Oxygen Question

[TheLocalMedic]

Again, I do not think that many patients truly deserve oxygen, but I make the argument that giving it is not the end of the world, and free radicals be d@mned. Going back to the origin of the thread, if your FTO or preceptor says jump, the best reply is "how high?".

 

[silver]

As for Silver's study he provided as an exemplar, it still begs the question; While the "markers of oxidative stress" were increased in patients placed on supplemental oxygen, was there any real harm done to those test subjects? Sure, if our entire atmosphere were oxygen-enriched we would undoubtedly see ill effects, but were there any identifiable physical detriments to these patients? As a corollary, how quickly did these markers then fall back to a normal baseline following the termination of the supplemental oxygen? What I mean to ask is, as before, can you find me any case where the administration of O2 - for the length of time that we are with a patient - has done any real harm to a patient? Argue with me all you like about free radicals and antioxidants, but bear in mind that theoretical medicine still does not trump the establishment. I do not care for arguments that provide a "maybe" or a "possibly", but rather for ones that can provide concrete data that can be reproduced.

"Induced hyperoxia is potentially toxic, since it may increase oxidative stress and peroxidative damage to deoxyribonucleic acid, lipids and proteins."

Shall I highlight the words 'potentially' and 'may'? Find me proof! And hopefully not in the form of a 'maybe'!

As for the argument proffered by Tigger, I reassert that the argument about glucose administration being comparative to that of oxygen is in fact a Straw Man argument. Not only is the means of administration different, but glucose has a greater and longer lasting metabolic effect than does oxygen. Giving oxygen to a patient who has a PaO2 of 100 mmHg is not equivalent to giving a patient with a BGL greater than 120 mg/dl glucose or dextrose. There are differences both with administration and effect, so there is no good comparison. If I were to accept this comparison, then should I also accept the following?

A: Sunny days are good.
B: If all days were sunny, we'd never have rain, and without rain, we'd have famine and death.

First I would like to note my first post. Look how 'may be' is bolded in your quoted text...

Tell me how you would run an adequately controlled experiment that examined these detriments. Effects of oxidative stress need not be linked to single instances as cumulative stress has been demonstrated to play causal roles in cardiovascular disease and cancers, for example. Additionally, we know that pathology due to oxidative stress from supplemental oxygen has been seen in neonates, which shows the direct potential. It is reasonable to be cautious of the use of O2.

This is how medicine works...that is the establishment. In fact, a large portion of medicine isn't based on evidence. Using this precursory data to indicate the need to eliminate the "it doesn't hurt to always give O2" mentality is appropriate. I wouldn't say we should never give it, but people are giving it for no reason.

 

[leoemt]

Tigger already answered this for me - "Medicine is medicine, BLS and ALS are artificial distinctions." The paramedic's assessment and treatment plan includes "BLS", but those skills are integrated with "ALS," not first do BLS then move on to ALS.

For example, I'm not going to get a BP on an actively seizing pt before treating - I'm getting someone on airway/breathing while I'm drawing up Versed. Same for the hypoglycemic pt. If I get the line before someone gets to the BP, the D50's going in. We titrate our BVM ventilations to an ETCO2 of 35-45 for the head trauma pt with signs of herniation, not some arbitrary rate mandated by BLS protocols. I want a 12-lead before O2 (if we even end up giving it at all) and NTG admin unless the pt has respiratory distress/failure. If I have a pt in anaphylactic shock, I'm throwing epi into them as soon as I can get it drawn up, without delay. Maybe my partner can get some O2 on them in the meantime, but probably nothing else before I'm sticking them in the thigh. How about pain management before splinting?

Most of the time the things BLS are trained to do will occur before the things medics are trained to do will occur, but that's not always the case. Again, the line between BLS and ALS is arbitrary for the medic. I don't break up my assessment an Tx decisions into these categories.

BTW, if you're ever on the scene before ALS, rest assured the medics will always do their own full assessment at some point, probably right away. It doesn't matter much how good or bad your assessment is. Same goes for the doctor and nurses taking the pt from medics at the ED.

I expect them to do their own. I do my own regardless of who I get the patient from. That said, lets agree to disagree and keep this on topic.

 

[zmedic]

My biggest problem with giving oxygen is that unless you also are doing capnography, a patient who has a decreased respiratory drive, say who is only breathing 3 times a minute, will maintain a fairly normal Sp02 if on 100% 02 by NRB. So their pulse ox will be fine but their C02 is climbing and you won't get any warning from the pulse ox until the patient suddenly goes into an arryhtmia. Where as if you have some drunk patient who start obstructing his airway, their pulse ox will drop a lot quicker while on room air and you are warned to reposition their airway. (Yes, I understand that one should be monitoring the patient's airway and mental status and not waiting for a drop in pulse ox to manage their airway. But you see this all the time on drunk patient who "got a little hypoxic" so the RN puts them on a nasal canula and leaves them on the monitor and walks away.")

 

[leoemt]

My biggest problem with giving oxygen is that unless you also are doing capnography, a patient who has a decreased respiratory drive, say who is only breathing 3 times a minute, will maintain a fairly normal Sp02 if on 100% 02 by NRB. So their pulse ox will be fine but their C02 is climbing and you won't get any warning from the pulse ox until the patient suddenly goes into an arryhtmia. Where as if you have some drunk patient who start obstructing his airway, their pulse ox will drop a lot quicker while on room air and you are warned to reposition their airway. (Yes, I understand that one should be monitoring the patient's airway and mental status and not waiting for a drop in pulse ox to manage their airway. But you see this all the time on drunk patient who "got a little hypoxic" so the RN puts them on a nasal canula and leaves them on the monitor and walks away.")

In your capnography example, wouldn't the patient still be showing signs and symptoms of Hypoxia though?

 

[zmedic]

If the patient is breathing 3 times a minute the capnographer will show that, even though the patient may not become hypoxic if they are on 02.

If you don't have them on capnography, it's much harder to tell when someone who just has altered mental status obstructs their ventillation if you have them on 02

 

[waaaemt]

I believe she did fracture her Clavicle. There was an obvious deformity upon palp, she screamed in pain upon palp and wanted to deck me when I palpated it. Additionally, movement of the arm caused pain to increase.

waittttt a second... you guy gave her a c collar? clavicle fractures are a contraindication for c collars am i right? from what i remember, the appropriate thing is the do blanket rolls right?

 

[leoemt]

waittttt a second... you guy gave her a c collar? clavicle fractures are a contraindication for c collars am i right? from what i remember, the appropriate thing is the do blanket rolls right?

I was on field training. I wasn't going to argue with my FTO on scene in front of a patient, which would have been worse.

I agree with you though.

 

[NYMedic828]

waittttt a second... you guy gave her a c collar? clavicle fractures are a contraindication for c collars am i right? from what i remember, the appropriate thing is the do blanket rolls right?

Who told you that one?

Its very common in situations like an MVA to sustain a clavicular fracture from the steatbelt at high speeds and potentially a cervical injury...

You can live without your clavicle being in one piece. Not so much your cervical spine...

 

[Aidey]

Unless that broken clavicle hits the sub clavian artery.

 

[NYMedic828]

Unless that broken clavicle hits the sub clavian artery.

They have a spare

 

[zmedic]

Unless that broken clavicle hits the sub clavian artery.

Find me a case report of a c-collar causing a broken clavicle to lacerate the subclavian. Otherwise I'm not worrying about it. Also a properly applied c-collar is putting pressure on the chin, sternum, occiput and back around C7. Shouldn't be a whole lot of pressure on the clavicle, especially in a patient lying on a backboard.

So don't worry about it.

 

[Aidey]

When was the last time you saw a properly applied c-collar? I would estimate 80 to 90% of the c-collars I see aren't applied correctly.

 

[NYMedic828]

When was the last time you saw a properly applied c-collar? I would estimate 80 to 90% of the c-collars I see aren't applied correctly.

Knowing where zmedic works, I can vouch that our c-collar application in NYC is pretty bad. But I doubt its 80% improper. Probably 50%.

 

[zmedic]

I'd say most of the improper collars are if anything turning the patients head. I don't think they are putting a lot of force on the clavicle.

 

[Veneficus]

As I understand most of the collars are meant to prevent vertical compression, not provide total immobilization?

 

[NYMedic828]

As I understand most of the collars are meant to prevent vertical compression, not provide total immobilization?

It's pretty easy to turn your neck in a collar if you really want...

 

[RocketMedic]

We don't need to care about anatomy, physiology or patient care here. It's all about protocols and tradition!

 

[DrankTheKoolaid]

As I understand most of the collars are meant to prevent vertical compression, not provide total immobilization?

When i use C-collars i always tell the patients that these wont save them from any harm but are there as a reminder for them to not move their heads. The sober ones anyways, with drunks and non compliant patients its not worth the effort when other things need to be tended to.

 

[Aidey]

Knowing where zmedic works, I can vouch that our c-collar application in NYC is pretty bad. But I doubt its 80% improper. Probably 50%.

I was including all of the people who have the collar on straight, but are hyperextended.