went to get portable o2 to give her until she caught her breath.  My driver once again bickered with our Medics about not being able to discontinue o2 unless we take her back to an ER....

What's  your guys opinion?


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## Medic Tim (Jan 3, 2013)

MidTech said:


> Similarly I am looking for an opinion on a related matter. I had a morbidly obese F pt, became SOB with minimal exertion who does not have prescribed o2 at home. Upon being discharged my driver said I cannot give her o2 because we are not allowed to discontinue a treatment unless we do so at an ER.  However, i simply said, "I will not hold back o2 if she needs it." After a little bickering we took her and left.
> 
> Anyway, our ALS unit backed us up on the lift assist into appt and sure enough she became SOB due to the exertion.  Our medics simply went to get portable o2 to give her until she caught her breath.  My driver once again bickered with our Medics about not being able to discontinue o2 unless we take her back to an ER....
> 
> What's  your guys opinion?



Sounds like the pts baseline.
 I would like to know why your partner thinks that you can't stop something you start until you get to the er. I would have some fun working with them. They would probably hate me by the end of shift.


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## VFlutter (Jan 3, 2013)

MidTech said:


> Similarly I am looking for an opinion on a related matter. I had a morbidly obese F pt, became SOB with minimal exertion who does not have prescribed o2 at home. Upon being discharged my driver said I cannot give her o2 because we are not allowed to discontinue a treatment unless we do so at an ER.  However, i simply said, "I will not hold back o2 if she needs it." After a little bickering we took her and left.
> 
> Anyway, our ALS unit backed us up on the lift assist into appt and sure enough she became SOB due to the exertion.  Our medics simply went to get portable o2 to give her until she caught her breath.  My driver once again bickered with our Medics about not being able to discontinue o2 unless we take her back to an ER....
> 
> What's  your guys opinion?



There are specific criteria a person must meet to qualify for home O2 and it appears this patient did not meet them. I do not see a problem with giving her 02 if she truly needed it and I see no reason why you would not be able to discontinue it without the ER. That being said it sound like there is some underlying problem causing her to become SOB on excretion so its not like you are really helping much overall.


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## Akulahawk (Jan 3, 2013)

Medic Tim said:


> Sounds like the pts baseline.
> I would like to know why your partner thinks that you can't stop something you start until you get to the er. I would have some fun working with them. They would probably hate me by the end of shift.


I think I would agree that this is the patient's normal baseline. Some patients get short of breath with minimal exertion and that is very normal for them just because of how they are. With those patients, I would see no problem in providing some additional oxygen while the patient is doing transfers to minimize the shortness of breath, and then withdrawing that oxygen when they are no longer short of breath at all. I would consider that a very appropriate use of a drug, and that drug would be used for one of its indications. When the patient no longer is short of breath, there likely is no more need for the supplemental oxygen at that time, therefore the therapy could be discontinued. 

I think I also would have a really fun time working with your partner, and by the end of  the shift, your partner would probably hate me with a deep and unrelenting passion. That would've been even with me as an EMT Basic, with me as a medic, I think I would be even worse.


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## VFlutter (Jan 3, 2013)

Akulahawk said:


> I think I also would have a really fun time working with your partner, and by the end of  the shift, your partner would probably hate me with a deep and unrelenting passion. That would've been even with me as an EMT Basic, with me as a medic, I think I would be even worse.



I think people would hate me if I got back on an ambulance, I would be ignorant. Also working as a Basic would be torture.


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## Akulahawk (Jan 4, 2013)

Chase said:


> I think people would hate me if I got back on an ambulance, I would be ignorant. Also working as a Basic would be torture.


I might play ignorant for little while, and then pull out some zingers that would probably make the partner suddenly come to the realization that I know a lot more than I let on. Playing ignorant at times like that can be incredibly fun! I would probably do  that for most of the shift, with the goal of letting my partner come to the conclusion that I'm a lot more well-educated than the partner is.

Doing that, however, is not a good idea when your partner is, in effect, your boss. I had a partner/supervisor that was clearly not anywhere near as well educated as I was and that did not result in a very favorable outcome for continuing my employment with that particular company.

For me, working as a basic would be really not that big of a deal. I did that for quite some time and found it to be very restful compared to my other job at the time, which was nonmedical. of course, I always assessed my patient as a paramedic, given the equipment available, and that I was working as a basic. The reason it was not difficult for me is that when I went to work as a basic, I understood that I was to be working as a basic, not as a paramedic. What would be torture  for me would be to be hired as a paramedic, and told to work as a basic.


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## ZombieEMT (Jan 4, 2013)

*More serious questions.*

I have a more serious question in relation to the OP response to all.

You don't look at paperwork because you don't want to step on your partners toes?

I can not speak for everyone else here, but I generaly read through all my reports whether I treated or drove. My name is on the report and I am just as liable. I also refuse to sign anything I have not read. Just because you did not treat does not mean you were not on the call.

I do not care about stepping on someone else's toes if they are doing the wrong thing and it effects patient care. Review what you are signing and putting your name too. I realize this is transport and generally there are no issues during a typical run but on special occasions like this I really think people need to focus on high quality documentation.


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## VA Transport EMT (Jan 4, 2013)

Thanks for the reply everyone, i didnt take into account of the pts norm. makes sense the more you think about.


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## leoemt (Jan 4, 2013)

A little friendly advice to the OP. You are a team, you need to act like one. Checking paperwork is not stepping on your partners toes. I often read the paperwork and both of us will listen to the Nurses report and ask pertinent questions. Did you or your partner talk to a nurse to get a report? Always make sure you do that. 

I am still new to this and learning. There are a lot of things I haven't seen yet and I might easily miss something. I rely on my partner to speak up if they see something that I have missed. Its not stepping on my toes, its being a good team. 

A doctor told me once "always treat the patient" there are textbook norms and there are real world norms. How many people have a BP of 120/80? Using the signs and symptoms and your questioning will help guide you down the right path. Don't be afraid to ask your partner.


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## mycrofft (Jan 4, 2013)

"Yes" to reply above.

As an old married know it all, I'm learning though that correcting every little thing is going to lead to your being ignored when the bigger things come along. Ten minutes of 2 lpm via nasal cannula, if unchallenged, is a small price to pay for for team harmony.

Maybe make a "mental post-it note" to talk about it over "7" *  sometime, about patient cost of the treatment when it really is not clinically significant.


*For you youngsters, "7" means "chow break" or other short out of service/call us if needed. As in "Control, Eight, we are seven at Hollywood and Vine" (i.e., stopping at the savings and loan there).


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## HMartinho (Jan 5, 2013)

TheLocalMedic said:


> Hmmmm...  So it was your partner's decision to just take them home?  In the future if you're not comfortable with that, then try talking to them, away from patient and family, to air your concerns.
> 
> What were lung sounds?  Did patient appear short of breath or did their rate just go up?  And were their hands cold?  I can't tell you the number of times *I've seen people get freaked out by a "low O2 sat" when the patient's hands were just cold.*



True. 

Under these circumstances, I take SpO2 on earlobe.

First thought that comes to my mind, was PE.

Vital signs?
JVD was present?
Lug sound?


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