Oxygen Question

[Veneficus]

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

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



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

What he said is the short and simple version.

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

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

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

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

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

In infants, to that list, add the retina.

 

[mycrofft]

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

 

[NYMedic828]

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

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

 

[Scott33]

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

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

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

 

[leoemt]

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

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

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

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

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

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

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

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

 

[mycrofft]

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

Fair enough.

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

 

[Milla3P]

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

I think I just had a stroke...

 

[Milla3P]

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

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

 

[JPINFV]

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

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

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

 

[PotatoMedic]

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

 

[Aidey]

Why does the type of rehab change your opinion?

 

[Cleric]

Oxygen? Harmful? How could it be?

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

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

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

 

[PotatoMedic]

Why does the type of rehab change your opinion?

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

 

[mycrofft]

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

 

[Tigger]

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

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

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

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

 

[Outbac1]

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

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

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

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

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

 

[leoemt]

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

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

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

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

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

 

[NYMedic828]

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

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

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

 

[Medic Tim]

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

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

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

 

[Tigger]

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

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