# Oxygen Question



## leoemt (Nov 14, 2012)

So a couple of weeks ago I was with my FTO and we responded to an unwitnessed fall at a rehab center. The patient was a 20's female who stated that she woke up on the floor and did not know how she got there. Her only complaint was right shoulder pain and I did notice deformity to right clavical upon palpation. 

We did c-spine precautions due to it being unwitnessed and the MOI and transported her priority to the hospital. 

Patient was alert and oriented x4 and was answering questions appropriately and in complete sentences. She did complain of dizziness and being tired though, no head pain or trauma though. All vital signs were normal for her age. We do not do pulse oximetry in the field in this county so unknown Sat's. At the hospital she was 100% on 2lpm.

In the back of the ambulance my FTO made me place the patient on oxygen. Patient had no signs or symptoms requiring a clinical need for oxygen in my opinion. She was not Hypoxic or Cyanotic and was breathing at about 14 times /min. Respirations were normal rate, rhythm and depth.Lung sounds clear all fields. I placed the patient on 2lpm via NC to appease my FTO. 

My FTO never told me a reason for him wanting her on O2 other than it was a Syncopal Episode. So that leads me to my question, was there a clinical need for this patient to be on Oxygen that I am missing? I am uncomfortable performing any intervention when I can't justify it to a doctor or nurse. Had the ER asked me why she was on O2 I wouldn't have had an answer to give them. 

My FTO was upset that I didn't put her on O2 earlier and I got marked down for it, though I don't think she needed it.


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## Medic Tim (Nov 14, 2012)

O2 and other things mentioned were not needed/indicated


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## leoemt (Nov 14, 2012)

Medic Tim said:


> O2 and other things mentioned were not needed/indicated



I agree. I would have done the spinal precautions had we found her on the floor (protocol) but the fall had happened about 3 hours prior and she ambulated with assistance of staff to our gurney and had been walking around since. C-spine precautions were long out the window. The center is staffed with RN's and they have their own O2 there if needed.

My only concern was her tiredness and dizziness but I think that was unrelated to the fall and more related to the reason she was in rehab.


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## Medic Tim (Nov 14, 2012)

leoemt said:


> I agree. I would have done the spinal precautions had we found her on the floor (protocol) but the fall had happened about 3 hours prior and she ambulated with assistance of staff to our gurney and had been walking around since. C-spine precautions were long out the window. The center is staffed with RN's and they have their own O2 there if needed.
> 
> My only concern was her tiredness and dizziness but I think that was unrelated to the fall and more related to the reason she was in rehab.


you had to board her (protocol) even though there is no neck/back pain, 0 deficits, the fall was probably from less than 3 ft and she has been up moving around for 3 hours under an RNs care?...crazy (I wont say more on this as I dont want to get off topic)


Yeah she would have gotten a slow/easy ride to the ed from me, transported in the position of least discomfort. She probably would have gotten some fent as well.


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## leoemt (Nov 14, 2012)

Medic Tim said:


> you had to board her (protocol) even though there is no neck/back pain, 0 deficits, the fall was probably from less than 3 ft and she has been up moving around for 3 hours under an RNs care?...crazy (I wont say more on this as I dont want to get off topic)
> 
> 
> Yeah she would have gotten a slow/easy ride to the ed from me, transported in the position of least discomfort. She probably would have gotten some fent as well.



No, I would have boarded her had we responded and she was still on the floor as that is what the protocol states for an unwitnessed fall. Sorry for the confusion. At the point we arrived she had been up walking around for quite sometime. 

I have no doubt she needed to be seen at the ER, but I don't think she needed the backboard or the Oxygen. 

This was my first Syncope call so I was hoping I didn't miss something.


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## abckidsmom (Nov 14, 2012)

What were her vital signs?  What was the EKG?  For what reason was she in the rehab place?

It sounds like there wasn't any reason for the oxygen to given, but we don't know the whole story here at all.


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## sneauxpod (Nov 14, 2012)

I would have given her O2 because of the dizziness, i mean its not exactly necessary, but to me its kind of a "it cant hurt" situation.


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## leoemt (Nov 14, 2012)

abckidsmom said:


> What were her vital signs?  What was the EKG?  For what reason was she in the rehab place?
> 
> It sounds like there wasn't any reason for the oxygen to given, but we don't know the whole story here at all.



I am a Basic so I don't do 12 leads. 

The vitals were all normal for her age (27). I don't remember exact numbers but BP was about 118 / 76, RR 14, PERRL, Lungs clear all fields, HR was mid 70's normal and strong. Skin was Pink, warm, dry with no diaphoresis. She was A&Ox4. Her walk was of normal gait with no pain upon walking. 

Drug addiction was  why she was in rehab. I don't know what drug or how long she had been off. Didn't think to ask those questions at the time. 

We don't do pulse ox in the field though the hospital makes us do it in the ER. She was 100% when we arrived. 

The nurses immediately removed the back board and C-collar upon our arrival.


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## Tigger (Nov 14, 2012)

sneauxpod said:


> I would have given her O2 because of the dizziness, i mean its not exactly necessary, but to me its kind of a "it cant hurt" situation.



Would you give her glucose too since that can't really hurt either?


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## NYMedic828 (Nov 14, 2012)

Would not have given her oxygen and I would probably have had her walk to the ambulance.






sneauxpod said:


> I would have given her O2 because of the dizziness, i mean its not exactly necessary, but to me its kind of a "it cant hurt" situation.



Are you certain it can't hurt? Or do you just think it can't hurt... In either instance, you would be mistaken.


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## leoemt (Nov 14, 2012)

sneauxpod said:


> I would have given her O2 because of the dizziness, i mean its not exactly necessary, but to me its kind of a "it cant hurt" situation.



Dizziness can be caused by a lot of reasons, most of which O2 isn't going to help. I believe the dizziness was caused by her withdrawing from substance abuse and not a ground level fall. Since she was A&Ox4 and PERRL with no trauma to Head, Neck or Back, denying pain and no deformities upon palp I don't think there was any neurological deficit. 

I don't like to do something "just because." It may be what the "book" says but its not how I operate. In Seattle, the doctors give us enough trust at the Basic level to make clinical decisions without consulting with them. When I walk into an ER I want to be able to tell the RN or MD exactly why I felt they needed a specific intervention, even if it is O2. 

In this case I didn't see a need for the O2, but I will admit I am new and don't know everything. Maybe there is something about Syncope that I don't know which is why I bring this up. 

Here in Seattle, the doctors and nurses are happy to answer our questions if they aren't busy so if you ask appropriate questions you can learn a wealth of information. 

If I did everything the book said, every patient would get 15lpm by NRB.


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## NYMedic828 (Nov 14, 2012)

leoemt said:


> Dizziness can be caused by a lot of reasons, most of which O2 isn't going to help. I believe the dizziness was caused by her withdrawing from substance abuse and not a ground level fall. Since she was A&Ox4 and PERRL with no trauma to Head, Neck or Back, denying pain and no deformities upon palp I don't think there was any neurological deficit.
> 
> I don't like to do something "just because." It may be what the "book" says but its not how I operate. In Seattle, the doctors give us enough trust at the Basic level to make clinical decisions without consulting with them. When I walk into an ER I want to be able to tell the RN or MD exactly why I felt they needed a specific intervention, even if it is O2.
> 
> ...



Good to see your attitude towards assessment and treatment has evolved. Couple months ago your answer was protocols say so. 

Now help get the word out


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## mycrofft (Nov 14, 2012)

Tigger said:


> Would you give her glucose too since that can't really hurt either?


 "Candy, Little Girl?".
	

	
	
		
		

		
			





Tell the FTO you are failing to find the protocol requiring oxygen ad lib without s/s.


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## MassEMT-B (Nov 14, 2012)

There seems no reason for o2 besides giving it just because they passed out. If hypoxia was honestly the reason for the syncopal episode and dizziness there would be other outward signs of it. Just a question, would those who use the NEXUS c spine criteria consider the shoulder pain coupled with the clavicle deformity a distracting injury?


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## NYMedic828 (Nov 14, 2012)

MassEMT-B said:


> There seems no reason for o2 besides giving it just because they passed out. If hypoxia was honestly the reason for the syncopal episode and dizziness there would be other outward signs of it. Just a question, would those who use the NEXUS c spine criteria consider the shoulder pain coupled with the clavicle deformity a distracting injury?



The clavicles are amongst the most easily fractured bones in the body. Due to the way the shoulder joint and the pectoral girdle meet with the clavicle when a person falls and uses their arm to brace themselves it often transfers the force to the clavicles and can cause fracture.

Many martial arts and self defense classes also  advocate the clavicle as a primary striking point because it is so poorly supported and fracturing it results in disabling (usually) of the arm on the affected side.

Nice thing about the clavicles for us is that they are so anterior and rarely covered by much fat. A clavicular fracture is usually not too hard to palpate or even spot if the often distinct clavicular line seems "off."

If she had fractured the clavical you would probably know. That said, any true fracture is a porentially distracting injury but if you are assuming injury was caused by a fall, that would imply she landed on her shoulder or arm and not C-spine worthy. A fall from standing height is not worthy of suspecting spinal injury in a non-elderly patient. The human body by design is capable of such falls without injury. If there was a ladder next to the patient things are different...


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## DrParasite (Nov 14, 2012)

I think the patient should have had a NRB at 15 lpm.  that's what the book says right?

also, request a helicopter because the patient needs rapid transport to a level 1 trauma center.


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## NYMedic828 (Nov 14, 2012)

DrParasite said:


> I think the patient should have had a NRB at 15 lpm.  that's what the book says right?
> 
> also, request a helicopter because the patient needs rapid transport to a level 1 trauma center.



I think an F35 lightning is more appropriate. A helicopter is too slow. 

I would suggest an F18, but its easier to land an F35 in a neighborhood...


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## JPINFV (Nov 14, 2012)

NYMedic828 said:


> I think an F35 lightning is more appropriate. A helicopter is too slow.
> 
> I would suggest an F18, but its easier to land an F35 in a neighborhood...




Easier? All planes are easy the land. As papa always says, haven't seen one stuck up there yet.


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## NYMedic828 (Nov 14, 2012)

JPINFV said:


> Easier? All planes are easy the land. As papa always says, haven't seen one stuck up there yet.



:rofl: like cats in trees. Never see a dead cat in a tree.

Side note, the F35 does that nifty hovering take-off trick like a harrier.


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## emtb31dcems (Nov 14, 2012)

*ANSWER regards to OXYGEN*

NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm.  Vital signs could have easily changed, you basically prevented from things getting worse.  Your FTO was right.


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## leoemt (Nov 14, 2012)

EMS is an ever evolving field and I am always trying to learn. My legal background has made it so I want to be able to justify my actions if ever questioned. 

I believe she did fracture her Clavicle. There was an obvious deformity upon palp, she screamed in pain upon palp and wanted to deck me when I palpated it. Additionally, movement of the arm caused pain to increase. 

Second question, is there anything that can be done in field for an injured clavicle? Would a sling and swathe have been appropriate? I didn't even consider that at the time, but in hindsight I am wondering if that would have been appropriate.


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## JPINFV (Nov 14, 2012)

emtb31dcems said:


> NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm.  Vital signs could have easily changed, you basically prevented from things getting worse.  Your FTO was right.



Lots of things "don't hurt." That doesn't mean it's the right treatment choice or helpful.


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## Medic Tim (Nov 14, 2012)

emtb31dcems said:


> NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm.  Vital signs could have easily changed, you basically prevented from things getting worse.  Your FTO was right.


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## Tigger (Nov 14, 2012)

leoemt said:


> Second question, is there anything that can be done in field for an injured clavicle? Would a sling and swathe have been appropriate? I didn't even consider that at the time, but in hindsight I am wondering if that would have been appropriate.



The sling and swath can provide comfort for many shoulder and clavicle injuries. It is not uncommon to find patients with these injuries to present with their injured arm being held across their chest. If that's the case, a sling can help ease the load. 

If nothing else it's worth a shot. If the patient finds a slung position helpful, use it. If not, oh well it was only a cravat and a minute of your time. There are some times when the body' position of least discomfort is better than a splint or other adjunct.


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## NYMedic828 (Nov 14, 2012)

leoemt said:


> EMS is an ever evolving field and I am always trying to learn. My legal background has made it so I want to be able to justify my actions if ever questioned.
> 
> I believe she did fracture her Clavicle. There was an obvious deformity upon palp, she screamed in pain upon palp and wanted to deck me when I palpated it. Additionally, movement of the arm caused pain to increase.
> 
> Second question, is there anything that can be done in field for an injured clavicle? Would a sling and swathe have been appropriate? I didn't even consider that at the time, but in hindsight I am wondering if that would have been appropriate.



Sounds broke lol.

As tigger said, sling and swath if they can bend their arm to the position.

Ice if you want.

ALS, pain management.


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## leoemt (Nov 14, 2012)

emtb31dcems said:


> NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm.  Vital signs could have easily changed, you basically prevented from things getting worse.  Your FTO was right.



Explain this clincally to me? 

Based on what I know Oxygen is used in a process called perfussion. When someone is perfusing normally, why should I give them extra Oxygen? What benefit am I providing to the patient for giving them extra oxygen when they are already at 100%? While I couldn't do a pulse ox, I did do a cap refill test on her. While that is not exactly accurate in adults, she was under 2 seconds. 

Our doctors teach us to treat a patient, not numbers. Which is why our protocols put so much emphasis and signs and symptoms. 

I give Oxygen because it is warranted based on clinical presentation, not because the book says so. 

If your going to advocate giving Oxygen that is fine, but back it up with a clinical explanation to support your reasoning.


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## NYMedic828 (Nov 14, 2012)

The short 101 version.

Ventilation - the mechanical process of expansion/relaxation of the lungs to move air in and out of the body.

Respiration comes in two forms.

External: exchange of CO2/o2 within the lungs between the alveoli and outside environment.

Internal: exchange of Co2/o2 by body cells and blood.

Oxygenation is the oxygenating of body cells/tissues. Essentially the same as internal respiration but a more frequently used term.

SpO2 - measurement of bound hemoglobin in blood. One molecule of hemoglobin can hold 4 molecules of O2 and one red blood cell can have 280million molecules of heme. 

PaO2/PO2 - measurement of the partial pressure of oxygen in the bloodstream. 

We can measure SpO2 with pulse oximetry under optimal conditions and an SpO2 of 100% is roughly equal to a PaO2 of 100mmHg. So with a 100% sat we can assume a PaO2 of atleast 100.

We can't force hemoglobin to hold more than it is capable, there for SpO2 can never exceed 100%. BUT, PaO2 can be increased and a higher PaO2 alters the weight of the concentration gradiant of oxygen which tries to force more oxygen onto hemoglobin even though it can't take it. This causes heme to more rapidly bind O2 and increases its ability to get into tissues. This is how hyperbaric therapies work, increasing the pressure of oxygen so it forces substances like carbon monoxide out.

You won't increase PaO2 with a nasal cannula or non-rebreather. To increase PaO2 requires increases in atomospheric pressure. A BVM/vent mask can potentially increase PaO2 if it isolates outside pressures. The body is constantly trying to reach equilibrium with himself and the outside environment it exchanges with.

In short, if the patient is satting at 100% and you believe that number to be accurate the NC @ 2 LPM serves no purpose outside of a placebo. But we don't give placebos...


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## the_negro_puppy (Nov 15, 2012)

emtb31dcems said:


> NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm.  Vital signs could have easily changed, you basically prevented from things getting worse.  Your FTO was right.


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## PotatoMedic (Nov 15, 2012)

Well I'm going to place myself on the side of the administer o2 due to the dizziness a the pt being lethargic.  2lpm.  My thinking is that even though vs looks good perfusion may be decreased.  If symptoms resolved after o2 i would continue to hospital.  If nothing got better i would remove.  Even if i left it on the length of the transport would not cause any adverse effects and probably would not even dry out their nose.  My bet is that she could live without it for duration.  But if i can enter that er and state pt complaining of xyz and abc did not relieve symptoms then the nurses and dr can have a better idea what's going on.


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## mgr22 (Nov 15, 2012)

As I understand it, cells can be damaged by exposure to more O2 than those cells are able to use. I think the mechanism is free radicals interfering with cellular metabolism. Vene, can you confirm? New ACLS guidelines for ACS and CVA recommend supplementary O2 only when the SpO2 falls below 94%. This definitely conflicts with decades-old primary training that O2 can't hurt.


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## medichopeful (Nov 15, 2012)

NYMedic828 said:


> I think an F35 lightning is more appropriate. A helicopter is too slow.



Yeah I gotta admit, for this patient I'd definitely consider calling an F35 in, mostly because I'd love to see the damn thing!


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## NYMedic828 (Nov 15, 2012)

FireWA1 said:


> Well I'm going to place myself on the side of the administer o2 due to the dizziness a the pt being lethargic.  2lpm.  My thinking is that even though vs looks good perfusion may be decreased.  If symptoms resolved after o2 i would continue to hospital.  If nothing got better i would remove.  Even if i left it on the length of the transport would not cause any adverse effects and probably would not even dry out their nose.  My bet is that she could live without it for duration.  But if i can enter that er and state pt complaining of xyz and abc did not relieve symptoms then the nurses and dr can have a better idea what's going on.



We
Do
Not
Administer
Treatments
That
Are
Not
Warranted


Dizziness without any underlying presumed pathology affecting oxygen delivery is NOT a reason to give O2. Half the patients I pick up complain they are dizzy and 1/4 of them if even do I put on O2. Patient has no respiratory complaint, lung sounds reveal no insult to the lungs with great air flow, where is the issue with oxygen delivery?

Administering O2 for chest pain in theory, useless. Stroke? Useless. The issue is not oxygen intake of the body it is oxygen delivery which can't be fixed in an ambulance. 

The three parts of oxygen delivery are vessels, Heme/RBCs, heart. If the blood/heme cannot reach the site, no amount of oxygen in the world is going to increase perfusion. 

It is not a warranted treatment 9/10 when EMS providers administer it.

If a patient states they are in fact short of breath, administer o2 titrated to effect don't just slap a NRB at 15lpm on them. They may only need 2 liters. Sometimes doing nothing at all does the most good.




mgr22 said:


> As I understand it, cells can be damaged by exposure to more O2 than those cells are able to use. I think the mechanism is free radicals interfering with cellular metabolism. Vene, can you confirm? New ACLS guidelines for ACS and CVA recommend supplementary O2 only when the SpO2 falls below 94%. This definitely conflicts with decades-old primary training that O2 can't hurt.



Yes. As I understand it, after talking with Vene a few times about it, the short version is the body is set up to intake 20.9% oxygen from the environment. Free radicals naturally occur as chemistry in the body utilizes oxygen and the body contains "antioxidants" to combat these free radicals that would otherwise harm tissues through the process of "oxidation." The unpaired electron of the superoxide O2- ion (free radical ion of oxygen) essentially steals an electron from what it comes in contact with, which is hopefully an antioxident such as glutathione that would prevent it from binding to tissues and interrupting important biological processes.

When we increase the FiO2 and the body has nowhere to put it, many more free radicals form than naturally would which can deplete the antioxidizing reserves of the body and actually worsen disease processes, lead to new disease or form localized scar tissue.



Oxidation: (yes I linked wikipedia)
http://en.wikipedia.org/wiki/Oxidation


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## Aidey (Nov 15, 2012)

Preach it! 

And if that doesn't work, start beating people with NRBs.


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## Aidey (Nov 15, 2012)

Out of curiosity, can anyone name any causes of dizziness that can be improved with oxygen? Besides hypoxia.


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## NYMedic828 (Nov 15, 2012)

Aidey said:


> Out of curiosity, can anyone name any causes of dizziness that can be improved with oxygen? Besides hypoxia.



Honestly... I got nothing. I'm sure one of these fancy RN/MD types will spew something out for it but as far as I can think of they all relate back to hypoxia/hypoxemia as the root cause if they truly need oxygen for it?


Hypoxia is technically the only treatable condition which warrants oxygen regardless of what is causing it...


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## PotatoMedic (Nov 15, 2012)

NYMedic828 said:


> We
> Do
> Not
> Administer
> ...



And in my opinion one or more of the symptoms could be an oxigenation issue.  You can disagree, which you will, but thats life.  No o2 is not warrented for 90% of the time we are told to put it on and i think in my two years as an emt i have used it less than 10 times.  But without seeing the pt and doing an assessment myself i will always lean to the conservative side.


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## NYMedic828 (Nov 15, 2012)

Opinion and fact are vastly different.

Please list for me the symptoms presenting that could in any way shape or form constitute an issue with oxygenation when you know for a fact the patient is adequately perfusing.

Mind you I imply use of proper assessment techniques and pulse oximetry.


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## mycrofft (Nov 15, 2012)

Aidey said:


> Out of curiosity, can anyone name any causes of dizziness that can be improved with oxygen? Besides hypoxia.



(Is there anything which can be profitably treated with an AED, besides a shockable rhythm?).

That's the way to take it down to the irreducible minimum, then *own* it.

Heck, can most new techs even describe the s/s of hypoxia/air hunger without resorting to something with AA batteries in it?


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## PotatoMedic (Nov 15, 2012)

Dizziness and her being lethargic are the two things that i know that could be an oxygenation issue and do we know for a fact that she was prefusing normally?  We have no spo2 and he never mentioned what the skin signs looked like.  Her head might be warm to the touch but are her hands cold?  The body may vaso constrict to keep the core warm and oxygenated.  Lack of o2 reduces the amount of atp generated reducing amount of energy causing lethargia.

Yes you are correct there are many other things that could be the cause of the pt's symptoms.  But with what little information we all have i can see someones logic in applying up to 2leiters of o2 and seeing if it resolves the issue.  Am i more then happy to not apply o2 if i see a reason not to like good skin signs and good prefusion with the symptoms above? Yes.  But again I dont know all the details i want to know to make a definitive answer.

Now since I like to learn can you take me through your thought process on what is going on with this pt and why?


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## NYMedic828 (Nov 15, 2012)

FireWA1 said:


> Dizziness and her being lethargic are the two things that i know that could be an oxygenation issue and do we know for a fact that she was prefusing normally?  We have no spo2 and he never mentioned what the skin signs looked like.  Her head might be warm to the touch but are her hands cold?  The body may vaso constrict to keep the core warm and oxygenated.  Lack of o2 reduces the amount of atp generated reducing amount of energy causing lethargia.
> 
> Yes you are correct there are many other things that could be the cause of the pt's symptoms.  But with what little information we all have i can see someones logic in applying up to 2leiters of o2 and seeing if it resolves the issue.  Am i more then happy to not apply o2 if i see a reason not to like good skin signs and good prefusion with the symptoms above? Yes.  But again I dont know all the details i want to know to make a definitive answer.
> 
> Now since I like to learn can you take me through your thought process on what is going on with this pt and why?



Rehab center, extremely painful clavicular/arm injury, syncope for unknown reason without more info and landed on her arm.


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## Veneficus (Nov 15, 2012)

NYMedic828 said:


> Yes. As I understand it, after talking with Vene a few times about it, the short version is the body is set up to intake 20.9% oxygen from the environment. Free radicals naturally occur as chemistry in the body utilizes oxygen and the body contains "antioxidants" to combat these free radicals that would otherwise harm tissues through the process of "oxidation." The unpaired electron of the superoxide O2- ion (free radical ion of oxygen) essentially steals an electron from what it comes in contact with, which is hopefully an antioxident such as glutathione that would prevent it from binding to tissues and interrupting important biological processes.
> 
> When we increase the FiO2 and the body has nowhere to put it, many more free radicals form than naturally would which can deplete the antioxidizing reserves of the body and actually worsen disease processes, lead to new disease or form localized scar tissue.
> 
> ...



What he said is the short and simple version.

I would just add the free radicals damage cell membranes (particularly RBCs), this damage can initiate apoptosis cascades, attract immune cells from IgM and IgG binding(like fixed macrophages in the spleen), which recognize the damaged cell as foreign, expose compliment binding proteins, and initiate inflammatory cascades. 

While this cellular damage may initially be subclinical, it can take days to manifest. Even if it doesn't manifest as acute injury, in can cause damage that will shave years off of both quality of life and total life.

If you think cellular injury is too small to care about, let me put it into perspective...

If you take a mole of oxygen, use 1/2 to deplete natural antioxidants, you will damage 1/2 a mole of tissues.

Those tissues most likely are going to be type I pneumocytes, RBCs, vascular epithelium, zone 3 liver cells, and renal medulary cells.

In infants, to that list, add the retina.


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## mycrofft (Nov 15, 2012)

Nursing home, lethargy, "dizziness" (vertigo or dizziness or lightheadedness?): 
1. Polypharmacy induced intoxication
2. Orthostatic hypotension with possible links to meds and too much bed rest.
3. Brain tumor?
4. Heavy metal intoxication?


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## NYMedic828 (Nov 15, 2012)

mycrofft said:


> Nursing home, lethargy, "dizziness" (vertigo or dizziness or lightheadedness?):
> 1. Polypharmacy induced intoxication
> 2. Orthostatic hypotension with possible links to meds and too much bed rest.
> 3. Brain tumor?
> 4. Heavy metal intoxication?



But none of those specifically relate to a need for supplemental oxygen which I believe was the main purpose of this thread.


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## Scott33 (Nov 15, 2012)

mgr22 said:


> As I understand it, cells can be damaged by exposure to more O2 than those cells are able to use. I think the mechanism is free radicals interfering with cellular metabolism.



You were the first person I ever heard this concept from - in the back of an ambulance about 7 years ago, maybe a little more. I have to confess I hadn't a clue what you were talking about.  Oxygen? Harmful? How could it be?

Of course you were right. It's just a shame (if this thread is anything to go by) that there are still places teaching that oxygen is a benign drug.


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## leoemt (Nov 15, 2012)

FireWA1 said:


> Dizziness and her being lethargic are the two things that i know that could be an oxygenation issue and do we know for a fact that she was prefusing normally?  We have no spo2 and he never mentioned what the skin signs looked like.  Her head might be warm to the touch but are her hands cold?  The body may vaso constrict to keep the core warm and oxygenated.  Lack of o2 reduces the amount of atp generated reducing amount of energy causing lethargia.
> 
> Yes you are correct there are many other things that could be the cause of the pt's symptoms.  But with what little information we all have i can see someones logic in applying up to 2leiters of o2 and seeing if it resolves the issue.  Am i more then happy to not apply o2 if i see a reason not to like good skin signs and good prefusion with the symptoms above? Yes.  But again I dont know all the details i want to know to make a definitive answer.
> 
> Now since I like to learn can you take me through your thought process on what is going on with this pt and why?



The patient was being treated for Substance Abuse. Unfortunately I don't know what substance nor do I know how long since she last abused. That said I am unaware of any issue relating to Oxygenation that would cause Syncope with the exception of Hypoxia. 

Patient had all of her vital signs within normal limits for her age. Patient was not presenting with any oxygen compromise and even when I asked her how her breathing was she stated fine. She screamed when I palpated her injury and was talking in normal, uninterupted sentences. 

The reason I brought this up was to educate myself as to oxygen delivery. When I bring a patient in I want to be able to tell the ER why I did something. I don't believe in "textbook" medicine. It is not in the patients best interest. 

I'm not really concerned that she got oxygen - it was less than a 5 minute trip to the ER. I am more concerned that I was marked down for this without being given a clinical explanation. The doctors removed her from the Oxygen upon her arriving at the ER.

If you can justify your reasoning then by all means, enlighten me.


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## mycrofft (Nov 15, 2012)

NYMedic828 said:


> But none of those specifically relate to a need for supplemental oxygen which I believe was the main purpose of this thread.



Fair enough.

The basic question has been answered repeatedly. The need for supplemental oxygen is hypoxia. Theoretically hypoxia can make one feel tired. "Dizzy": not a classic symptom, and we have not established if this was vertigo, dizziness, or light-headedness. No objective external signs of hypoxia cited.
So, as presented, no signs presented which clearly indicated the need for supplemental oxygen.
5=4


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## Milla3P (Nov 15, 2012)

emtb31dcems said:


> NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm.  Vital signs could have easily changed, you basically prevented from things getting worse.  Your FTO was right.



I think I just had a stroke...


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## Milla3P (Nov 15, 2012)

Stretchers are for SICK people... O2 is for hypoxia. 

Bls not being able to do spo2 makes my brain hurt.


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## JPINFV (Nov 15, 2012)

Milla3P said:


> Stretchers are for SICK people... O2 is for hypoxia.
> 
> Bls not being able to do spo2 makes my brain hurt.




Roses are red, 
violets are blue,
EMS is for sick people,
and not for you.


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## PotatoMedic (Nov 15, 2012)

ahh that kind of rehab center.  I was thinking SNF rehab.  Either way yes you are all correct in the fact that the pt did not need o2 as presented.  Yes initially I said I would admin o2 but I was working with a different picture at that point.  And admittedly I was a bad person and focusing on mostly the o2 aspect of the issue since that was the main theme of the thread and not so much on the clavicle issue.


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## Aidey (Nov 15, 2012)

Why does the type of rehab change your opinion?


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## Cleric (Nov 15, 2012)

Scott33 said:


> Oxygen? Harmful? How could it be?
> 
> Of course you were right. It's just a shame (if this thread is anything to go by) that there are still places teaching that oxygen is a benign drug.



I registered specifically to speak on this. I'm just entering an EMT-B class in the coming spring, and even with my basic 'civilian' knowledge I can understand the Free Radical idea, as well as the concept of *only giving indicated treatment*. The students and teachers that say "oxygen CAN'T be harmful, it's a basic need," are unbelievably ignorant. Glucose is a basic nutrient necessary for life, it shouldn't be harmful, it's just like candy, so let's give it to EVERYBODY! Water is necessary for life, it can't be harmful, right? Until, of course, you dilute the electrolytes in your system and start seizing due to hyponatremia.

If I go into my first class on O2 usage, and my instructor says it's harmless, I'll take that as a cue to perhaps scrutinize his instructions a little more closely.


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## PotatoMedic (Nov 15, 2012)

Aidey said:


> Why does the type of rehab change your opinion?



Type of pt.  Drug rehab I would expect more detox issues where snf rehab center I would expect... well anything.  Those places are crazy.  Now when I get there and the pt presents with something completely different or even just slightly different than what I was thinking.  I'll paint a whole new picture with what the pt presents.  But yes when I get dispatched to a drug rehab center verses a SNF rehab center I have two different starting points.


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## mycrofft (Nov 15, 2012)

SNF patients are more prone to chronic oxygenation and circulatory issues, and polypharmacy.


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## Tigger (Nov 15, 2012)

FireWA1 said:


> Dizziness and her being lethargic are the two things that i know that could be an oxygenation issue and do we know for a fact that she was prefusing normally?  We have no spo2 and he never mentioned what the skin signs looked like.  Her head might be warm to the touch but are her hands cold?  The body may vaso constrict to keep the core warm and oxygenated.  Lack of o2 reduces the amount of atp generated reducing amount of energy causing lethargia.
> 
> Yes you are correct there are many other things that could be the cause of the pt's symptoms.  But with what little information we all have i can see someones logic in applying up to 2leiters of o2 and seeing if it resolves the issue.  Am i more then happy to not apply o2 if i see a reason not to like good skin signs and good prefusion with the symptoms above? Yes.  But again I dont know all the details i want to know to make a definitive answer.
> 
> Now since I like to learn can you take me through your thought process on what is going on with this pt and why?



This is a classic case of "if you only have a hammer, everything looks like a nail." The patient is not feeling 100%, and as healthcare providers, it is your goal to fix that. However, when you have very few tools to assist you in that task, you try and manipulate the patient's complaint into something that you can address at your level, so that you can attempt to alleviate the issue. While you want to care for your patient to the best of your ability, sometimes that means doing nothing but holding someone's hand and telling them that they'll be in the ED shortly.


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## Outbac1 (Nov 15, 2012)

"I am uncomfortable performing any intervention when I can't justify it to a doctor or nurse."

 "Our doctors teach us to treat a patient, not numbers. Which is why our protocols put so much emphasis and signs and symptoms. 

 I give Oxygen because it is warranted based on clinical presentation, not because the book says so. 

 If your going to advocate giving Oxygen that is fine, but back it up with a clinical explanation to support your reasoning."

 I think here is hope. Please get educated in medicine. Then you can give your FTO the two clues they apparently lack. 
 From your description there was much done on the call that was not warranted.


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## leoemt (Nov 15, 2012)

Milla3P said:


> Stretchers are for SICK people... O2 is for hypoxia.
> 
> Bls not being able to do spo2 makes my brain hurt.



Its not that we can't do spo2. It is a Basic skill in this state. We do it when we arrive at the ER. However, in King County, the medical director believes in treating the patient and not the numbers.

While it would be helpful to have a pulse ox, I can see where they are coming from. You begin to rely on it. Since I don't have access to one in this county in the field, I have to rely on other methods to determine saturation and adequate oxygenation. 

As a result, my ability to differentiate lung sounds has increased. I also feel that my pathology knowledge is increasing and I am begining to understand what is going on with patients without use of a pulse ox.


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## NYMedic828 (Nov 15, 2012)

Cleric said:


> I registered specifically to speak on this. I'm just entering an EMT-B class in the coming spring, and even with my basic 'civilian' knowledge I can understand the Free Radical idea, as well as the concept of *only giving indicated treatment*. The students and teachers that say "oxygen CAN'T be harmful, it's a basic need," are unbelievably ignorant. Glucose is a basic nutrient necessary for life, it shouldn't be harmful, it's just like candy, so let's give it to EVERYBODY! Water is necessary for life, it can't be harmful, right? Until, of course, you dilute the electrolytes in your system and start seizing due to hyponatremia.
> 
> If I go into my first class on O2 usage, and my instructor says it's harmless, I'll take that as a cue to perhaps scrutinize his instructions a little more closely.



You are too smart for EMS. Run while you still can.


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## Medic Tim (Nov 15, 2012)

Cleric said:


> I registered specifically to speak on this. I'm just entering an EMT-B class in the coming spring, and even with my basic 'civilian' knowledge I can understand the Free Radical idea, as well as the concept of *only giving indicated treatment*. The students and teachers that say "oxygen CAN'T be harmful, it's a basic need," are unbelievably ignorant. Glucose is a basic nutrient necessary for life, it shouldn't be harmful, it's just like candy, so let's give it to EVERYBODY! Water is necessary for life, it can't be harmful, right? Until, of course, you dilute the electrolytes in your system and start seizing due to hyponatremia.
> 
> If I go into my first class on O2 usage, and my instructor says it's harmless, I'll take that as a cue to perhaps scrutinize his instructions a little more closely.



It's unfortunate but sometimes you need to play by their rules while in school and for testing purposes. A major issue with ems education is that it is skills based and not education based. There is a good chance you emt instructor doesn't know any better because he is teaching what he was taught.


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## Tigger (Nov 15, 2012)

leoemt said:


> Its not that we can't do spo2. It is a Basic skill in this state. We do it when we arrive at the ER. However, in King County, the medical director believes in treating the patient and not the numbers.



This is awful reasoning on the MD's part if it is indeed the reasoning. Did the MD also get rid of monitors on ALS units?


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## leoemt (Nov 15, 2012)

Tigger said:


> This is awful reasoning on the MD's part if it is indeed the reasoning. Did the MD also get rid of monitors on ALS units?



Nope, they still got the monitors. I think it came out of too many EMT's using the pulse ox to obtain a HR rather than do the skill themselves. 

Most counties around here have them on the BLS units. I would prefer to have them but I have gotten pretty good at making oxygenation evaluations.

You make due with the tools your given. I can't do glucometry either, even though it is a basic skill in this state.


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## mycrofft (Nov 16, 2012)

That's what they mean by "Stay hungry". Know there's more and you can go for it.


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## AnthonyM83 (Nov 16, 2012)

So, what do you do if you have an unconscious patient and you can't see their oxygen saturation? No everyone with a low 90s pulse ox is going to have outward signs of hypoxia.


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## Akulahawk (Nov 16, 2012)

Just reading the previous few posts, including the first ones of this thread, it struck me that it was probably likely that the patient did not need the C-spine or the oxygen to be administered. Even though the patient was alert and oriented, but did not know why she fell, tells me that she may have had a seizure given the fact that she's in a drug rehab facility. A thorough examination should rule out spinal precautions as something that is necessary, and the fact that she is breathing, has no shortness of breath issues, is warm pink and dry, and so on tells me that she probably does not need supplemental oxygen. If I were to hazard a guess, she probably fell on her side, with her arms at her side, or she fell on something that resulted in fracture of her clavicle. I think that is the only injury she sustained based on these signs and symptoms she had: a deformity and point tender on her clavicle.

I can understand placing the patient C-spine precautions by protocol, because you have to, for unwitnessed mechanical fall, even if it's a ground-level fall. Given her overall presentation, I do not see any indication for oxygen at this time. Most likely, even if I had a pulse oximetry are handy, I would not have used it, unless I had to by protocol.

My treatment plans are derived from my own evaluation of the patient. I say evaluation instead of assessment, because I don't just take into consideration physical findings, I try to look at as much of the clinical picture as I can. I then come up with a treatment plan that makes sense given the presentation. I then implement what I can, based upon my limitations as a provider. If I'm working as an EMT, I only do EMT stuff, if I'm working as a paramedic, I add the paramedic level stuff as well.

That particular patient, I probably would consider not putting the patient in C-spine, I would not put the patient oxygen, I probably would however provide an ice pack of some sort to control pain. That would be if I was working as an EMT. As far as transport decision goes, no lights, no siren, no drama. If I was a paramedic working that particular call, I would probably do the same things as above, and consider opiate pain control measures if the ice was not working, depending upon specific protocol for pain control and trauma. Otherwise, I would just "BLS it in" and call it good.

The only thing else I would add would be finding out why the patient was admitted to the drug rehab facility. We can see polypharmacy issues in skilled nursing facilities, but it is not out of the realm of possibilities that polypharmacy could be a big issue with these types of facilities too.

So, after all of this rambling, taking all of the above into consideration, I would simply transport patient in a position of comfort, cold pack on the clavicle, nice quiet ride to the ED for evaluation. The other guys have certainly covered the issues of too much oxygenation. My take on oxygen is simply this: it is a drug, it is relatively benign, like all drugs it can be harmful if used improperly. That is why you only give it when it is indicated in the amounts that it is indicated for.


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## mycrofft (Nov 16, 2012)

AnthonyM83 said:


> So, what do you do if you have an unconscious patient and you can't see their oxygen saturation? No everyone with a low 90s pulse ox is going to have outward signs of hypoxia.



True, but are they all in need of resuscitation? I pulse-ox around 94 quite often but don't need resuscitation. I get a little gray, however....


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## AnthonyM83 (Nov 16, 2012)

mycrofft said:


> True, but are they all in need of resuscitation? I pulse-ox around 94 quite often but don't need resuscitation. I get a little gray, however....



It does get gray...As much as people get indignant about not giving oxygen (and I definitely don't like handing it out like candy), it's not always clear cut.

But yes, if you read the actual AHA language, it does say you look at the oxygen saturation IF they're dyspneic, hypoxemic, or obvious signs of heart failure. Low oxygen saturation alone isn't an indication for O2. But if he's unconscious and only mild hypoxia, how will we know he has dyspnea?

Wording from guidelines: "there is insufficient evidence to support its routine use in uncomplicated ACS. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, providers should titrate therapy, based on monitoring of oxyhemoglobin saturation, to ≥94% (Class I, LOE C)." 

Keyword is ***ACS***  What about all the various other non-ACS/CVA cases? Do we have Class I evidence for or against? What about trauma with significant injury? Trauma with shock? Trauma with head injury (can get into capnography here)? 

What about shortness of breath with accessory muscle use but pulse ox of 95% ?


----------



## leoemt (Nov 16, 2012)

Akulahawk said:


> Just reading the previous few posts, including the first ones of this thread, it struck me that it was probably likely that the patient did not need the C-spine or the oxygen to be administered. Even though the patient was alert and oriented, but did not know why she fell, tells me that she may have had a seizure given the fact that she's in a drug rehab facility. A thorough examination should rule out spinal precautions as something that is necessary, and the fact that she is breathing, has no shortness of breath issues, is warm pink and dry, and so on tells me that she probably does not need supplemental oxygen. If I were to hazard a guess, she probably fell on her side, with her arms at her side, or she fell on something that resulted in fracture of her clavicle. I think that is the only injury she sustained based on these signs and symptoms she had: a deformity and point tender on her clavicle.
> 
> I can understand placing the patient C-spine precautions by protocol, because you have to, for unwitnessed mechanical fall, even if it's a ground-level fall. Given her overall presentation, I do not see any indication for oxygen at this time. Most likely, even if I had a pulse oximetry are handy, I would not have used it, unless I had to by protocol.
> 
> ...



My running theory is she fell out of bed and landed on her right arm causing the clavicle injury. 

Anthony, if they are unconscious then I am going to look at why they are in that state. I will give Oxygen if necessary. While I like using pulse ox when I have one, it is not a definitive tool. Cold fingers, dirty fingers, fingernail polish, etc. can all alter the readings. 

While you can check accuracy of the pulse ox by palpating the radial pulse and comparing that to what the pulse ox says, there are plenty of reasons why it could be wrong. It is an assessment tool that can be beneficial but I am not going to make an oxygen decision based solely on a pulse ox reading. Treat the patient.


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## silver (Nov 16, 2012)

leoemt said:


> Its not that we can't do spo2. It is a Basic skill in this state. We do it when we arrive at the ER. However, in King County, the medical director believes in treating the patient and not the numbers.



Its pretty useful for trending to clue you to re-assess situation.


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## silver (Nov 16, 2012)

Veneficus said:


> What he said is the short and simple version.
> 
> I would just add the free radicals damage cell membranes (particularly RBCs), this damage can initiate apoptosis cascades, attract immune cells from IgM and IgG binding(like fixed macrophages in the spleen), which recognize the damaged cell as foreign, expose *compliment* binding proteins, and initiate inflammatory cascades.
> 
> ...



I chuckled at this. The body gives other organisms (or self) the worst compliments ever...


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## JPINFV (Nov 16, 2012)

AnthonyM83 said:


> Wording from guidelines: "there is insufficient evidence to support its routine use in uncomplicated ACS. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, providers should titrate therapy, based on monitoring of oxyhemoglobin saturation, to ≥94% (Class I, LOE C)."
> 
> Keyword is ***ACS***  What about all the various other non-ACS/CVA cases? Do we have Class I evidence for or against? What about trauma with significant injury? Trauma with shock? Trauma with head injury (can get into capnography here)?
> 
> What about shortness of breath with accessory muscle use but pulse ox of 95% ?



I personally think that LOE C should never be considered a class 1 recommendation. After all, it basically means, "It works great... because we said so."


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## nwhitney (Nov 16, 2012)

Medic Tim said:


> It's unfortunate but sometimes you need to play by their rules while in school and for testing purposes. A major issue with ems education is that it is skills based and not education based. There is a good chance you emt instructor doesn't know any better because he is teaching what he was taught.



Was just talking with a EMT instructor about this last night.  We ran the EMT students through a code using a Hi-Fi manican and afterwards discussing the usefulness of it vs. getting them ready for the state skills test and the NREMT.

Anyways, for the medics if this pt. is in rehab for an addiction to some sort of opiate drug would that change how your approach to pain managment?


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## nwhitney (Nov 16, 2012)

Veneficus said:


> What he said is the short and simple version.
> 
> I would just add the free radicals damage cell membranes (particularly RBCs), this damage can initiate apoptosis cascades, attract immune cells from IgM and IgG binding(like fixed macrophages in the spleen), which recognize the damaged cell as foreign, expose compliment binding proteins, and initiate inflammatory cascades.
> 
> ...



How long does it take to go from initiating O2 therapy to cellular damage?  I get that it can take days to manifest but when does the damamge start?


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## NYMedic828 (Nov 16, 2012)

nwhitney said:


> How long does it take to go from initiating O2 therapy to cellular damage?  I get that it can take days to manifest but when does the damamge start?



Immediately upon formation of truly free radicals. I imagine it would vary from person to person based upon factors like diet and how much of a reserve of antioxidants a person has.

As soon as you administer more oxygen than the body knows what to do with, free radicals can begin to form and cause damage starting in the lungs and making its way through the vasculature and liver.


Pain management for an opioid user or past user only has a couple of factors.

1. They may have a very high tolerance and simply need more medicine to have the desired effect.

2. They often refuse treatment with opioids for fear of relapse into their old "habits."


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## MKwolek (Nov 16, 2012)

Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia. 

I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.


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## Tigger (Nov 16, 2012)

MKwolek said:


> Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.
> 
> I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.



It very well may have been caused by literally anything else, yet you are only going to choose to give 02?

I ask again, why not give some glucose then too? After all her sugar could have been low and that's why she passed out.

Why give 02 "just in case?"


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## Tigger (Nov 16, 2012)

MKwolek said:


> Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.
> 
> I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.



Also, smoking is not shown to have any effect on SpO2 readings.

http://www.ncbi.nlm.nih.gov/pubmed/18272090


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## Medic Tim (Nov 16, 2012)

MKwolek said:


> Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.



so you would base your treatment/interventions off of a chief complaint/MOI rather than a good assessment / evaluation?

If I fell out of bed, had all vs normal with no distress, had an asthma attack the night before....would you give me a neb treatment because it could have been from my asthma? I would certainly hope not.

We provide treatment or lack there of (sometimes doing nothing is doing everything) based on our assessment/evaluation findings.


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## NYMedic828 (Nov 16, 2012)

MKwolek said:


> Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.
> 
> I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.



Doesn't matter if the syncope was secondary to hypoxia, it's gone now and we won't know. We treat presenting signs and symptoms in the pre-hospital setting we don't perform prophylactic measures. 

I don't give patients versed because they may have had a seizure I give it to them because they are seizing.

One of the favorite quotes in these parts is "The delivery of good medical care is to do as much nothing as possible." - House of god.  

This means we don't do something just because we can.


Smoking doesn't produce false SpO2 readings its produces lower SpO2 readings that are still equally accurate as anyone's. Smoking damages the physical architecture of the lungs similar to emphysema and decreases available alveolar surface area for gas exchange ultimately resulting in decreased perfusion.

Most people who smoke and aren't Dx with emphysema/COPD usually sat at 94-98% vs the normal 96-100%. AHA doesn't even recommend O2 administration unless there is respiratory complaint or an O2 sat of <94%.

If you follow the Bohr curve (oxygen disassociation curve) dangerous SpO2 levels don't occur until about 90-92%. At that saturation PaO2 is assumed to be decreased which lowers the affinity of oxygen for hemoglobin and any lower you fall off the shoulder of the curve and rapidly become hypoxic.

As far as a false reading in general goes, that's why we "treat the patient not the numbers." We use diagnostic tools such as a pulseoximeter to form an impression of our patient. In the end a good "clinician" if you will, uses all of the data they have collected through their assessment to form a general impression and treatment plan for the patient. Never is treatment solely based on one aspect of assessment, unless of course you are a chef following the cookbook because you don't know any better, aka an EM-Technician... (As mycrofft likes to say )

Knowledge is power. No one can question your treatment when you posses the knowledge to stand behind it.



Edit: Screw you Tim, beat me by 2 minutes!


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## leoemt (Nov 16, 2012)

MKwolek said:


> Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.
> 
> I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.



First as stated, we don't do Pulse ox in the field here in King County. She was 100% at the ER. I did a cap refill on her prior to putting her on o2 and it was less than 2 seconds. I don't believe there is a right or wrong answer as long as you can justify it. 

So, with that said: you wheel this patient into the ER. A very well known and respected doctor (on the national level) looks at the patient and listens to your report. He then asks you, "why did you put this patient on oxygen?" What will you tell him? Keep in mind the patient is fully alert and can hear your reply as well. 

Patients need us to make decisions that are clinically appropriate for the situation presenting at that time. 

Even if her fall had been Hypoxia induced, any signs of Hypoxia were long gone. 

Oxygen is a drug and we seem to forget that. Just as Aspirin may not be appropriate for every ache or pain, Oxygen is also not appropriate in every situation. 

Are you going to take a aspirin because you had a headache 5 hours ago but no longer feel it?

If you can't justify your interventions medically, your not a professional - your a taxi driver. My patients expect me to be a professional and that means they expect me to be educated.


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## mycrofft (Nov 19, 2012)

Chronic smoking causes lowered oxygenation due to tissue damage. Doesn't acute smoke inhalation of most sorts potentially cause false elevations of fingertip oximetry when chemicals in the smoke (carbon monoxide, amongst others) cause haemoglobin to appear "nice and red" to the photometer?


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## Veneficus (Nov 19, 2012)

Tigger said:


> This is awful reasoning on the MD's part if it is indeed the reasoning. Did the MD also get rid of monitors on ALS units?



Also consider that there may be a study involved, whch is why this is done in the ED and not prior.

The madness does not always reveal its method.


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## zmedic (Nov 19, 2012)

Tigger; said:
			
		

> This is awful reasoning on the MD's part if it is indeed the reasoning. Did the MD also get rid of monitors on ALS units?



I guess it depends on the number. But I could see getting pissed after the 20th patient with a nonrespiratory complaint comes in on 02 "because their pulse ox was 20," and the machine has a poor wave form, or they are on 02 for a pulse ox of 93.


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## NYMedic828 (Nov 19, 2012)

mycrofft said:


> Chronic smoking causes lowered oxygenation due to tissue damage. Doesn't acute smoke inhalation of most sorts potentially cause false elevations of fingertip oximetry when chemicals in the smoke (carbon monoxide, amongst others) cause haemoglobin to appear "nice and red" to the photometer?



Realistically though you should treat them based on the environment they came out of and presenting symptoms.

The patient in the scenario was just dizzy I doubt we are concerned with ruling out hydrogen cyanide or carbon monoxide in a rehab facility bedroom with no other aided.


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## Tigger (Nov 19, 2012)

Veneficus said:


> Also consider that there may be a study involved, whch is why this is done in the ED and not prior.
> 
> The madness does not always reveal its method.





zmedic said:


> I guess it depends on the number. But I could see getting pissed after the 20th patient with a nonrespiratory complaint comes in on 02 "because their pulse ox was 20," and the machine has a poor wave form, or they are on 02 for a pulse ox of 93.



I find the phrase "treat the patient, not the machine." to be plainly awful. If you cannot recognize the fact the a pusle ox is adjunct to your assessment and not _the_ assessment, you have no business working.


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## silver (Nov 19, 2012)

mycrofft said:


> Chronic smoking causes lowered oxygenation due to tissue damage. Doesn't acute smoke inhalation of most sorts potentially cause false elevations of fingertip oximetry when chemicals in the smoke (carbon monoxide, amongst others) cause haemoglobin to appear "nice and red" to the photometer?



I believe different types of smoking methods can cause up to 1/4 of your hemoglobin to be carboxyhemoglobin.

Can't confirm by looking have exam in morning and I shouldn't be posting this. However, food for thought.


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## Anonymous (Nov 19, 2012)

How does increasing the percentage of inhaled oxygen increase oxygen consumption/usage by cells at normal atmospheric pressure in non-ischemic cells? I understand reperfusion injury but I am having a hard time understanding the harm in administering oxygen to someone who is not hypoxic.


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## NYMedic828 (Nov 19, 2012)

NYMedic828 said:
			
		

> Yes. As I understand it, after talking with Vene a few times about it, the short version is the body is set up to intake 20.9% oxygen from the environment. Free radicals naturally occur as chemistry in the body utilizes oxygen and the body contains "antioxidants" to combat these free radicals that would otherwise harm tissues through the process of "oxidation." The unpaired electron of the superoxide O2- ion (free radical ion of oxygen) essentially steals an electron from what it comes in contact with, which is hopefully an antioxident such as glutathione that would prevent it from binding to tissues and interrupting important biological processes.
> 
> When we increase the FiO2 and the body has nowhere to put it, many more free radicals form than naturally would which can deplete the antioxidizing reserves of the body and actually worsen disease processes, lead to new disease or form localized scar tissue.
> 
> ...



The above.


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## 46Young (Nov 19, 2012)

Tigger said:


> I find the phrase "treat the patient, not the machine." to be plainly awful. If you cannot recognize the fact the a pusle ox is adjunct to your assessment and not _the_ assessment, you have no business working.



+1000

We have many phrases such as this in EMS that are obviously intended for the lowest common denominator in education level. A little piece of me dies whenever someone says "BLS before ALS," for example haha


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## NYMedic828 (Nov 19, 2012)

Vene will go on to further explain that these free radicals primarily cause damage the first cells they contact.

First they will attack the type 1 pnuemocytes which comprise a very thin layer of easily destroyed alveolar tissue, then enter the bloodstream causing damage to the interior epithelial walls of blood vessels and eventually damage the cells of the liver.

In infants the retina is always affected. You could be leading that newborn neonate towards impaired vision by putting a non-rebreather on them for a long trip...


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## leoemt (Nov 19, 2012)

46Young said:


> +1000
> 
> We have many phrases such as this in EMS that are obviously intended for the lowest common denominator in education level. A little piece of me dies whenever someone says "BLS before ALS," for example haha



Why? You can't effectively treat a patient without BLS skills. Yes, ALS can do drugs and do advanced interventions, but it comes down to BLS.

Its not a Paramedic thing - Life comes down to the ABC's simple as that. A good paramedic will recognize the importance of BLS skills. 

Without good BLS, ALS is worthless. 

Same goes with "treat the patient, not the machine" noone is saying that machines and numbers aren't important. What the point is is for the provider to look at the entire picture from a clinical stand point. If you have a blood pressure of 80/60 is the patient showing signs and symptoms consistent with those readings?

Healthcare is a team effort made up of many varied educations. It isn't about one being better than the other - its about everyone working together. If I as a Basic do a poor assessment, then I have just made the Medic or Doctors job more difficult.  All the fancy cardiac drugs will be worthless if I am performing poor CPR for example.


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## NYMedic828 (Nov 19, 2012)

leoemt said:


> Why? You can't effectively treat a patient without BLS skills. Yes, ALS can do drugs and do advanced interventions, but it comes down to BLS.
> 
> Its not a Paramedic thing - Life comes down to the ABC's simple as that. A good paramedic will recognize the importance of BLS skills.
> 
> ...


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## TheLocalMedic (Nov 19, 2012)

Why is this oxygen question a big deal?  So the guy disagrees with his FTO about giving a patient a little O2, BIG DEAL!  Don't try and pull the pseudo-intellectual card about free radicals and argue the what ifs...  Unless the oxygen therapy is continued for a long time there really aren't any adverse effects.  Please, find me ONE documented case where there has been real damage done by giving supplemental O2 during the course of a transport and I'll eat my hat.  

Granted, there wasn't really a reason to give oxygen (or c-spine) but from the practical perspective, it really doesn't hurt them.  Yeah yeah, I heard the glucose doesn't hurt either argument, so stow it, that argument is a straw man http://en.wikipedia.org/wiki/Straw_man and isn't equivalent.  I agree that we should only treat (OMG, oxygen's a DRUG??) conditions as appropriate, but all this argument is just silly.  

Hey buddy, just do as your FTO says, and then when you're doing things on your own you can change your treatment modalities as you see fit.  If you want to give them O2, great!  If not, then that's fine too!  The number of cases where giving supplemental oxygen truly makes a difference are few enough, and I challenge any one of you to find me a case where foregoing supplemental oxygen resulted in harm.


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## NYMedic828 (Nov 19, 2012)

TheLocalMedic said:


> Why is this oxygen question a big deal?  So the guy disagrees with his FTO about giving a patient a little O2, BIG DEAL!  Don't try and pull the pseudo-intellectual card about free radicals and argue the what ifs...  Unless the oxygen therapy is continued for a long time there really aren't any adverse effects.  Please, find me ONE documented case where there has been real damage done by giving supplemental O2 during the course of a transport and I'll eat my hat.
> 
> Granted, there wasn't really a reason to give oxygen (or c-spine) but from the practical perspective, it really doesn't hurt them.  Yeah yeah, I heard the glucose doesn't hurt either argument, so stow it, that argument is a straw man http://en.wikipedia.org/wiki/Straw_man and isn't equivalent.  I agree that we should only treat (OMG, oxygen's a DRUG??) conditions as appropriate, but all this argument is just silly.
> 
> Hey buddy, just do as your FTO says, and then when you're doing things on your own you can change your treatment modalities as you see fit.  If you want to give them O2, great!  If not, then that's fine too!  The number of cases where giving supplemental oxygen truly makes a difference are few enough, and I challenge any one of you to find me a case where foregoing supplemental oxygen resulted in harm.



Typical EMS mentality. If we can't prove its our fault, it must not be!

I'm sure the pathologist with more knowledge than most of us combined has nooooo idea what he's talking about.


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## TheLocalMedic (Nov 19, 2012)

NYMedic828 said:


> Typical EMS mentality. If we can't prove its our fault, it must not be!
> 
> I'm sure the pathologist with more knowledge than most of us combined has nooooo idea what he's talking about.



Again, I challenge you to provide me with any real information besides speculation or anecdotes or disparaging comments to refute my argument.  And to that end, please find me any pathologist who will commit to the idea that giving supplemental oxygen for the limited amount of time we are with a patient may be harmful.  Seriously.  

And not that I would have given O2 to this patient (I actually seldom find myself giving it to anyone), but it really is not going to "shave years off of their life" or give them cancer or cause birth defects or make the US dollar depreciate in value or anything.


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## NYMedic828 (Nov 19, 2012)

TheLocalMedic said:


> Again, I challenge you to provide me with any real information besides speculation or anecdotes or disparaging comments to refute my argument.  And to that end, please find me any pathologist who will commit to the idea that giving supplemental oxygen for the limited amount of time we are with a patient may be harmful.  Seriously.
> 
> And not that I would have given O2 to this patient (I actually seldom find myself giving it to anyone), but it really is not going to "shave years off of their life" or give them cancer or cause birth defects or make the US dollar depreciate in value or anything.



Its rare to find ANY study related to pre-hospital care let alone one on oxygen.

I challenge you to prove to me that we don't cause damage. The discovery that oxygen causes damage hasn't been around that long. EMS is the last to pick up on just about everything. It hasn't made its way to us yet.

Can you prove that it doesn't cause cancer? birth defects? retinal damage?

All it takes is a patient with a low bodily reserve of antioxidants to combat free radicals, such as sick patients, you know, the kind who call an ambulance sometimes... Maybe like those with cancer or COPD and you could be causing damage off the bat.

Would you rather take a risk for no reason or would you rather administer a treatment that is appropriate and isn't just "because we can." That is the difference between a technician and a "clinician" if you will.


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## silver (Nov 19, 2012)

TheLocalMedic said:


> Again, I challenge you to provide me with any real information besides speculation or anecdotes or disparaging comments to refute my argument.  And to that end, please find me any pathologist who will commit to the idea that giving supplemental oxygen for the limited amount of time we are with a patient *may be* harmful.  Seriously.
> 
> And not that I would have given O2 to this patient (I actually seldom find myself giving it to anyone), but it really is not going to "shave years off of their life" or give them cancer or cause birth defects or make the US dollar depreciate in value or anything.



http://www.ncbi.nlm.nih.gov/pubmed/12570108

+1 for pseudo-intellectualism.

There are limitations of this study, but people should inform themselves. I have other stuff to do than explain.


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## Tigger (Nov 20, 2012)

TheLocalMedic said:


> Granted, there wasn't really a reason to give oxygen (or c-spine) but from the practical perspective, it really doesn't hurt them.  Yeah yeah, I heard the glucose doesn't hurt either argument, so stow it, that argument is a straw man http://en.wikipedia.org/wiki/Straw_man and isn't equivalent.  I agree that we should only treat (OMG, oxygen's a DRUG??) conditions as appropriate, but all this argument is just silly.



I fail to see how that is a straw man. You said it yourself, we should only treat conditions as appropriate. In this case O2 was not appropriate. It was given under the guise of "well it can't hurt, let's make it look like we are doing something." The same thing could absoultey be done with glucose, but for some reason that's a _real_ drug and O2 is not.


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## Tigger (Nov 20, 2012)

leoemt said:


> Why? You can't effectively treat a patient without BLS skills. Yes, ALS can do drugs and do advanced interventions, but it comes down to BLS.
> 
> Its not a Paramedic thing - Life comes down to the ABC's simple as that. A good paramedic will recognize the importance of BLS skills.
> 
> ...



Medicine is not about skills. Unfortunately, EMS is but that's a whole different rant. Medicine is medicine, BLS and ALS are artificial distinctions. Someone with the knowledge necessary for the use of ALS interventions does not need to delineate between the two, but rather they use whatever is the most appropriate. If the most appropriate intervention happens to be "ALS" in nature, they do not first go through the "BLS" side of things. No, they do what is effective, and then they are done.


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## 46Young (Nov 20, 2012)

leoemt said:


> Why? You can't effectively treat a patient without BLS skills. Yes, ALS can do drugs and do advanced interventions, but it comes down to BLS.
> 
> Its not a Paramedic thing - Life comes down to the ABC's simple as that. A good paramedic will recognize the importance of BLS skills.
> 
> ...



Tigger already answered this for me - "Medicine is medicine, BLS and ALS are artificial distinctions." The paramedic's assessment and treatment plan includes "BLS", but those skills are integrated with "ALS," not first do BLS then move on to ALS. 

For example, I'm not going to get a BP on an actively seizing pt before treating - I'm getting someone on airway/breathing while I'm drawing up Versed. Same for the hypoglycemic pt. If I get the line before someone gets to the BP, the D50's going in. We titrate our BVM ventilations to an ETCO2 of 35-45 for the head trauma pt with signs of herniation, not some arbitrary rate mandated by BLS protocols. I want a 12-lead before O2 (if we even end up giving it at all) and NTG admin unless the pt has respiratory distress/failure. If I have a pt in anaphylactic shock, I'm throwing epi into them as soon as I can get it drawn up, without delay. Maybe my partner can get some O2 on them in the meantime, but probably nothing else before I'm sticking them in the thigh. How about pain management before splinting?

Most of the time the things BLS are trained to do will occur before the things medics are trained to do will occur, but that's not always the case. Again, the line between BLS and ALS is arbitrary for the medic. I don't break up my assessment an Tx decisions into these categories.

BTW, if you're ever on the scene before ALS, rest assured the medics will always do their own full assessment at some point, probably right away. It doesn't matter much how good or bad your assessment is. Same goes for the doctor and nurses taking the pt from medics at the ED.


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## TheLocalMedic (Nov 20, 2012)

As for Silver's study he provided as an exemplar, it still begs the question; While the "markers of oxidative stress" were increased in patients placed on supplemental oxygen, was there any real harm done to those test subjects?  Sure, if our entire atmosphere were oxygen-enriched we would undoubtedly see ill effects, but were there _any_ identifiable physical detriments to these patients?  As a corollary, how quickly did these markers then fall back to a normal baseline following the termination of the supplemental oxygen?  What I mean to ask is, as before, can you find me any case where the administration of O2  - for the length of time that we are with a patient -  has done any real harm to a patient?  Argue with me all you like about free radicals and antioxidants, but bear in mind that theoretical medicine still does not trump the establishment.  I do not care for arguments that provide a "maybe" or a "possibly", but rather for ones that can provide concrete data that can be reproduced. 

 "Induced hyperoxia is potentially toxic, since it may increase oxidative stress and peroxidative damage to deoxyribonucleic acid, lipids and proteins."

Shall I highlight the words 'potentially' and 'may'?  Find me proof!  And hopefully not in the form of a 'maybe'!

As for the argument proffered by Tigger, I reassert that the argument about glucose administration being comparative to that of oxygen is in fact a Straw Man argument.  Not only is the means of administration different, but glucose has a greater and longer lasting metabolic effect than does oxygen.  Giving oxygen to a patient who has a PaO2 of 100 mmHg is not equivalent to giving a patient with a BGL greater than 120 mg/dl glucose or dextrose.  There are differences both with administration and effect, so there is no good comparison.  If I were to accept this comparison, then should I also accept the following? 

    A: Sunny days are good.
    B: If all days were sunny, we'd never have rain, and without rain, we'd have famine and death.


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## TheLocalMedic (Nov 20, 2012)

Again, I do not think that many patients truly deserve oxygen, but I make the argument that giving it is not the end of the world, and free radicals be d@mned.  Going back to the origin of the thread, if your FTO or preceptor says jump, the best reply is "how high?".


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## silver (Nov 20, 2012)

TheLocalMedic said:


> As for Silver's study he provided as an exemplar, it still begs the question; While the "markers of oxidative stress" were increased in patients placed on supplemental oxygen, was there any real harm done to those test subjects?  Sure, if our entire atmosphere were oxygen-enriched we would undoubtedly see ill effects, but were there _any_ identifiable physical detriments to these patients?  As a corollary, how quickly did these markers then fall back to a normal baseline following the termination of the supplemental oxygen?  What I mean to ask is, as before, can you find me any case where the administration of O2  - for the length of time that we are with a patient -  has done any real harm to a patient?  Argue with me all you like about free radicals and antioxidants, but bear in mind that theoretical medicine still does not trump the establishment.  I do not care for arguments that provide a "maybe" or a "possibly", but rather for ones that can provide concrete data that can be reproduced.
> 
> "Induced hyperoxia is potentially toxic, since it may increase oxidative stress and peroxidative damage to deoxyribonucleic acid, lipids and proteins."
> 
> ...



First I would like to note my first post. Look how 'may be' is bolded in your quoted text...

Tell me how you would run an adequately controlled experiment that examined these detriments. Effects of oxidative stress need not be linked to single instances as cumulative stress has been demonstrated to play causal roles in cardiovascular disease and cancers, for example. Additionally, we know that pathology due to oxidative stress from supplemental oxygen has been seen in neonates, which shows the direct potential. It is reasonable to be cautious of the use of O2.

This is how medicine works...that is the establishment. In fact, a large portion of medicine isn't based on evidence. Using this precursory data to indicate the need to eliminate the "it doesn't hurt to always give O2" mentality is appropriate. I wouldn't say we should never give it, but people are giving it for no reason.


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## leoemt (Nov 20, 2012)

46Young said:


> Tigger already answered this for me - "Medicine is medicine, BLS and ALS are artificial distinctions." The paramedic's assessment and treatment plan includes "BLS", but those skills are integrated with "ALS," not first do BLS then move on to ALS.
> 
> For example, I'm not going to get a BP on an actively seizing pt before treating - I'm getting someone on airway/breathing while I'm drawing up Versed. Same for the hypoglycemic pt. If I get the line before someone gets to the BP, the D50's going in. We titrate our BVM ventilations to an ETCO2 of 35-45 for the head trauma pt with signs of herniation, not some arbitrary rate mandated by BLS protocols. I want a 12-lead before O2 (if we even end up giving it at all) and NTG admin unless the pt has respiratory distress/failure. If I have a pt in anaphylactic shock, I'm throwing epi into them as soon as I can get it drawn up, without delay. Maybe my partner can get some O2 on them in the meantime, but probably nothing else before I'm sticking them in the thigh. How about pain management before splinting?
> 
> ...



I expect them to do their own. I do my own regardless of who I get the patient from. That said, lets agree to disagree and keep this on topic.


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## zmedic (Nov 20, 2012)

My biggest problem with giving oxygen is that unless you also are doing capnography, a patient who has a decreased respiratory drive, say who is only breathing 3 times a minute, will maintain a fairly normal Sp02 if on 100% 02 by NRB. So their pulse ox will be fine but their C02 is climbing and you won't get any warning from the pulse ox until the patient suddenly goes into an arryhtmia. Where as if you have some drunk patient who start obstructing his airway, their pulse ox will drop a lot quicker while on room air and you are warned to reposition their airway. (Yes, I understand that one should be monitoring the patient's airway and mental status and not waiting for a drop in pulse ox to manage their airway. But you see this all the time on drunk patient who "got a little hypoxic" so the RN puts them on a nasal canula and leaves them on the monitor and walks away.")


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## leoemt (Nov 20, 2012)

zmedic said:


> My biggest problem with giving oxygen is that unless you also are doing capnography, a patient who has a decreased respiratory drive, say who is only breathing 3 times a minute, will maintain a fairly normal Sp02 if on 100% 02 by NRB. So their pulse ox will be fine but their C02 is climbing and you won't get any warning from the pulse ox until the patient suddenly goes into an arryhtmia. Where as if you have some drunk patient who start obstructing his airway, their pulse ox will drop a lot quicker while on room air and you are warned to reposition their airway. (Yes, I understand that one should be monitoring the patient's airway and mental status and not waiting for a drop in pulse ox to manage their airway. But you see this all the time on drunk patient who "got a little hypoxic" so the RN puts them on a nasal canula and leaves them on the monitor and walks away.")



In your capnography example, wouldn't the patient still be showing signs and symptoms of Hypoxia though?


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## zmedic (Nov 20, 2012)

If the patient is breathing 3 times a minute the capnographer will show that, even though the patient may not become hypoxic if they are on 02. 

If you don't have them on capnography, it's much harder to tell when someone who just has altered mental status obstructs their ventillation if you have them on 02


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## waaaemt (Nov 24, 2012)

leoemt said:


> I believe she did fracture her Clavicle. There was an obvious deformity upon palp, she screamed in pain upon palp and wanted to deck me when I palpated it. Additionally, movement of the arm caused pain to increase.



waittttt a second... you guy gave her a c collar? clavicle fractures are a contraindication for c collars am i right? from what i remember, the appropriate thing is the do blanket rolls right?


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## leoemt (Nov 24, 2012)

oogemsquagger said:


> waittttt a second... you guy gave her a c collar? clavicle fractures are a contraindication for c collars am i right? from what i remember, the appropriate thing is the do blanket rolls right?



I was on field training. I wasn't going to argue with my FTO on scene in front of a patient, which would have been worse. 

I agree with you though.


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## NYMedic828 (Nov 24, 2012)

oogemsquagger said:


> waittttt a second... you guy gave her a c collar? clavicle fractures are a contraindication for c collars am i right? from what i remember, the appropriate thing is the do blanket rolls right?



Who told you that one?

Its very common in situations like an MVA to sustain a clavicular fracture from the steatbelt at high speeds and potentially a cervical injury...

You can live without your clavicle being in one piece. Not so much your cervical spine...


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## Aidey (Nov 24, 2012)

Unless that broken clavicle hits the sub clavian artery.


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## NYMedic828 (Nov 24, 2012)

Aidey said:


> Unless that broken clavicle hits the sub clavian artery.



They have a spare


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## zmedic (Nov 24, 2012)

Aidey; said:
			
		

> Unless that broken clavicle hits the sub clavian artery.



Find me a case report of a c-collar causing a broken clavicle to lacerate the subclavian. Otherwise I'm not worrying about it. Also a properly applied c-collar is putting pressure on the chin, sternum, occiput and back around C7. Shouldn't be a whole lot of pressure on the clavicle, especially in a patient lying on a backboard. 

So don't worry about it.


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## Aidey (Nov 24, 2012)

When was the last time you saw a properly applied c-collar? I would estimate 80 to 90% of the c-collars I see aren't applied correctly.


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## NYMedic828 (Nov 24, 2012)

Aidey said:


> When was the last time you saw a properly applied c-collar? I would estimate 80 to 90% of the c-collars I see aren't applied correctly.



Knowing where zmedic works, I can vouch that our c-collar application in NYC is pretty bad. But I doubt its 80% improper. Probably 50%.


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## zmedic (Nov 24, 2012)

I'd say most of the improper collars are if anything turning the patients head. I don't think they are putting a lot of force on the clavicle.


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## Veneficus (Nov 24, 2012)

As I understand most of the collars are meant to prevent vertical compression, not provide total immobilization?


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## NYMedic828 (Nov 24, 2012)

Veneficus said:


> As I understand most of the collars are meant to prevent vertical compression, not provide total immobilization?



It's pretty easy to turn your neck in a collar if you really want...


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## RocketMedic (Nov 24, 2012)

We don't need to care about anatomy, physiology or patient care here. It's all about protocols and tradition!


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## DrankTheKoolaid (Nov 24, 2012)

Veneficus said:


> As I understand most of the collars are meant to prevent vertical compression, not provide total immobilization?



When i use C-collars i always tell the patients that these wont save them from any harm but are there as a reminder for them to not move their heads.  The sober ones anyways, with drunks and non compliant patients its not worth the effort when other things need to be tended to.


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## Aidey (Nov 24, 2012)

NYMedic828 said:


> Knowing where zmedic works, I can vouch that our c-collar application in NYC is pretty bad. But I doubt its 80% improper. Probably 50%.



I was including all of the people who have the collar on straight, but are hyperextended.


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## Aprz (Nov 26, 2012)

Rocketmedic40 said:


> We don't need to care about anatomy, physiology or patient care here. It's all about protocols and tradition!


If this a Facebook status, I'd like it. Kool-Aid!


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## DrParasite (Nov 26, 2012)

NYMedic828 said:


> It's pretty easy to turn your neck in a collar if you really want...


but if you have a neck injury, and it hurts, why would you want to?


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## NYMedic828 (Nov 26, 2012)

DrParasite said:


> but if you have a neck injury, and it hurts, why would you want to?



Ding ding ding we have a winner!

Self splinting is more effective than our ridiculous methods.


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## Trashtruck (Nov 26, 2012)

Medic Tim said:


>




The perfect response. It 'says' everything I was thinking after reading that post(#20)


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## Clare (Nov 27, 2012)

Oxygen is a specific treatment for patients who are hypoxic; it is not a "general treatment" for patients who are unwell or injured and does not necessarily provide benefit.  

If oxygen is not required it should not be given end of story, if it is required it should be given in the lowest concentration effective to maintain SpO2 of > 94%


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## Veneficus (Nov 27, 2012)

Clare said:


> Oxygen is a specific treatment for patients who are hypoxic; it is not a "general treatment" for patients who are unwell or injured and does not necessarily provide benefit.
> 
> If oxygen is not required it should not be given end of story, *if it is required it should be given in the lowest concentration effective to maintain SpO2 of > 94%*



I think your statement leaves out the need for high concentration oxygen in CO poisoning and hyperbaric therapy.


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## Clare (Nov 27, 2012)

Veneficus said:


> I think your statement leaves out the need for high concentration oxygen in CO poisoning and hyperbaric therapy.



True, but I think it also comes down to using your head; for patients who require higher concentrations of oxygen via a reservoir mask then if 10 litres is the "lowest concentration" they require then that is what they require.

There was a point in the old procedures for smoke or toxic gas inhalation to give oxygen via reservoir mask at 10-15 lpm but it is no longer there.  

I've only seen one CO poisoning, a young guy 20 or so, about three years ago, was pretty much a case of give oxygen and take to hospital.


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