# Pulse ox and upgrading



## shademt (Sep 15, 2014)

In regards to assessing oxygen saturation via an electronic pulse oximeter and taking into account the other vital signs, at what percent O2 would you consider upgrading the call to code 3 or ALS? 

Thanks for the feedback


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## teedubbyaw (Sep 15, 2014)

SpO2 does not dictate how emergent the call is. You have to look at the whole picture. Someone with sats in the 80's could be completely normal for them.


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## luke_31 (Sep 15, 2014)

Patient in obvious respiratory distress.  Relying on a pulse ox reason isn't a great idea as there are a multitude of factors that can cause them to give incorrect readings.


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## Akulahawk (Sep 15, 2014)

shademt said:


> In regards to assessing oxygen saturation via an electronic pulse oximeter and taking into account the other vital signs, at what percent O2 would you consider upgrading the call to code 3 or ALS?
> 
> Thanks for the feedback


Oxygen saturation is but one part of the puzzle. I've never based my decision to transport emergently or bring in an ALS provider simply upon a pulse oximetry reading all by itself.


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## DesertMedic66 (Sep 16, 2014)

There is no exact limit. A patient with 100% O2 sat may still be a critically ill patient while a patient with 90% may be stable.


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## Ewok Jerky (Sep 16, 2014)

"Treat your patient not the number"

I'm not upgrading unless my patient requires an intervention I can't provide and medics are closer than the hospital.

I will upgrade to code 3 if they have chest pain, diaphoresis, diff breathing, RR <12 or >30, or poor skin signs. Or some other obviously bad thing. 

Use your clinical judgement and go with your gut. Act in the best interest of your patient, if medics are far away just transport yourself.


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## WildlandEMT89 (Sep 16, 2014)

I treat pulse ox as a tool for assessing any interventions done.

We recently were dispatched code 3 for respiratory failure to an urgent care facility. Upon arrival we find the pt who is aox4 and speaking in complete and appropriate sentences. Pulse ox is found to be on the low side (86) but all other vitals found to be wnl. Pt states that she smokes approximately 5 cigarettes a day and came into the urgent care for unrelated pain due to a fall 2 weeks prior. Pt advised of findings and concerns but refuses transport and we clear from the scene.


For me to consider upgrading due to a pulse ox reading I would have to see a drastic change in readings in a quick period of time  or  a downward trend over time and be stumped as to what to do next.


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## Handsome Robb (Sep 16, 2014)

beano said:


> "Treat your patient not the number"
> 
> I'm not upgrading unless my patient requires an intervention I can't provide and medics are closer than the hospital.
> 
> ...









Rarely, rarely, rarely is risking you, your partner's, your patient's and everyone else who's on the road lives in the best interest of the patient.

I'm not going to parrot the other good advice given here.

I don't carry 50lbs of ALS gear for ****s and giggles.

Two words: clinical correlation.


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## Ewok Jerky (Sep 16, 2014)

Handsome Robb said:


> Rarely, rarely, rarely is risking you, your partner's, your patient's and everyone else who's on the road lives in the best interest of the patient.
> 
> I don't carry 50lbs of ALS gear for ****s and giggles.
> 
> Two words: clinical correlation.




Not sure what your point is.  Are you saying that BLS should not transport code 3 (only rarely, rarely, rarely) but rather wait for ALS if they think a patient is crumping?


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## Jason (Sep 16, 2014)

shademt said:


> In regards to assessing oxygen saturation via an electronic pulse oximeter and taking into account the other vital signs, at what percent O2 would you consider upgrading the call to code 3 or ALS?
> 
> Thanks for the feedback



Ok ... so I'm just gonna go out on a limb and say my 2 cents on this matter ...
Maybe it's misunderstanding ... maybe it's training ... 
There is nothing the Pulse Ox is gonna tell me that my basic EMT skill level assessment can't tell me more.  It's not my ALS assessment, it's a BLS assessment.  There is no piece of equipment, by itself, on my rig that tells me the Pt is in trouble.  The Pulse Ox should never have become a standard of care.  It's too easy to fool, too easy to get wrong numbers.  Basic assessment rules over Pulse Ox any day of the week.  
Bottom line - learn to do a good assessment and learn to trust your instinct and "gut".


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## Carlos Danger (Sep 16, 2014)

Jason said:


> Ok ... so I'm just gonna go out on a limb and say my 2 cents on this matter ...
> Maybe it's misunderstanding ... maybe it's training ...
> *There is nothing the Pulse Ox is gonna tell me that my basic EMT skill level assessment can't tell me more*.  It's not my ALS assessment, it's a BLS assessment.  There is no piece of equipment, by itself, on my rig that tells me the Pt is in trouble.  The Pulse Ox should never have become a standard of care.  It's too easy to fool, too easy to get wrong numbers.  Basic assessment rules over Pulse Ox any day of the week.
> Bottom line - learn to do a good assessment and learn to trust your instinct and "gut".



I suppose that may be true about the very earliest phases of patient assessment. You should be able to walk into someone's living room and within the first few seconds of the encounter judge their level of respiratory distress, which is a proxy for their gas-exchange status.

But I wouldn't go nearly as far as to say that "it shouldn't be the standard of care". In the big picture, the hemoglobin saturation is arguably one of the most important objective pieces of information. It's one of the biggest pieces of the overall objective-data-puzzle. Widespread use of pulse oximetry is considered by many to be the single most important contributor (among many) to the dramatically improved patient safety seen in anesthesia and critical care over the past few decades.

Unless you are getting an erroneous reading (which can be easily judged by the waveform), a low Sp02 is not something to ignore.


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## Carlos Danger (Sep 16, 2014)

double post


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## Akulahawk (Sep 17, 2014)

Remi said:


> I suppose that may be true about the very earliest phases of patient assessment. You should be able to walk into someone's living room and within the first few seconds of the encounter judge their level of respiratory distress, which is a proxy for their gas-exchange status.
> 
> But I wouldn't go nearly as far as to say that "it shouldn't be the standard of care". In the big picture, the hemoglobin saturation is arguably one of the most important objective pieces of information. It's one of the biggest pieces of the overall objective-data-puzzle. *Widespread use of pulse oximetry is considered by many to be the single most important contributor (among many) to the dramatically improved patient safety seen in anesthesia and critical care over the past few decades.*
> 
> Unless you are getting an erroneous reading (which can be easily judged by the waveform), a low Sp02 is not something to ignore.


Indeed it is, but the tool by itself isn't worth much. Clinical correlation and watching trend data is what's helping. I'm going to get very, very busy if I see a patient who isn't doing well and whose SpO2 trend is declining. If my patient has an SpO2 in the mid-high 80's, and that's stable, along with good mentation (and not lethargic), I'm going to not be too worried. The patient has likely adapted to the situation.


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## Handsome Robb (Sep 17, 2014)

beano said:


> Not sure what your point is.  Are you saying that BLS should not transport code 3 (only rarely, rarely, rarely) but rather wait for ALS if they think a patient is crumping?




I'm saying that rarely is any patient we see truly time critical and many ALS interventions have show absolutely no effect on morbidity and mortality. 

Emergent transport hasn't shown an effect either except in a small patient population and is a high risk ordeal. Just because the patient has an "ALS" complaint shouldn't warrant a code 3 transport. 

Point is emergent transport (and response) is  widely overused both by BLS and ALS crews.


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## gonefishing (Sep 17, 2014)

Treat the patient not the machine.


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## STXmedic (Sep 17, 2014)

gonefishing said:


> Treat the patient not the machine.


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## Handsome Robb (Sep 17, 2014)

gonefishing said:


> Treat the patient not the machine.



I've said it a million times and I'll say it again. I don't lug around my ALS gear to disregard the quantitative and qualitative information it provides me.

Clinical correlation.

I cannot stand that saying. You're basically saying we should just drive empty ambulances since you're not going to listen to what your tools tell you.


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## gonefishing (Sep 17, 2014)

Handsome Robb said:


> I've said it a million times and I'll say it again. I don't lug around my ALS gear to disregard the quantitative and qualitative information it provides me.
> 
> Clinical correlation.
> 
> I cannot stand that saying. You're basically saying we should just drive empty ambulances since you're not going to listen to what your tools tell you.


No... not at all.  I would go through the proper of checking the machinery on myself if the patient was obviously fine but a low saturation.   Respiratory distress will show itself if you remember your basic signs and symptoms.   My mother had pna last year.  By testing her cap refill, watching her alright breathing and taking some lung sounds I didn't need a machine to tell me "oh hey shes sinking" I could see it.  I than place a pulse ox on her and sure as apple pie she was at a sat of 86% yea cool tool but an assessment did just the same for me to know the issue.  Didn't need a machine to do that.  Helpful yes.  BUT anyone could walk into a smoke filled room exit and maintain 100% on a ox but patient could say different.   So I know you wouldn't go with the machine and say they were faking.lol


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## Akulahawk (Sep 17, 2014)

Gonefishing, it's clear that you're hearing the words but not understanding the message. Yes, at some point we all get beaten into our head "treat the patient, not the monitor" but at some point, it's clear that you need to learn to clinically correlate findings from all your tools to what your physical assessment shows. I have seen patients with satting at 86% and they seem to be doing fine. I've seen patients satting 96% and are starting to circle the drain.

So, do you then not take vital signs? After all, those are "monitors" that could lie to you...

My hands, eyes, ears, stethoscope, EKG machine, glucometer, pulse oximeter... all those are tools that I use to assess my patient. You'd better believe that I'm not going to leave my equipment behind just because I think I can make a good field diagnosis without them. If I didn't need the stuff, things would be a whole lot easier because I wouldn't have to lug many pounds of extra equipment around just to look important...


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## gonefishing (Sep 17, 2014)

Akulahawk said:


> Gonefishing, it's clear that you're hearing the words but not understanding the message. Yes, at some point we all get beaten into our head "treat the patient, not the monitor" but at some point, it's clear that you need to learn to clinically correlate findings from all your tools to what your physical assessment shows. I have seen patients with satting at 86% and they seem to be doing fine. I've seen patients satting 96% and are starting to circle the drain.
> 
> So, do you then not take vital signs? After all, those are "monitors" that could lie to you...
> 
> My hands, eyes, ears, stethoscope, EKG machine, glucometer, pulse oximeter... all those are tools that I use to assess my patient. You'd better believe that I'm not going to leave my equipment behind just because I think I can make a good field diagnosis without them. If I didn't need the stuff, things would be a whole lot easier because I wouldn't have to lug many pounds of extra equipment around just to look important...


I didn't say anything about leaving equipment behind..... I did not ever say such a thing.  What I am meaning to say is just don't treat the machine.  YES the tools are necessary.   I love them I use them.  But what people need to ensure is that they are placing all the puzzle pieces together.  Go with your gut and your signs and symptoms not just a machine.  In my sentence the machine is included.  I'm not anti machine or advancement in technology or a beleive in keeping it simple like the johnny and roy days.  I think it was a simple misunderstanding.  My example is most times you can tell a patient going down the drain by your signs and symptoms as well as with a basic assessment.  Yes use the tools.  Did not say ANYTHING about leaving them behind.


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## Carlos Danger (Sep 17, 2014)

Akulahawk said:


> Indeed it is, but the tool by itself isn't worth much. Clinical correlation and watching trend data is what's helping. I'm going to get very, very busy if I see a patient who isn't doing well and whose SpO2 trend is declining. If my patient has an SpO2 in the mid-high 80's, and that's stable, along with good mentation (and not lethargic), I'm going to not be too worried. The patient has likely adapted to the situation.



People always say things like that when the conversation turns to pulse oximetry, and I don't really understand why. 

An Sp02 of 85% is abnormal and is in fact indicative of a potentially life-threatening pathology. Sure, there may be some patients with long-standing disease for whom a low Sp02 is "normal" and they tolerate it well, but generally speaking, a low Sp02 should raise your hackles the same way a low blood pressure or a very high heart rate or an altered mental status does.


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## Brandon O (Sep 17, 2014)

Remi said:


> An Sp02 of 85% is abnormal and is in fact indicative of a potentially life-threatening pathology. Sure, there may be some patients with long-standing disease for whom a low Sp02 is "normal" and they tolerate it well, but generally speaking, a low Sp02 should raise your hackles the same way a low blood pressure or a very high heart rate or an altered mental status does.


 
You guys aren't disagreeing. A sat of 85% is abnormal. The question is whether it's a chronic and tolerated issue or an acute and decompensated one. (Occasional it could be acute but tolerated, but that's unusual, particularly the more extreme the abnormality.)

I think you'd both say that with a sat of 85%, you'd be very wary and investigate the patient's oxygenation status, but if everything else seemed normal you'd warily hand them off for another provider to work up and worry about in the long term.


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## Ewok Jerky (Sep 17, 2014)

The question posed by the OP is whether this warrants an ALS upgrade or code 3 return.

Of course it's hypothetical and the decision will depend on a lot of the circumstances and the patient presentation.  But for me, no, a n abnormal SpO2 by itself does not warrant either, especially because my nasal cannula is just as good as an ALS one.  

if my patient is in acute distress, now I need to consider transport time vs response time of closest ALS unit.  I have no problem tea sporting an ALS complaint if I will get them to the hospital quicker...and still alive.  And I will use code 3 if I suspect imminent life threat like pneumo, MI, pulmonary edema (unless I have cpap), etc.


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## cprted (Sep 17, 2014)

beano said:


> Not sure what your point is.  Are you saying that BLS should not transport code 3 (only rarely, rarely, rarely) but rather wait for ALS if they think a patient is crumping?


There are very few patients out there that saving that extra 30 seconds - 2 minutes by transporting code 3 will actually have an impact.  That goes for ALS or BLS.


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## Ewok Jerky (Sep 17, 2014)

cprted said:


> There are very few patients out there that saving that extra 30 seconds - 2 minutes by transporting code 3 will actually have an impact.  That goes for ALS or BLS.


 
I agree with you when you consider short transport times.  I am a firm believer in safe driving.  But sometimes I really cannot justify bringing in a "big sick" patient Code 2 ie. Septic shock, stroke, maybe SOB or diff breathing etc.

My point was that if I have a time sensitive patient on my hands, I will transport Code 3 BLS if I can get there faster than an ALS intercept.


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## Akulahawk (Sep 17, 2014)

Brandon O said:


> You guys aren't disagreeing. A sat of 85% is abnormal.* The question is whether it's a chronic and tolerated issue or an acute and decompensated one.* (Occasional it could be acute but tolerated, but that's unusual, particularly the more extreme the abnormality.)
> 
> I think you'd both say that with a sat of 85%, you'd be very wary and investigate the patient's oxygenation status, but if everything else seemed normal you'd warily hand them off for another provider to work up and worry about in the long term.


Bingo! 

What _would_ make me very worried and suspicious about my equipment at the same time would be the rare acutely low but tolerated reading. Another way to think about this is if you're a pilot and you feel something's off with the airplane, you're not going to disregard your instruments and warning light panel. You're going to cross-check your instruments and warning lights. After you've done that, you'll have a better idea of what's wrong. Then you can develop a plan to deal with the problem. Same idea with doing patient assessments. I'm going to cross-check my equipment  readings with my assessment findings. If one of those equipment pieces is giving me an abnormal reading that's not correlating with the other stuff, I'm going to troubleshoot the equipment and do it quickly. Sometimes the equipment is faulty, sometimes it's a harbinger of bad stuff to come...

We really aren't disagreeing... it's just that if you're not doing the "cross-checking" that we call clinical correlation, you could very potentially be putting yourself or others in danger by emergently running a patient in to the ED for care when such speedy travel isn't necessary, all because you're fixated on a number. 

When do I upgrade to Code 3/Emergent transport? When I need to get my patient to  the hospital with minimal delay because any delay could be detrimental to the patient. I very rarely upgrade...


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## Handsome Robb (Sep 17, 2014)

Akulahawk said:


> Bingo!
> 
> What _would_ make me very worried and suspicious about my equipment at the same time would be the rare acutely low but tolerated reading. Another way to think about this is if you're a pilot and you feel something's off with the airplane, you're not going to disregard your instruments and warning light panel. You're going to cross-check your instruments and warning lights. After you've done that, you'll have a better idea of what's wrong. Then you can develop a plan to deal with the problem. Same idea with doing patient assessments. I'm going to cross-check my equipment  readings with my assessment findings. If one of those equipment pieces is giving me an abnormal reading that's not correlating with the other stuff, I'm going to troubleshoot the equipment and do it quickly. Sometimes the equipment is faulty, sometimes it's a harbinger of bad stuff to come...
> 
> ...



This.


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## Jason (Sep 17, 2014)

Back again ...
It seems many people have good thoughts and that this is a button pusher topic.  And that many people seems to have similar thoughts about Pt care.  
Maybe I was a bit strong in my 2 cents early.  However, I still believe it's not a good standard of care for the critical patient or for anesthesia.  I work in departments and staff with anesthesia and we use capnography to assist our evaluation of the Pt.  
I also agree with some people, in that ... I rarely go CODE 3 to the hospital.  
Pulse Ox, like other pieces of equipment, it's just a piece of the puzzle (or slice of the pie) that makes up the patient as a whole.


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## Chewy20 (Sep 17, 2014)

I guess I can see why people have issues with going L&S's with a PT, but on the other hand, if you are driving like you normally would without them and not trying to ricky bobby other cars there should not be that much of an issue. Yes there is bone head drivers, but if you are driving normally all the L&S's should do is let people know youre coming so they can try and traverse over to the right. I see where accidents can take place i.e. bombing into the other lane to pass cars that are having a hard time moving over, or people trying to get through a intersection to fast. This is all my opinion, but if the PT meets my protocols for code three then that's how they will be getting to the hospital.

And to the OP, use the pulseox to go along with your assessment. If the pulseox is around what you think it should be, then investigate more if found abnormal. They give us tools for a reason, granted pulseox can be invalid due to numerous things, it is usually a good indicator if what you have found matches the number.


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## Carlos Danger (Sep 17, 2014)

Jason said:


> Back again ...
> It seems many people have good thoughts and that this is a button pusher topic.  And that many people seems to have similar thoughts about Pt care.
> Maybe I was a bit strong in my 2 cents early.  However, *I still believe it's not a good standard of care for the critical patient or for anesthesia.*  I work in departments and staff with anesthesia and we use capnography to assist our evaluation of the Pt.
> I also agree with some people, in that ... I rarely go CODE 3 to the hospital.
> Pulse Ox, like other pieces of equipment, it's just a piece of the puzzle (or slice of the pie) that makes up the patient as a whole.



You can believe what you want of course, but know that your opinion is at odds with the standards published by the American Society of Anesthesiologists, American Association of Nurse Anesthetists, and International Anesthesia Research Society, and probably others. The ASA has a large closed claims database that shows that a very large percentage of claims are found due to inadequate monitoring.....and continuous pulse oximetry is actually the only monitor that is considered absolutely mandatory for the entire course of every anesthetic procedure, whether MAC, general, or regional. 

Of course you are aware that clinical signs of hypoxemia are not consistently evident until the Sp02 drops to at least 80%, at which point you are right on the steepest part of the oxyhemoglobin dissociation curve where things can go downhill very quickly. Also, you understand that capnography and pulse oximetry measure different things and that you can have profound hypoxemia with a normal capnograph, especially in the setting of a poorly perfused patient with an A-a gradient and impaired hypoxic pulmonary vasoconstriction, which all general anesthetics induce.


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## Handsome Robb (Sep 17, 2014)

What are your protocols for code 3 transport? 

Mine says ***paraphrased**** 'paramedic's discretion if the gain outweighs the risk'.

You could be driving the speed limit and being very cautious but all it takes at an intersection is one car that's missed and misses you and you just probably killed your partner and the patient. 

Last time I caught my partner opposing with me in the back I told them to shut down after we cleared the intersection.


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## Brandon O (Sep 17, 2014)

Remi said:


> You can believe what you want of course, but know that your opinion is at odds with the standards published by the American Society of Anesthesiologists, American Association of Nurse Anesthetists, and International Anesthesia Research Society, and probably others. The ASA has a large closed claims database that shows that a very large percentage of claims are found due to inadequate monitoring.....and continuous pulse oximetry is actually the only monitor that is considered absolutely mandatory for the entire course of every anesthetic procedure, whether MAC, general, or regional.



For what it's worth, I'm not sure whether the anesthesia world is an appropriate comparison when it comes to prehospital assessment. Different environment, goals, and patients.


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## Brandon O (Sep 17, 2014)

I have always felt, by the way, that getting the patient to faster relief of pain, nausea, or other symptoms is a perfectly good reason for judicious lights and sirens. But I'm not sure if y'all medics can fully sympathize with that.


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## Handsome Robb (Sep 17, 2014)

Brandon O said:


> I have always felt, by the way, that getting the patient to faster relief of pain, nausea, or other symptoms is a perfectly good reason for judicious lights and sirens. But I'm not sure if y'all medics can fully sympathize with that.



So you, your partner's, your patient's and everyone else who're on the road lives are less important than symptom relief in a single person? I highly doubt taking the nauseous patient emergent is going to do anything besides make them more nauseous. Same goes for that patient with a painful injury or any pain for that matter. 

Emergent transportation, except in long drives or severe traffic save literally seconds. Maybe a minute or two tops.

Sorry, not trying to be a **** but I adamantly disagree with you and that's not just the medic in me talking.


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## cprted (Sep 17, 2014)

Brandon O said:


> I have always felt, by the way, that getting the patient to faster relief of pain, nausea, or other symptoms is a perfectly good reason for judicious lights and sirens. But I'm not sure if y'all medics can fully sympathize with that.


That's a terrible reason to go Code 3.  I get where you're coming from, but it just isn't good risk/reward.  

There are so many other areas where you can speed up a call to get a patient the treatments they need faster.  Cutting down on scene times, efficient extrication, reducing chute times ... these are all things that will save way more time than lights and sirens ever will.


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## Brandon O (Sep 18, 2014)

This is one of those situations where it really behooves people to understand that one EMS system is not like the next. I have saved many, many minutes on some of my transports with lights and sirens, and I would not be doing it if it couldn't be done safely. (That's not to say that it always saves time, or that it's absolutely always safe; I remember occasions when I accidentally took a lane or something and immediately realized there wasn't visibility and it was a Bad Idea to stay there. But that's exactly the kind of recognition that allows it to be safe in general. Use your noodle.)

I am also someone who will put on their hazards and drive at 2 MPH in the slow lane if that better serves the patient. Judgment is needed. I'm a big believer in keeping my butt alive, and there are people who don't have the ability to drive safely no matter how they do it, but using too broad a brush is a disservice here.


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## Carlos Danger (Sep 18, 2014)

Brandon O said:


> For what it's worth, I'm not sure whether the anesthesia world is an appropriate comparison when it comes to prehospital assessment. Different environment, goals, and patients.



I was responding specifically to the statement that pulse oximetry is not "the standard of care" in anesthesia or critical care. It absolutely is, and for good reason.


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## Jason (Sep 18, 2014)

Remi said:


> I was responding specifically to the statement that pulse oximetry is not "the standard of care" in anesthesia or critical care. It absolutely is, and for good reason.


 
Remi - You bring up excellent points. Valid and true.  Maybe I worded some things wrongly.  And I admit I might be jaded about the Pulse Ox in the field.  Pulse Ox with good wave form is a good tool, not stand alone.  I've gotten tired of too many First Responders telling me that the patient is ok, the Pulse Ox is 98% ... and can blatantly see the Patient struggling to breath.   As for anesthesia, Pulse Ox is used, with a waveform, and in conjunction with capnography (two tools making assessment better than one).  Many of the field Pulse Ox devices used on scene in my area are numeric only, waveform Pulse Ox is only on the Cardiac Monitor.  So, in turn, I get people telling me how fine the Patient is and not having any urgency to give appropriate care.   
I'm still a believer in basic assessment tools, my eyes, ears, ...  My "toys" on the truck just add information to the puzzle that make each Patient.


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## Chewy20 (Sep 18, 2014)

Handsome Robb said:


> What are your protocols for code 3 transport?
> 
> Mine says ***paraphrased**** 'paramedic's discretion if the gain outweighs the risk'.
> 
> ...


 
Maybe I should have said in heavy traffic, both cities I have been in would take about 30 minutes to go two miles for the majority of the day if it were not for lights and sirens. You may get mad at your partner for going through an intersection, but if you come to a red light at an intersection and STOP, eventually people will stop after seeing you from all other 3 streets and then it would be safe to proceed at a slow speed. I don't know who your partners are but it sounds like you have been thrown around in the back of the box a lot and don't trust their driving. If the pt is stable (like most are) than no they may not be going into the ER with sirens blaring, but I have zero problem with going through a city or highway with them on.


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## vcuemt (Sep 19, 2014)

Chewy20 said:


> Maybe I should have said in heavy traffic, both cities I have been in would take about 30 minutes to go two miles for the majority of the day if it were not for lights and sirens. You may get mad at your partner for going through an intersection, but if you come to a red light at an intersection and STOP, eventually people will stop after seeing you from all other 3 streets and then it would be safe to proceed at a slow speed. I don't know who your partners are but it sounds like you have been thrown around in the back of the box a lot and don't trust their driving. If the pt is stable (like most are) than no they may not be going into the ER with sirens blaring, but I have zero problem with going through a city or highway with them on.


"Let's head on out... lights and sirens, nice and easy," is how I've heard that before.


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## chaz90 (Sep 19, 2014)

vcuemt said:


> "Let's head on out... lights and sirens, nice and easy," is how I've heard that before.


That's the only way I ever request L&S, and rarely at that.


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## JPINFV (Sep 19, 2014)

Jason said:


> Ok ... so I'm just gonna go out on a limb and say my 2 cents on this matter ...
> Maybe it's misunderstanding ... maybe it's training ...
> There is nothing the Pulse Ox is gonna tell me that my basic EMT skill level assessment can't tell me more.  It's not my ALS assessment, it's a BLS assessment.  There is no piece of equipment, by itself, on my rig that tells me the Pt is in trouble.  The Pulse Ox should never have become a standard of care.  It's too easy to fool, too easy to get wrong numbers.  Basic assessment rules over Pulse Ox any day of the week.
> Bottom line - learn to do a good assessment and learn to trust your instinct and "gut".




You know, except response to treatment. If oxygenation improves and the clinical picture doesn't, then you have a second problem someplace that needs to be found.


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## Brandon O (Sep 19, 2014)

vcuemt said:


> "Let's head on out... lights and sirens, nice and easy," is how I've heard that before.



The Boston area is fond of the "easy 2."


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## Handsome Robb (Sep 19, 2014)

Chewy20 said:


> Maybe I should have said in heavy traffic, both cities I have been in would take about 30 minutes to go two miles for the majority of the day if it were not for lights and sirens. You may get mad at your partner for going through an intersection, but if you come to a red light at an intersection and STOP, eventually people will stop after seeing you from all other 3 streets and then it would be safe to proceed at a slow speed. I don't know who your partners are but it sounds like you have been thrown around in the back of the box a lot and don't trust their driving. If the pt is stable (like most are) than no they may not be going into the ER with sirens blaring, but I have zero problem with going through a city or highway with them on.



When I say opposing I meant in opposing lanes of traffic, not intersections. Sorry for the confusion.
Brandon I still disagree with you. If you're having to transport lights and sirens for symptom relief that's a failure on the part of your system. There's no excuse for that whatsoever. There's nothing you can say to make it not dangerous. Sure driving safely you reduce the risk but there's still an increased risk using red lights and sirens. People do dumb **** around emergency vehicles when they aren't going emergent. Add in the disco lights and the wee woos and it gets even worse.


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## Akulahawk (Sep 19, 2014)

JPINFV said:


> You know, except response to treatment. If oxygenation improves and the clinical picture doesn't, then you have a second problem someplace that needs to be found.


Yep. Heck, I look for those anyway because sometimes the problem you see might cause you to miss the other one....


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## JPINFV (Sep 19, 2014)

Akulahawk said:


> Yep. Heck, I look for those anyway because sometimes the problem you see might cause you to miss the other one....




To quote Atlas Shrugged (I'll take useful quotes where ever I can find one), "I'll give you a hint. Contradictions do not exist. Whenever you think that you are facing a contradiction, check your premises. You will find that one of them is wrong."


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## Carlos Danger (Sep 20, 2014)

JPINFV said:


> To quote Atlas Shrugged (I'll take useful quotes where ever I can find one), "I'll give you a hint. Contradictions do not exist. Whenever you think that you are facing a contradiction, check your premises. You will find that one of them is wrong."



That is a great quote from a great book. Signature-line-worthy, even....


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## Brandon O (Sep 21, 2014)

Handsome Robb said:


> Brandon I still disagree with you. If you're having to transport lights and sirens for symptom relief that's a failure on the part of your system. There's no excuse for that whatsoever.



I agree about system failure, but it's unfortunately a common one. I'll be happier when medics everywhere can be relied upon to provide palliative measures if called to intercept for a non-life-threatening complaint, and even happier when BLS units can offer appropriate meds themselves. But until then, I think relieving suffering is as good a reason for safely expedited transport as any, and better than most.

Cure seldom, relieve often, comfort always.


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## johnrsemt (Sep 23, 2014)

Personally I run about 90% when I am breathing fine;  and abou 96-98% when I am having major issues (asthma).  So if you go by the numbers I don't need any O2 or a neb treatment.  And I have had people refuse to give me help (and one medic took my Neb tx away when I was using my own tubing and Albuterol and just using company O2:  Cause my numbers were too good and I wasn't wheezing)


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## Underoath87 (Sep 25, 2014)

johnrsemt said:


> *Personally I run about 90% when I am breathing fine*;  and abou 96-98% when I am having major issues (asthma).  So if you go by the numbers I don't need any O2 or a neb treatment.  And I have had people refuse to give me help (and one medic took my Neb tx away when I was using my own tubing and Albuterol and just using company O2:  Cause my numbers were too good and I wasn't wheezing)



Huh?  Do you have COPD too, or just the asthma?


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## medichopeful (Oct 2, 2014)

gonefishing said:


> Treat the patient not the machine.



Treat both until you have a damn good reason not too (equipment failure, multiple false readings, etc).


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## DesertMedic66 (Oct 2, 2014)

medichopeful said:


> Treat both until you have a damn good reason not too (equipment failure, multiple false readings, etc).


Thank you


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## gnosis (Oct 4, 2014)

Underoath87 said:


> Huh?  Do you have COPD too, or just the asthma?



It's not that unusual. I tend to run about 92 when I'm at rest. Unless I'm moving or talking, I generally only breathe four or five times a minute. Add that to being a heavy sleeper, and I've more or less accepted that I will eventually be woken from a nap by someone trying to ventilate me.


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## MedicD (Oct 7, 2014)

shademt said:


> In regards to assessing oxygen saturation via an electronic pulse oximeter and taking into account the other vital signs, at what percent O2 would you consider upgrading the call to code 3 or ALS?
> 
> Thanks for the feedback



I hate to sound like broken record and drop the whole "Treat the patient, not the monitor" line but it couldn't be more true.  In fact, there are often times when you don't want patients to be at 100% and many protocols dictate to titrate lower.

On a side note, if you are upgrading based on pulse ox alone, look closer... Odds are, if the patient truly needs ALS interventions, there are other s/s that will cement your decision to upgrade.


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## gronch (Oct 7, 2014)

MedicD said:


> I hate to sound like broken record and drop the whole "Treat the patient, not the monitor" line but it couldn't be more true.  In fact, there are often times when you don't want patients to be at 100% and many protocols dictate to titrate lower.
> 
> On a side note, if you are upgrading based on pulse ox alone, look closer... Odds are, if the patient truly needs ALS interventions, there are other s/s that will cement your decision to upgrade.



I hit 91% during my asthma attack, and it sucked.  Pulse ox is a great tool.


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## Angel (Oct 9, 2014)

im sure its been said but if your patient has rales, is cyanotic and can barely speak let alone breathe who cares what their sp02 is? are you going to delay treatment to get a number back? its nice to have but shouldnt be _the_ deciding factor.


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## medichopeful (Oct 9, 2014)

Angel said:


> im sure its been said but if your patient has rales, is cyanotic and can barely speak let alone breathe who cares what their sp02 is? are you going to delay treatment to get a number back? its nice to have but shouldnt be _the_ deciding factor.



Put the probe on and then start treating them!  Getting everything set up and doing auscultation is going to give the probe enough time to get a reading.


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## Household6 (Oct 10, 2014)

gronch said:


> I hit 91% during my asthma attack, and it sucked.  Pulse ox is a great tool.


I've had some doozy asthma attacks while on call, one at a fire stand-by.. My partner offered me an Aero-neb, I declined, he offered manual exhalation assistance.. I told him to stop dreaming, he's not touching my b**bies. Good ol Proventil works everytime..

I had just started out, and we responded to a 2 car wreck on a MN roadside in January. One pt was sitting on the side of the road, I did my assessment, his sats were running low 70's.. Green little Probie me says, "OMG, medic, we need to get him on an NRB!" Medic comes over, introduces himself, shakes the guy's hand, asks him a couple questions. Says to me, "He's fine" Grabs the guy a heat pack from the rig for his freezing fingers that I tried to take a sat reading from. Well... 

Experience noted, squirreled away in my brain for future reference. Patient exhibited zero symptoms of hypoxia, but in my inexperience, all I saw was the saturation.


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## NPO (Oct 25, 2014)

If you're using the pulse ox to decide if you need ALS, you're already too late.

EDIT: Oh... This is already on page 6. Oops.


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## evantheEMT (Oct 27, 2014)

I think its nice to have one but dont rely solely on it.Like others have said look at the big picture with the other vital signs.


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