# O2 Almost killed my patient.



## NPO (Jan 17, 2013)

We were dispatched to an acute care facility for an 80-something year-old male complaint of SOB. Upon arrival he was upright in bed with no current complaints. He was sat-ing 98-99% on 1lpm O2. While I took a report from the nurse my partner grabbed an updates set of vitals. All within normal limits. A short time later the patient complained of SOB and sure enough o2 sat was down to 93% and dropping. I consulted with the nurse out of professional curtesy, as it was still his patient. He told me under no circumstances should the oxygen be turned up to more than 1lpm due to the patients COPD, and that much O2 could kill him. 

Now, I assume the nurse has more education than I do at my present point in my career, but can 2lpm really kill a COPD patient? 

I ordered an RT from the facility for the patient and he received a breathing treatment before being transported.

I'm not an "everyone needs O2" kinda guy. In fact fewer than half of my patients present with a reason for oxygen, but this guy was symptomatic.


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## AnthonyTheEmt (Jan 17, 2013)

If your patient is complaining of sob, and his sats are low, you give them oxygen regardless of if they have COPD. High flow oxygen over a long period hurts patients with COPD, but not short term exposure to it.  but if they're complaining of sob, give them o's


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## joegrizzly (Jan 17, 2013)

Look up hypoxic drive in COPD patients. Basically what the nurse was getting at is that in copd patients, the stimulus to breath is reversed to low levels of o2. Even with this cool tid bit of physiology, o2 is *never* witheld from a patient in EMS. Good call on the RT in my book, granted I'm just an EMT-Bandaid; but I do not believe 2 lpm of or greater o2 in the short term would be an extreme threat to a patient. Granted our guide lines in CA is to never withold o2, but I would love to hear a respone from a RT or medic on the issue of transporting a patient with a Hx of copd with hypoxic drive.


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## NPO (Jan 17, 2013)

I did in fact ask the RT. She chuckled and said. "I've been doing this a while and I've never seen that happen."

Here in Cali I can't monitor o2 sat as a basic because I'm not educated enough to read numbers apparently. So I made for darn sure he was good to go before loading him up.


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## JPINFV (Jan 17, 2013)

NPO said:


> Here in Cali I can't monitor o2 sat as a basic because I'm not educated enough to read numbers apparently.




Reading and interpreting are two different things. On that note, "withholding" and "not indicated" are also two different things, and as long as EMTs keep equating the two I can't really argue that they should be interpreting a percent saturation.


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## DesertMedic66 (Jan 17, 2013)

NPO said:


> I did in fact ask the RT. She chuckled and said. "I've been doing this a while and I've never seen that happen."
> 
> Here in Cali I can't monitor o2 sat as a basic because I'm not educated enough to read numbers apparently. So I made for darn sure he was good to go before loading him up.



A lot more counties in SoCal are allowing EMTs to monitor SpO2. I'm in a super restrictive county and we can do SpO2.


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## VFlutter (Jan 17, 2013)

NPO said:


> Here in Cali I can't monitor o2 sat as a basic because I'm not educated enough to read numbers apparently



Well to be honest you are most likely not educated enough to effectively monitor SpO2. SpO2 is more than just reading a number. Not that I think it shouldn't be allowed but I can see the argument.


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## mycrofft (Jan 17, 2013)

Had such a pt before, wearing a MASK, not a nasal cannula. Cranking it to 6 lpm made quite a difference, they gave us the pt because they thought she was dying...and she was. Iatrogenically.

SOMe people still teach about the COPD/drive boogeyman. Maybe the MD wrote an order? 

_*DO*_ MD orders ever get relayed to transport techs, or just generic instructionsf rom the facility which might hopefully embody the MD's order?


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## Veneficus (Jan 17, 2013)

mycrofft said:


> SOMe people still teach about the COPD/drive boogeyman. Maybe the MD wrote an order?



I think it is like many things in EMS, while true, it is exceedingly rare, and somebody once saw it, had a cousin who saw it, heard that a long ago retired paramedic saw it, etc, and now it is given more ugency than it really deserves. 

As you know, I hunted down this rare pathology on purpose, to see if it does exist, and I was shown it. A long term care facility is the most likely place EMS will see this. But it is still very rare.

I would imagine that the 1lpm order was written by a MD based on ABG and normal resting requirements on this patient.

I would also think (or at least I want to believe) that the MD may have believed that if the patient needed an increase in O2 from this 1 LPM baseline, that the patient may need to be evaluated for either an acute exacerbation or another acute pathology like pneumonia.

I cannot imagine she wrote anywhere on the chart not to increase o2 past 1lpm because the patient would die.  



mycrofft said:


> _*DO*_ MD orders ever get relayed to transport techs, or just generic instructionsf rom the facility which might hopefully embody the MD's order?



Even if they are relayed, I would suspect most EMS providers would not follow them and mention some line about them not being an emergency doctor, medical control, etc. 

Usually, you get a brief verbal report/instructions, and a really big stack of paperwork that would take ages to sort through. Some with outdated information.


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## mycrofft (Jan 17, 2013)

_"Even if they are relayed, I would suspect most EMS providers would not follow them and mention some line about them not being an emergency doctor, medical control, etc"_

Holy CR^P.

I always liked the line "Well, they're in MY vehicle now and I have to treat them as I see fit".

If I'm on the litter, I'm bailing at that point.


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## systemet (Jan 17, 2013)

joegrizzly said:


> Even with this cool tid bit of physiology, o2 is *never* witheld from a patient in EMS.



I routinely withhold oxygen from my altered mental status patients who have good saturation.  I routintely withhold oxygen from my ACS patients, and my STEMIs who have a saturation of > 92%, and lack significant work or breathing or dyspnea, etc.

A lot of my patients don't get O2.

Am I awesome? Yes, probably.


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## Akulahawk (Jan 17, 2013)

systemet said:


> I routinely withhold oxygen from my altered mental status patients who have good saturation.  I routintely withhold oxygen from my ACS patients, and my STEMIs who have a saturation of > 92%, and lack significant work or breathing or dyspnea, etc.
> 
> A lot of my patients don't get O2.
> 
> Am I awesome? Yes, probably.


No, you are not withholding oxygen from your patients. You are not giving oxygen because it is not indicated. If you are withholding oxygen from your patients, that would mean that oxygen is indicated and you are not giving it. One of those means that you are utilizing good judgment, the other means that you clearly are not.


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## Aidey (Jan 17, 2013)

Akulahawk said:


> *No, you are not withholding oxygen from your patients.* You are not giving oxygen because it is not indicated. If you are withholding oxygen from your patients, that would mean that oxygen is indicated and you are not giving it. One of those means that you are utilizing good judgment, the other means that you clearly are not.



If he did that I think it would mean he is asphyxiating all of them...21% O2 FTW! :lol::lol::lol:


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## Akulahawk (Jan 17, 2013)

Aidey said:


> If he did that I think it would mean he is asphyxiating all of them...21% O2 FTW! :lol::lol::lol:


Yes, that would be the ultimate withholding oxygen from your patients…:blink::blink::blink:

I think, of course, I think what he really means is that he is withholding _supplemental _oxygen. But I think we already knew that.


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## Aidey (Jan 17, 2013)

Just because I'm a CL doesn't meant I can't be a smart arse too.


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## systemet (Jan 17, 2013)

Akulahawk said:


> I think, of course, I think what he really means is that he is withholding _supplemental _oxygen. But I think we already knew that.



That is, indeed, what this poster meant.  Aside from a couple of quickly recognised and corrected esophageal intubations, I have generally managed not to withhold too much of that 21%.


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## joegrizzly (Jan 17, 2013)

systemet said:


> I routinely withhold oxygen from my altered mental status patients *who have good saturation*.  I routintely withhold oxygen from my ACS patients, and my STEMIs *(Our STEMI protical is NRB @ 15lpm, but hey, thats my county)* who have a saturation of > 92%, and *lack significant work or breathing or dyspnea*, etc.
> 
> A lot of my patients don't get O2.
> 
> Am I awesome? Yes, probably.



Well look at you life saver, you saver of lives you. My statement applies to how as a whole and by the book, EMS is taught to never withhold o2 from a patient. I should have added it earlier but I was hoping the magical words of "as indicated" would have fallen some where in the department of common sense. I did not mean start bagging and jam the o2 bottle down a patients throat for every illness or fall. If your patient is throwing good sats and it is not in your protical, by all means withhold o2 and eat your heart out kid. Thank you for pointing out my mistake and allowing me to correct myself.


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## systemet (Jan 17, 2013)

joegrizzly said:


> Well look at you life saver, you saver of lives you.



Thanks!



> My statement applies to how as a whole and by the book, EMS is taught to never withhold o2 from a patient.



And mine reflected my general irritation at the amounts of times I see people putting oxygen on perfectly healthy people for no apparent reason other than some other perpetuated institutional superstition.

Maybe you do this, maybe you don't.  And if you don't, great. If I came across as arrogant or confrontational, then my apologies, it wasn't my intent.



> I should have added it earlier but I was hoping the magical words of "as indicated" would have fallen some where in the department of common sense.



You'd be surprised how often people seem to administer oxygen without first engaging common sense.



> Thank you for pointing out my mistake and allowing me to correct myself.



For what it's worth, I wasn't trying to start an argument.  All the best.


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## systemet (Jan 17, 2013)

In the spirit of having a discussion, versus the argument that this is, unfortunately, likely to become:

I see something bolded about giving a NRB @ 15 LPM to everyone with a STEMI up there -- are you sure that's a good idea?


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## Aidey (Jan 17, 2013)

I don't think you can claim that is "as a whole and by the book" since the whole high flow O2 for everyone has been going out the window for a while now. Titrating O2 to SpO2 has been increasingly common for a while. Unfortunately there are still enough "15 lpm O2 via NRB for everyone" people out that it is necessary to specify what you mean.


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## joegrizzly (Jan 17, 2013)

systemet said:


> And mine reflected my general irritation at the amounts of times I see people putting oxygen on perfectly healthy people for no apparent reason other than some other perpetuated institutional superstition.
> 
> Maybe you do this, maybe you don't.  And if you don't, great. If I came across as arrogant or confrontational, then my apologies, it wasn't my intent.



Your absolutely right and I am in the same ball park with the irritation at seeing a mask on someone for no reason. I should have put "as indicated" in my original post, so I apologize if I saw you coming from a different direction.

As for 15 lpm for STEMI, I guess it just started in our county recently because last shift we got blown up about having a code STEMI come through the door without a mask on.


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## Aidey (Jan 17, 2013)

Rather than putting a mask on everyone you might want to have the hospital read the current AHA guidelines.


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## joegrizzly (Jan 17, 2013)

Orange County, tis a silly place.


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## eprex (Jan 18, 2013)

I'm a newb but it sounds to me like you should have given him more O2, provided you were the one to give him the oxygen via nasal cannula.

I haven't done the research yet but I've read and have been told that COPD patients won't see any harm from oxygen unless it's on for a significant amount of time at a reasonably high rate. We're talking like 2 hours or more.

Feel free to offer any reputable sources though because I'm curious.


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## jrm818 (Jan 18, 2013)

www.bmj.com/content/341/bmj.c5462

It's not all about the "hypoxic drive"....


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## Handsome Robb (Jan 18, 2013)

93% is a fantastic SpO2% for a COPDer.

Sounds like he needed a treatment, which he got, not his FiO2% increased. 

Whoever was talking about not being to monitor SpO2%. while yes it's only a number, some people are too thick headed to understand that without a proper pleth wave the number doesn't mean diddly. If I had a nickel for every time fire or a newer EMT partner has wigged out about a "low" SpO2% on a patient with no respiratory distress or outward signs of hypoxia.


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## NPO (Jan 18, 2013)

Robb said:


> 93% is a fantastic SpO2% for a COPDer.
> 
> Sounds like he needed a treatment, which he got, not his FiO2% increased.



Just a slight interjection, it was 93% when I walked back into the room. I sat with him talking to him because to me a number doesn't mean much. He described SOB and spoke in short bursts while gasping. I watched the saturation fall to a low of 89% in the minute or so I was talking to him. 

The RT showed up less than 5 minutes after I requested her and he was fine following the treatment. 

The reason I posted this is because I wanted to understand what the nurse's perspective was. I was not concerned about giving 02. Had the patient been on my ambulance I would have increased o2 until he was breathing adequately. But seeing as he was still at the facility, and I had other resources available to me (the RT) I chose that route.


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## Aidey (Jan 18, 2013)

Just FYI, increasing the O2 until he is breathing adequately isn't a great plan. Depending on why he is hypoxic more oxygen isn't going to help. If he has pulmonary edema, pneumonia, asthma, COPD, a pulmonary embolism etc you could be giving him 40lpm and he will still have SOB.


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## CANDawg (Jan 18, 2013)

Never withhold O2 from a patient that needs it. (Note the NEEDS it part.) If the patient has COPD, just closely monitor the respiratory rate and be prepared to assist with a BVM if necessary. 

O2 used to be contraindicated with COPD, but it isn't anymore.


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## Handsome Robb (Jan 19, 2013)

albertaEMS said:


> O2 used to be contraindicated with COPD, but it isn't anymore.



Long term high flow O2 can be detrimental to COPD patients. Google "hypoxic drive". 

In the short term EMS setting I highly doubt you're going to knock out a COPDer's respiratory drive. 

With that said, they don't need a higher FiO2, they need bronchodilators.


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## CANDawg (Jan 19, 2013)

Robb said:


> Long term high flow O2 can be detrimental to COPD patients. Google "hypoxic drive".



I'm fully aware of that fact and what hypoxic drive is. I was referring specifically to a pre-hospital environment. The change was exactly because of your statement: the minimal time EMS has the patient on O2 is highly unlikely to cause apnea.


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## VFlutter (Jan 19, 2013)

albertaEMS said:


> I'm fully aware of that fact and what hypoxic drive is. I was referring specifically to a pre-hospital environment. The change was exactly because of your statement: the minimal time EMS has the patient on O2 is highly unlikely to cause apnea.



To play the devil's advocate, even though EMS may not see the apnea it does not mean that you have not caused long term harm to the patient.

But like Vene mentioned it is extremely rare and only present in a small subset of patients that EMS does not commonly see.


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## CANDawg (Jan 19, 2013)

Chase said:


> To play the devil's advocate, even though EMS may not see the apnea it does not mean that you have not caused long term harm to the patient.
> 
> But like Vene mentioned it is extremely rare and only present in a small subset of patients that EMS does not commonly see.



Can you explain? I suppose even mild depression induced by the O2 could worsen the respiratory acidosis...


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## mycrofft (Jan 19, 2013)

Chase said:


> To play the devil's advocate, even though EMS may not see the apnea it does not mean that you have not caused long term harm to the patient.
> 
> But like Vene mentioned it is extremely rare and only present in a small subset of patients that EMS does not commonly see.



Elaborate?


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## mycrofft (Jan 19, 2013)

albertaEMS said:


> Can you explain? I suppose even mild depression induced by the O2 could worsen the respiratory acidosis...



Wouldn't the extra oxygen militate against buildup of CO2, thereby combating acidosis?

As mentioned above, for time frames used in PEMS, not usually a problem.


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## CANDawg (Jan 19, 2013)

--Accidental post removed--


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## mycrofft (Jan 19, 2013)

BTW, don't laugh, a succinct article n WIKIPEDIA:

http://en.wikipedia.org/wiki/Hypoxic_drive

And I quote:

"Recent studies have proven that COPD patients who have chronically compensated elevated CO2 levels (known as "CO2 Retainers") are not in fact dependent on hypoxic drive to breathe. However, when in respiratory failure and put on high inspired oxygen, the CO2 in their blood may increase via three mechanisms, namely the Haldane Effect, the Ventilation/Perfusion mismatch (where the regional pulmonary hypoxic vasoconstriction is released) and by the removal or reduction of the hypoxic drive itself."

Time element is still a major factor though.


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## VFlutter (Jan 19, 2013)

mycrofft said:


> Elaborate?



http://www.emtlife.com/showpost.php?p=450809&postcount=82


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## mycrofft (Jan 20, 2013)

THanks Chase.

The quote from Veneficus:

"Have you considered the oxygen you apply today may take time off of a patient's life decades later? That it may reduce the quality of their life faster and increase their medical bills over time? Have you considered the stress involved with the elderly, particularly on a fixed income and immobile, and the negative health influences of trying to pay for and navigate the health system are?

Let me put it into perspective?

lets say a 65 year old male over the course of his life has lost X% of pulmonary function to age and various pathology.

Let's assume that you put them on 15l of NRB and drive them 30 minutes to the hospital. During this time, you observe them calm down.

3 or 4 months later they develop shortness of breath. They return to the hospital where they are now diagnosed with more advanced pulmonary deficency. They are now not able to carry on their daily routine and their quality of life and maybe even their income is reduced. Perhaps their renal function or liver function as well. 

Perhaps that person could have gone another 2-3 maybe 5 years without such a decrease if you hadn't overdosed him on oxygen?

Just something to think about... "

I'm still in the dark, but I know it's my own private dark now...h34r:


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## Akulahawk (Jan 20, 2013)

I blame the radicals. Always trying to be free...


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## JPINFV (Jan 20, 2013)

Akulahawk said:


> I blame the radicals. Always trying to be free...



Occupy the Electrons!


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## KellyBracket (Jan 22, 2013)

The evidence suggests that the "hypoxic drive" is (as many people have said) of little clinical importance. They have done studies where they took COPD patients, either at _high risk_ of intubation, or in the process of being _weaned_ from the ventilator, and watched what an increase in inspired oxygen did to them.

The answer: not much. 

Still, a study in Tasmania suggested harm with oxygen used by EMS. Actually, it showed a huge jump in mortality _just_ from EMS use of high-flow oxygen.

If you want a closer look at these studies, check out *COPD: Is EMS Killing Patients with Oxygen? Part 1* and* Part 2*. As always, informative and somewhat witty.

Spoiler: It's not the oxygen, it's the _ventilation_. Prehospital CPAP!

Added - jrm818 referred to the Tasmanian study as well. Essential reading for EMS, but should be taken with a toss of salt.


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## Akulahawk (Jan 23, 2013)

As KellyBracket said: "It's not the oxygen, it's the _ventilation_. Prehospital CPAP!" To that end, I seem to recall that at times, mixed gas has been used too. CPAP with heliox might just be the ticket at times. That might be a bit expensive to do though, and is probably only truly useful in a certain population... however, it would be highly entertaining to hear people talking like Donald Duck at times...


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## MSDeltaFlt (Jan 23, 2013)

When referring to COPD and hypoxic drive I'm going to try to put this in philosophical terms for those treating COPD pts and are concerned with knocking out their hypoxic drive.

In order to be a CO2 retainer with a true hypoxic drive you will need documentation of such. And that requires ABG's. And they'll have values in the range of (and these are "ish" ranges) pH of 7.3 or higher, PaCO2 > 60, PaO2 60-80 on 1, maybe 2 - 2 1/2 L/min NC, and HCO3 = > 30.  These pts will ALWAYS be short of breath.  They will have SpO2's of 88% on 1.5 L/min with orders to not let SpO2 get above certain levels.  If they have any auscultated breath sounds at all they'll be decreased with wheezes.  Little to no lung function left.  They'll be pursed lip breathing speaking in broken sentences on a regular day.  When they have an acute exacerbation, they won't speak at all to anyone.  They're too short of breath and are too focused on breathing.  They'll also be looking emaciated. Because chewing food makes them short of breath.  These people might also have active DNR's.  

To have a hypoxic drive literally means you must be hypoxic and short of breath in order to breathe.  We healthy people don't. We have a hypercarbic drive.  Our primary stimulus to breathe is when our PaCO2 increases, secondary is hypoxia.

About the only CO2 retainers with a known hypoxic drive that I get nervous with are the pts with Pickwickian Syndrome. These are the pts walking through the grocery store with a room air SpO2 of 75% and not short of breath at all.

Hope this makes sense.


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## med109 (Feb 1, 2013)

This discussion reminds me of a very stubborn patient I had once.

80's year old female c/o trouble breathing. No significant medical history, no COPD, no home O2, no meds. Answers all questions correctly, she is actually very with it, she is having trouble breathing however. 2-3 word dyspnea, tri-podding. Vitals are WNL, O2 Sat is 90 and dropping, with wheezing. I get out the cannula and begin to put it on her, and she FREAKS out! Slapping at me and trying to climb off the gurney. I step back and ask what is wrong, she tells me she is very allergic to o2! I ask again if she has COPD and she says no (paperwork from Dr doesn't mention it either). Any other allergies...nope just oxygen. I tried calling it something else (O2, air, ect) she still refused it. I tried a mask thinking maybe I could "trick" her into thinking it was something else, no luck. I told her I needed to give a Neb, but as soon as she saw the tubing it was a no go. I tried explaning that she could not be allergic as she is breathing it all the time, told her what could happen if she didn't get it, tried changing partners (maybe he could talk her into it). NOTHING worked, she was convienced she was allergic. Very stressful call, but we laugh about it now


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## CANDawg (Feb 1, 2013)

med109 said:


> This discussion reminds me of a very stubborn patient I had once.
> 
> 80's year old female c/o trouble breathing. No significant medical history, no COPD, no home O2, no meds. Answers all questions correctly, she is actually very with it, she is having trouble breathing however. 2-3 word dyspnea, tri-podding. Vitals are WNL, O2 Sat is 90 and dropping, with wheezing. I get out the cannula and begin to put it on her, and she FREAKS out! Slapping at me and trying to climb off the gurney. I step back and ask what is wrong, she tells me she is very allergic to o2! I ask again if she has COPD and she says no (paperwork from Dr doesn't mention it either). Any other allergies...nope just oxygen. I tried calling it something else (O2, air, ect) she still refused it. I tried a mask thinking maybe I could "trick" her into thinking it was something else, no luck. I told her I needed to give a Neb, but as soon as she saw the tubing it was a no go. I tried explaning that she could not be allergic as she is breathing it all the time, told her what could happen if she didn't get it, tried changing partners (maybe he could talk her into it). NOTHING worked, she was convienced she was allergic. Very stressful call, but we laugh about it now



People don't have to be smart to be able to make their own medical decisions.


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## ThadeusJ (Feb 1, 2013)

@Med109.  That's a great example of informed consent (however you want to define "informed") and the patient exercising the right to refuse treatment.


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## Carlos Danger (Feb 1, 2013)

NPO said:


> The reason I posted this is because I wanted to understand what the nurse's perspective was. I was not concerned about giving 02.



The nurses' perspective was probably just that he was following written MD orders.

Also, being someone who takes care of elderly COPD patients regularly, he's probably quite used to presentations such as what you describe, and realizes that it doesn't equate to an emergency.



NPO said:


> the patient been on my ambulance I would have increased o2 until he was breathing adequately. But seeing as he was still at the facility, and I had other resources available to me (the RT) I chose that route.



Well, assuming he has a pathology causing his low Sp02, increasing 02 won't cause him to breathe adequately. 

It may increase his Sp02, but it won't affect his minute volume (in fact it may reduce it), or do anything to address the cause of his dyspnea.



Robb said:


> 93% is a fantastic SpO2% for a COPDer.
> Sounds like he needed a treatment, which he got, not his FiO2% increased.



Exactly.

Serious complications of high flow rates in a COPD patient are rare, but they are not non-existent.

Usually, what happens is not that the patient stops breathing shortly after you increase the Fi02. 

What happens is that they show up to a busy ED with a great Sp02, so they get triaged to a back room and no one pays attention to them for a while because they're busy wrestling with drunks and dealing with patients looking for a Percocet refill. A couple hours later, they find your patient with a Co2 of 90 and a reduced LOC and now he's admitted to the ICU. When all he really needed was some albuterol.


I'm not saying that you did anything wrong at all. As an EMT-B, you did exactly what you were trained to do.

I'm just saying that it wasn't wrong of the nurse to discourage high flow oxygen, as it wasn't going to fix the problem and it just may worsen it.


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## medic17 (Feb 18, 2013)

As far as my system is concerned the short term O2 would not kill him although there have been rare cases of it happening in the long term. short term being under 40 MIN or so. As for the MDs order we must follow to the letter if we know for sure the he is an MD and not just an imposter. Although once he is in our care medical control can counter the order.


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