# odd call...



## uhbt420 (Nov 23, 2010)

dispatched to SNF the other day for "sick unknown".  turns out to be a patient with pain and mild bleeding from the rectum.  92 yo female, hx of mild dementia, type 2 diabetes mellitus, bowel incontience.

rn says that another nurse attempted to give pt an enema because she hadn't gone in four days.  enema attempt didnt turn out so well-- most of the fluid flushed back out and evidenltly there was minor damage to the rectal wall

pt was very angry and combative after the injury.  rn says the pt often gets angry when things dont "go her way"

vitals:  b/p 138/76, resp 24, 94 bpm, 98.8 tympanic, 97 sp02 ra

we cancelled fire als, gave pt 6 lpm via nc, and tranpsorted in position of comfort.

did we handle the situation properly?  it was a bit of a weird call that didn't really fit into our protocols.


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## amberdt03 (Nov 23, 2010)

I think you handled it as well as you could. Not much anyone can do for the patient in the field. Just try and make them as comfortable as possible.


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## C.T.E.M.R. (Nov 23, 2010)

I think you handled it Fine, i wasnt there so i cant say for sure. But did you keep an eye on vitals the entire transport? We most likely would have picked up a medic. I agree with amberdt03, keep the PT comfortable.


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## b2dragun (Nov 25, 2010)

Not much you can do...fluids aren't needed, drugs aren't needed.  I prob would have went with 2 lpm, 6 can be pretty uncomfortable and she was at 97%.  Position of comfort and diesel.


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## Shishkabob (Nov 25, 2010)

I would have skipped the O2, wasn't called for in this case.


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## Aidey (Nov 25, 2010)

Yeah, I would have forgone the O2 also. There really isn't anything we can do except monitor.


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## firetender (Nov 25, 2010)

uhbt420 said:


> pt was very angry and combative after the injury.  rn says the pt often gets angry when things dont "go her way"
> 
> .



Were someone to probe my anus and draw blood, I too would be combative. Just getting her out of there was appropriate intervention.


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## lampnyter (Nov 25, 2010)

Was she bleeding the whole ride to the hospital?


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## TransportJockey (Nov 25, 2010)

Minus the 02 that's probably all I would have done. Doesn't warrant IV or any invasive procedures. Just monitor vitals on the way to the ED


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## uhbt420 (Nov 25, 2010)

C.T.E.M.R. said:


> I think you handled it Fine, i wasnt there so i cant say for sure. But did you keep an eye on vitals the entire transport? We most likely would have picked up a medic. I agree with amberdt03, keep the PT comfortable.


my partner wanted to keep als intact and i seriously considered it, but from what i could tell the elevated b/p was more from agitation/combativeness than anything else.  it dropped within normal limits shortly after loading the pt in the ambulance.



lampnyter said:


> Was she bleeding the whole ride to the hospital?


bleeding stopped prior to arrival.  only concern was that a large amount of the enema's fluid (saline?) had basically washed right back out of the rectum.  it was a totally botched enema for sure.

i am aware that o2 was not necessarily warranted in this case, but i sometimes use it for placebo effect.  the pt did not become uncomfortable with the 6 lpm and mellowed out a bit, but whether that was due to 02 or just being treated like a human being remains to be seen

thanks for the input.


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## 8jimi8 (Nov 25, 2010)

Pass on the o2  Y'all did fine... I can't understand why 911 was called for a "botched" enema.  Unless we are talking massive amounts of blood... But you did say the bleeding had stopped.


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## TransportJockey (Nov 26, 2010)

He did say it was a snf call  do they ever have a reason that makes sense for transfers the majority of the time? 





8jimi8 said:


> Pass on the o2  Y'all did fine... I can't understand why 911 was called for a "botched" enema.  Unless we are talking massive amounts of blood... But you did say the bleeding had stopped.


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## Veneficus (Nov 26, 2010)

jtpaintball70 said:


> He did say it was a snf call  do they ever have a reason that makes sense for transfers the majority of the time?



Sure they do. 

They are incapable and don't want to deal with the patient so they punt to the ED.

Patient giving you a hard time? Find a reason to send them to the ED.

Patient laying quietly for hours in DKA, call ambulance sometime tomorrow. 

See the pattern?


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## LAS46 (Nov 26, 2010)

Veneficus said:


> Sure they do.
> 
> They are incapable and don't want to deal with the patient so they punt to the ED.
> 
> ...


*Yeah this seems to happen all the time here with the SNF because they get fed up with a PT and want to get rid of them for a bit. I hate doing those transfers because it is RIGHT ACROSS the street from their facility to the ED. What a waste of time and resources.*


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## hurt88 (Nov 29, 2010)

Some have said pass on the o2 but I dont see the problem with it. I'm just a student though and I don't know if it causes a hassle or what but our instructor tells us trauma or no trauma you can never go wrong with o2 as long as the patient comfortably takes it.

As you said even if it is nothing more then making the patient think it is helping should be more then enough reason to give them o2 just to calm them down. Atleast thats how I look at it


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## RNL (Nov 29, 2010)

hurt88 said:


> Some have said pass on the o2 but I dont see the problem with it. I'm just a student though and I don't know if it causes a hassle or what but our instructor tells us trauma or no trauma you can never go wrong with o2 as long as the patient comfortably takes it.
> 
> As you said even if it is nothing more then making the patient think it is helping should be more then enough reason to give them o2 just to calm them down. Atleast thats how I look at it



There is a group of patients who may be killed that way quite easly...those COPD patients adapted to hypoxia in whom the high level of CO2 is the only stimulus keeping them breathing spontaneously...


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## hurt88 (Nov 29, 2010)

RNL said:


> There is a group of patients who may be killed that way quite easly...those addopted to hypoxia in whom the high level of CO2 is the only stimulus keeping them breathing spontaneously...




and I learn a bit more...He has always just told us the exact opposite in that o2 wont kill anyone. So I've just gone off the basis of if you think o2 will help calm the paitent or if you arn't sure if they need it then give it anyways.


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## Veneficus (Nov 29, 2010)

hurt88 said:


> and I learn a bit more...He has always just told us the exact opposite in that o2 wont kill anyone. So I've just gone off the basis of if you think o2 will help calm the paitent or if you arn't sure if they need it then give it anyways.




When it comes to medicine and medical care, listen to the doctor over the instructor.


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## SDog (Sep 21, 2012)

Realistically In pre-hospital care the Pt contact is not long enough to cause harm using O2. And they would of hopefully been informed by staff at the snf if indeed the pt had copd and most people with copd are on 2lpm or 4lpm via nc anyways.


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## SDog (Sep 22, 2012)

RNL said:


> There is a group of patients who may be killed that way quite easly...those COPD patients adapted to hypoxia in whom the high level of CO2 is the only stimulus keeping them breathing spontaneously...



People with copd do operate with a hypoxic drive but that is low levels of oxygen. In normal circumstances people have a hypercarbic drive, breathing  that is regualted by the chemorecepters and are semsitive to high levels of CO2.


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## Handsome Robb (Sep 22, 2012)

It's been beaten to death, but other than the o2 I'd have done the exact same thing, well I would've driven and my partner would've taken the call  

There's 8 million threads about o2 administration in EMS, do we really need another one?

As far as her vitals technically she still is WNL and like you said she's pissed off that someone just tried and failed to give an enema so her vitals make perfect sense to be slightly elevated.


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## shfd739 (Sep 22, 2012)

Why was a thread from 2 years ago replied to?


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## Handsome Robb (Sep 22, 2012)

shfd739 said:


> Why was a thread from 2 years ago replied to?



Because when people start new threads they get yelled at for not searching :lol:


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## Veneficus (Sep 22, 2012)

shfd739 said:


> Why was a thread from 2 years ago replied to?



Desperate desire to raise the dead?



SDog said:


> Realistically In pre-hospital care the Pt contact is not long enough to cause harm using O2



I beg to differ, want to argue it with me?


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## VFlutter (Sep 22, 2012)

Veneficus said:


> I beg to differ, want to argue it with me?


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## SDog (Sep 22, 2012)

I think it's pretty straight forward I don't really know what your argument would be for?


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## SDog (Sep 22, 2012)

And vene just to be clear I was talking specifically about causing harm to the pt with copd by administering O2 in the prehospital setting.


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## VFlutter (Sep 22, 2012)

SDog said:


> I think it's pretty straight forward I don't really know what your argument would be for?



There was a study (I will try to find it) that showed similar poor outcomes with both hypoexemia and extreme hyperoxemia in TBI patients. They argued that there is a very narrow PaO2 range that is ideal and that any variation outside of that, both hypo and hyper, is associated with poor outcomes and increased mortality. You have plenty of time during a transport to jack a patients Pa02 up. 

Just one example. I am sure Vene will do a much better job than me


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## Aidey (Sep 22, 2012)

SDog said:


> I think it's pretty straight forward I don't really know what your argument would be for?



The argument would be for not giving the patient a medication they don't need.


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## SDog (Sep 22, 2012)

SDog said:


> And vene just to be clear I was talking specifically about causing harm to the pt with copd by administering O2 in the prehospital setting.



Don't make me quote myself...


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## SDog (Sep 22, 2012)

If you read all my post from this thread it should be clear what I'm stating not saying it's ok to administer a medication that is not warranted (yes I know O2 is a medication) just disputing the incorrect information on the pt population with COPD and the risks of administering 02 to them. Was the the 02 in this particular scenario needed... In my oppinion probably not. Did it hurt I don't believe so. Would I have givin O2? Not unless pt requested.


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## Veneficus (Sep 22, 2012)

SDog said:


> *Realistically In pre-hospital care the Pt contact is not long enough to cause harm using O2.* And they would of hopefully been informed by staff at the snf if indeed the pt had copd and most people with copd are on 2lpm or 4lpm via nc anyways.



That statement does not look like it is limited to COPD patients to me.



SDog said:


> If you read all my post from this thread it should be clear what I'm stating not saying it's ok to administer a medication that is not warranted (yes I know O2 is a medication)* just disputing the incorrect information on the pt population with COPD and the risks of administering 02 to them.* Was the the 02 in this particular scenario needed... In my oppinion probably not. Did it hurt I don't believe so. Would I have givin O2? Not unless pt requested.



I think I just typed something about this very topic here a few days ago...

http://www.emtlife.com/showthread.php?t=31932


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## SDog (Sep 22, 2012)

Vene I did clarify in post right after that one that I was specifically referring to pt with copd and it seems like it would be stupid to argue about what I meant. So I am telling you what I meant.


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## Veneficus (Sep 22, 2012)

SDog said:


> Vene I did clarify in post right after that one that I was specifically referring to pt with copd and it seems like it would be stupid to argue about what I meant. So I am telling you what I meant.



Please refer to my posts in the thread I linked to save me the trouble of typing them again.


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## SDog (Sep 22, 2012)

I really think your misinterpreting what I was saying. And have missed other post so there for you are making good arguments but not valid to our particular discussion. Obviously very knowledgable but my point still remains that O2 administration to the pt with copd in the pre hospital setting is enough to effect there hypoxic drive into respiratory arrest. To further clarify in a long transport situation I would hope that you would a pt history that included there copd and you would follow the guidelines of that piticular pt o2 administration that many live with. Wether or not we ( ems) as a whole are causing more damage with our habits of giving o2 to people who don't nessarliy need it, was at no point in my thought process and to me is a completely different subject that I was not referring too or even thinking about.  Hope this helps and we are on the same page. That was an interesting  thread you sent me to thanks.


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## Veneficus (Sep 22, 2012)

SDog said:


> I really think your misinterpreting what I was saying. And have missed other post so there for you are making good arguments but not valid to our particular discussion. Obviously very knowledgable but my point still remains that O2 administration to the pt with copd in the pre hospital setting is enough to effect there hypoxic drive into respiratory arrest..



I understood this point. 

My point is that there is a very specific patient population that EMS probably very rarely sees where the oxygen given to a COPD pt can cause harm.

As pointed out in my statement, these patients are often found hospitalized, however, they may be found occasionally in long term care facilities. 

As I am sure you have discovered responding to most nursing homes, the staff there usually know very little about their patients, if anything at all. So it is not unreasonable to explore the possibility that any given patient found there may potentially be from this very limited COPD population. 

Also consider subclinical effects that EMS does not see, but subsequent providers must deal with. 



SDog said:


> To further clarify in a long transport situation I would hope that you would a pt history that included there copd and you would follow the guidelines of that piticular pt o2 administration that many live with..



If I may?

I would suspect that if the pt had COPD and was having an acute exacerbation in the prehospital environment and they were normally on o2, that their Po2 would be abnormally decreased from their baseline to cause a worsening of symptoms. 

In particular to history, since home oxygen therapy permits symptomatic relief and increases quality of life on a temporary basis, how long they have been on home oxygen as well as their presentation would probably lead me to positive pressure being the better treatment choice. If given the ability to adjust oxygen content, I would try a slight elevation in the amount of oxygen provided they didn't look like an end stage "blue bloater" which I have been specifically educated to recognize as the subset of COPD patients that will be harmed by high flow oxygen administration.

It stands to reason that if a COPD patient who is normally prescribed oxygen is having an exacerbation significant enough to activate 911, then their current oxygen dose must not be adequete?

In all likelyhood, assuming the non specific subset of COPD patient, and absent a positive pressure device, I would elect to increase the amount of oxygen being administered from their normal prescription.

What I would certainly not do is put them on 15l of NRB. That is like using a cannon to kill a mosquito. As I pointed out, it can also cause pulmonary injury that appears post EMS contact. Patients with long term COPD don't have a percent or two of pulmonary reserve they can spare and are already suseptable to infection and inflammation without adding superoxide to the equation.


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## SDog (Sep 22, 2012)

I can agree with all of that


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