# "Shelf Life" of O2 humidification



## medicdan (May 24, 2007)

In class today I was talking to another student (who has considerably more experience in EMS then I do)-- we were taking about the indications for humidified O2-- he said that in an urban/suburban area-- transport times are so short that in many cases it doesn't make sense but in some pediatric cases it may be necessary.  
I also understand that many paramedics will spike two units of saline in their rig at the start of their shift (they write the date and time on the bags) to make things easier on calls (and that generally, those bags are safe for 24 hours). From my microbiology classes, it doesn't seem that water sitting in a rig for 8-24 hours is going to accumulate any bacteria-- so why do we not leave water in the container during shifts? 
Assuming that it takes no more time to setup, are there any drawbacks (contraindications) to humidified O2? 
In reality, in the field, how often do you use it? In what cases?

Thanks a lot for your help!
DES


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## Ridryder911 (May 24, 2007)

Couple of things, the saline in the IV's are not the same as the sterile water in the humidifier. If you note, the saline says not for inhalation use, as well they have preservatives. Thus the longer life ... 

With that said, it has been about 12+ years since I have seen humidified oxygen, other than long term. Even in ER, we do not usually have it, for many reasons. The patient will probably be there for a short period of time, second the costs of humidifiers (since they are disposed after each patient). 

R/r 911


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## FF894 (May 24, 2007)

Funny you should bring up humidified oxygen.  One of my partners and I were just talking about it the other day.  He didn't even believe we had it on the rig until I dug the canister out of the back of the oxygen cabinet.  I have never used it myself nor seen it used on a real xport.  Only training and that was something like 8 years ago.  Our xports are not long enough to warrant the use.


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## VentMedic (May 24, 2007)

Even in Neo/Pedi transports, humidifiers are not used.

For adults in the hospital long term, the flow of a NC has to be over 4 L and then it is doubtful it will do any good. For proper humidification it has to be of the as same body temperature and humidity; 37 degrees at 44% relative humidity.  We do have devices in the hospital that achieve this when we are running high flow NC devices such as a Vapotherm which can go to a flow of 40 L/M. But when the flow is running at exact temp and relative humidity, it will feel like a gentle warm breeze and not a blast. (Sorry, probably too much info)  

Also, attaching a humidifier to your flowmeter will hamper switching to a mask or BVM if the pt requires more O2 or rescusitating quickly.


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## VentMedic (May 24, 2007)

oops double post


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## Anomalous (May 25, 2007)

emt-student said:


> ...I also understand that many paramedics will spike two units of saline in their rig at the start of their shift (they write the date and time on the bags) to make things easier on calls (and that generally, those bags are safe for 24 hours)...
> DES




Our Project Medical Director would have a fit if we spiked a bag ahead of time.


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## Jon (May 25, 2007)

I've never done a transport with humidified O2... never had a reason to.

The other issue with leaving the humidifier set up is that it ISN'T as sterile as a properly spiked as closed IV Set... stuff can get in there.

Also... what happens if the next crew doesn't change the humidifer... or the crew after them?


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## Canoeman (May 25, 2007)

*Humidifiers*

Our NYS ambulance list calls for a humified 02 bottle. I have not used humidified 02 on an emergency call in 25 years but have used it several times on transports over 2-2 hours.
Our humidified O2 bottle are purchased sealed and have expiration date on them. If they are required --- this is the way to go - they have a shelf life of 3 years.


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## VentMedic (May 25, 2007)

Ambulances don't carry the "IV" fluid suitable for Respiratory inhalation. You will see an IV bag hanging on ventilators but it is preservative free sterile water designed for a closed respiratory circuits to prevent contamination.  

Non-disposable containers are things of the very distant past and should be avoided unless you have a contract with a sterilization department to sterilize between patients. These are considered open systems and easily contaminated. Only disposble systems if any should be used which are costly as Rid stated. 

I've seen EMTs and Paramedics both trying to do a transport with a humidifier on portable O2 tanks and have ruined  $900 regulators too many times. 

Small port humidifier bottles are not for use on Simple Masks and NRBMs. They are used only for NC 4 - 6L for long term. 

Large port humidifier bottles require large bore tubing and an aerosol mask. This system is okay for croup (sometimes) but usually just makes the patient wet and cold without humidity added to airways.  Wet does not always equal humidity.


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## KEVD18 (May 28, 2007)

the oonly time i have ever used humidified o2 is for an interfacility txp where the pt is already on humid o2, and i think ive done that once. wheher the little disposable bottle u attach to the flowmeter and run the tubing off of actually work due the afroementioned science i have no idea. i also dont care. its very rarely done pre hospital.


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## Ravamedic (Jun 16, 2007)

I'm not sure what you guys have in the states - in Australia we are able to Nebulise (Atomise) salbutamol (albuterol I think). 

I often place NS in the neb bowl during a transport for paeds - or between nebs for adults.


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## SMC (Jun 19, 2007)

*Ok*

We have disposable humidifiers attached to the flow meter.  We change them out every two weeks.  Rural EMS system with some transport times of 45 minutes.  I don't think we need it, but hey it's there?  

BTW  I exploded one about a month ago.  Scared the you know what out of me.  We heard the high pitched sound but didn't realize it until it was to late.  No patient in the rig thank god.
----------------------------------------------------

If there is a pre spiked bag in my truck when I come on shift with a date on it.   I chunk it.  Takes only a few seconds to spike it, and if the patient is bad enough that he needs it 30 seconds sooner then I'm on a good call and  I have fire fighters who responded who can spike it for me while I get some good manual vital signs.


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## VentMedic (Jun 19, 2007)

SMC said:


> We change them out every two weeks.  Rural EMS system with some transport times of 45 minutes.



I'm grossed out now. Has any Health department ever cultured these? Just by the handling with connecting the O2 tubing to the humidifier contaminates the container itself. After a couple patients, this can be pretty nasty.  In most hospitals, patients won't get humidifiers unless they  are on more than 4 liters and after 24 hours. Day surgery pts (23 hour stays)=NO Humidifer.  We do everything possible to reduce nosocomial infections. 



SMC said:


> BTW  I exploded one about a month ago.  Scared the you know what out of me.  We heard the high pitched sound but didn't realize it until it was to late.  No patient in the rig thank god.
> ----------------------------------------------------



Too easy to forget and hang a mask on them. Never more than 6 liters on small bore. After that you decrease the output flow proportionate to the flowmeter setting. Hence, you think they're on a 10 liter mask and they're on 4 -6L.


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## emtwacker710 (Apr 23, 2008)

emt-student said:


> I also understand that many paramedics will spike two units of saline in their rig at the start of their shift (they write the date and time on the bags) to make things easier on calls (and that generally, those bags are safe for 24 hours). DES



sorry to sidetrack this thread but hanging the bags ahead of time isn't always good, a medic, myself and our 1st LT. talked about this the other day, example being..he could hang a bag at the start of his shift, and put the time and date and then lets say another medic comes in that doesn't like him, well he could inject any type of medication into that bag and you may not know until you get it hooked up to the pt. you never know today....:glare:


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## KEVD18 (Apr 23, 2008)

first, you brought back a thread thats almost a year deceased? id flog you with a wet noodle if i could.

second, sure some vindictive employee could do that. but anybody that would so blatantly risk a patients life over a personal squabble quite literally needs to be taken out back and shot. repeatedly. tp my car, tone test my shift every night i work, put lasix in my coffee, whatever. if we have a beef and you want to screw with me over it instead of approaching it like an adult fine. but jeopardize my patients lives once and i'll find you and drag you out onto the sidewalk and kick you until you piss blood. thats so far beyond unprofessional as to be asinine.


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## VentMedic (Apr 23, 2008)

emtwacker710 has a very valid point.  Even in the confines of a secure ICU, we never ASSUME anything.   Also for infection control, nothing is spiked until it is to be used.   

If would also be very easy for someone that knows your habits to taint a bag while you are in the ED and didn't lock your doors.   That could be a disgruntled ex-employee or an unbalanced person unhappy with their bill.

For some CCT and especially on Specialty transports such as neonatal, the team will hang their own fluids and meds.  Not that we think anyone in the other hospital is incompetent, we just want our own quality control.


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## KEVD18 (Apr 24, 2008)

i dont disagree. i would be more concerned about infection control than disgruntled employees spiking(with an additive, not a drip set(sweet pun huh)) though.


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## Jon (Apr 24, 2008)

To that extent, though, couldn't they "spike" the bag while still in the plastic wrap? The med injection port isn't really sealed in any way... I'm sure I could inject something INTO the bag if I felt like trying hard enough.

But I think at that point... we're being paranoid.


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## VentMedic (Apr 24, 2008)

> To that extent, though, couldn't they "spike" the bag while still in the plastic wrap? The med injection port isn't really sealed in any way... I'm sure I could inject something INTO the bag if I felt like trying hard enough.



That's the point.  Once the bag is out of the bag, it is fair game for anything.   You will not see RNs leaving even their NS bags for even a moment to get equipment or another med until it is labeled.   H2O bags for ventilators do not have med ports so they can not be easily confused.  A lot of thought has go into the design of bags to prevent medical errors.  Just like other safety seals, packaging is meant for a reason.  




> But I think at that point... we're being paranoid.




It may sound a little paranoid but:

 When there is someone like Efren Saldivar (RT) and his almost 200 kills with a paralytic... 
The consequences from him may follow the California RT profession for years to come. 

 AMR EMT feels his criminal actions were justified - Lake Worth, Florida
http://www.emsnetwork.org/artman2/publish/printer_29157.shtml


And then this week's headlines for Florida EMS that demonstrates opportunity:
Prescription Drugs Allegedly Stolen from Florida Fire and EMS Stations 
http://www.emsresponder.com/article/article.jsp?siteSection=1&id=7410

There are other numerous incidents both intentional and in error that just makes me more cautious.


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## medicdan (Apr 24, 2008)

Okay, this topic is officially back from the dead, and has mutated, thats fine...
I understand your point, it just seems that if you had a vindictive ex-employee, there are easier/more accessible ways to screw you up then then "taint" your spiked bags of IV fluid. There are a lot of "ifs" in that plan. 
Are you really THAT worried about sabotage? I'm not going to get dreamy, but it seems like there are easier ways...


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## emtwacker710 (Apr 24, 2008)

VentMedic said:


> emtwacker710 has a very valid point.  Even in the confines of a secure ICU, we never ASSUME anything.   Also for infection control, nothing is spiked until it is to be used.
> 
> If would also be very easy for someone that knows your habits to taint a bag while you are in the ED and didn't lock your doors.   That could be a disgruntled ex-employee or an unbalanced person unhappy with their bill.
> 
> For some CCT and especially on Specialty transports such as neonatal, the team will hang their own fluids and meds.  Not that we think anyone in the other hospital is incompetent, we just want our own quality control.



thank you for agreeing, and I'm not only saying that someone could taint the bag, its also more sterile to just hang it when you need it, it doesnt take that long especially if you have 2-3 people to a crew..


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## emtwacker710 (Apr 24, 2008)

emt-student said:


> Okay, this topic is officially back from the dead, and has mutated, thats fine...
> I understand your point, it just seems that if you had a vindictive ex-employee, there are easier/more accessible ways to screw you up then then "taint" your spiked bags of IV fluid. There are a lot of "ifs" in that plan.
> Are you really THAT worried about sabotage? I'm not going to get dreamy, but it seems like there are easier ways...



no im not THAT worried about sabatoge, anyways I'm just a basic so I assist with the IV process but don't touch sharps or meds anyways, what I'm just trying to do is open peoples eyes to the real world...not everything is as secure as you think..ok I'm done..sorry I brought this tread back from the dead..


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## VentMedic (Apr 24, 2008)

emt-student said:


> Okay, this topic is officially back from the dead, and has mutated, thats fine...
> I understand your point, it just seems that if you had a vindictive ex-employee, there are easier/more accessible ways to screw you up then then "taint" your spiked bags of IV fluid. There are a lot of "ifs" in that plan.
> Are you really THAT worried about sabotage? I'm not going to get dreamy, but it seems like there are easier ways...



Unfortunately, it is not "ifs" and it has happened as I referred to the California "incident".   It's been 5 years since he go his life sentence but the CA Respiratory Therapist will be doing a 3 hour ETHICS class for the renewal with a "How Thou Shall Not Kill" or "How to Recognize a Killer" theme for a long time.  It also got their scope of practice severely scrutinized.  That only took one person to almost screw up things for several thousand professionals.  

There have also been numerous cases involving RNs that have been tried for murder.  Rarely do they do this to their own patients. 

And yes, there have been a couple of Paramedics in the mix.  One guy was recently featured again on a TV show profiling criminals.  He went on to be a physician so he could better carry out his deeds.   The older Paramedics on this forum might remember his name which he notoriously made in the early '90s.

We've also had parents euthanize their ailing loved ones including babies in the hospital.  Miami had a really frightening death involving a man killing his child who was severely damaged by anoxia in an accident. 

About the same time that one went to trial, another man who was a doctor was being tried for shutting off the ventilator on his baby who also had a poor prognosis.   

The incident in Florida with the employee as a suspect just occurred although that wasn't deadly but will have some consequences as the investigation continues. 

A nasty infection from a bag the gets contaminated during the course of a shift can also be deadly to a patient. 

It doesn't have to be with a criminal intent.  Someone could have forgotten to throw a bag away that had meds mixed in it and no labels.  Now that can occur easily especially on long CCT calls where an extra bag of something might be taken along just incase.  Although most bags are premixed and labeled but in an emergency, one can easily grap the wrong one.   I myself have reached for something thinking everything was in order and have also given something that could be very harmful.   Drawing up meds that are in similar containers is a major cause of medical errors.    

We do have to be very careful in hospitals because of the number of people in and out every day.  Anybody can also put on an EMT uniform and roam the halls.  Agency personnel of various types who you don't know are around working with you.  Attorneys also have hired licensed professionals to go into hospitals as agency workers to get info on a case from other employees.   I have also sent home a few people in RT as have the nursing supervisors who were not the same person as on the license.   That is an entirely different and frightening subject, but yes it makes one cautious and no, it is not a dreamland story.  

So, no, I don't leave alot of things open or misplaced.   The only times there might be bags ready to go are in trauma rooms and that has been limited at the hospital I work at to now having them in bins near the bed but still in the package.  The fluids in the Cardiac Surgery Recovery ICU are not spiked until the 30 minute call from the OR.  Then, the pressurer transducer lines are flushed and calibrated.  

In may ways EMS is very isolated which can be both good and bad.  The world of medicine continues to evolve around them with news that leads to more education about infectious diseases and medical errors.  Then, EMS personnel act surprised when something happens in their own backyard.  Please see the RSI thread under News.   Other professionals, including professional EMS teams, learned long ago that certain steps must be followed to ensure patient safety when doing advanced procedures.  Those incidents were deadly mistakes.  It may only take one forgotten step or precaution to have loss of life and loss of one's license.  

To get slightly back on track, the H2O bottles for humidifiers are meant to be single patient use. However, some ambulances that used to use them left them on the flowmeter for all patients and/or until the bottle was empty.  That does become a harbor for many pathogens.

When you are dealing with the life of a patient, you owe it to that patient and the public that trusts you to do everything to prevent medical errors.  You owe it to your co-workers not to set them up for mistakes also. 

One preventable death is one too many.

EDIT: Sorry emtwacker710 but I had to give a speech.  Since the pubicized RSI incident, we have taken time to review all of our P&Ps, competencies and safety issues to make sure nothing bites us in the tail.  But, since there are many incidents that we hear about that the press doesn't, we are constantly reviewing and critiquing. 

This should have been another thread because safety and preventing medical errors, which can definitely happen at the Basic level also, are very important.


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## emtwacker710 (Apr 24, 2008)

no problem at all with you giving the speech, it just helps support what I was trying to say, I was a bit skeptical when the "theory" was brought to my attention the other day and then I thought about it and did some internet searching and found that it does happen...


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