56 y/o, f

[Melclin]

Actually we had a meeting with our new medical director that just took over about a month ago about this recently, he showed up pictures of coronary arteries of an otherwise healthy person on room air and on high concentrations of O2. The people with O2 had much more limited blood flow to the heart, it was actually scary what the difference was. The people with high flow O2 looked like they had a partial occlusion of the vessels. Also instructed us to not place patients on O2 unless they have a SaO2 of 90% or less, and that our target should be 94%.

That may be so, and it is roughly consistent with my understand as well, but it doesn't, in itself, really constitute compelling evidence against O2. The peak body recommendations are what they are and I'm sure the British thoracic society considered those 'pictures' along with many others when they suggested empirical high concentration O2 in 'critical illness'. It has to be said, arrythmias are not usually listed in that category but the evidence doesn't really strongly point one way or the other as far as I'm aware. If you were to place this pt on O2 for 5-10 mins while you sorted everything else out, paying particular attention to the presence of critical illness that may require O2 and especially the reliability of the oximetry, then you titrated the O2 to a more reasonable level, you would probably not be sent to hell for being a terrible clinician is all I'm saying.

 

[Veneficus]

That may be so, and it is roughly consistent with my understand as well, but it doesn't, in itself, really constitute compelling evidence against O2. The peak body recommendations are what they are and I'm sure the British thoracic society considered those 'pictures' along with many others when they suggested empirical high concentration O2 in 'critical illness'. It has to be said, arrythmias are not usually listed in that category but the evidence doesn't really strongly point one way or the other as far as I'm aware. If you were to place this pt on O2 for 5-10 mins while you sorted everything else out, paying particular attention to the presence of critical illness that may require O2 and especially the reliability of the oximetry, then you titrated the O2 to a more reasonable level, you would probably not be sent to hell for being a terrible clinician is all I'm saying.

In response to this and your earlier post regarding high concentration o2.

Many of the guidlines have not changed for reasons other than the preponderance of evidence.

Not least of which is tradition and many providers who no matter what or how much evidence you present have the mental fortitude to admit prior recommendations were ineffective or wrong.

The EBM justification to this is usually to say the studies were small or "inconclusive." One of my favorites is "there is no harm in the short term."

Because it is saying just because in the short term there is subclinical harm while I have the patient, I don't really care what the subsequent patient condition may be.

It is based on a long outdated concept of acute disease.

Major society recommendations are consensus. Consensus does not make something correct. It does mean a compromise everyone can live with has been reached.

30 years ago if you stood up and said "backboards cause harm, do no good, and I am not using it. " You would have been sent to hell as a terrible clinician. You would not be following the "expert society guidlines." You would be no less wrong.

Once you get over the ineffective "emergency save lives now!" mentality and start looking down the trail a bit, you start to realize that some of those emergency now treatments reduce quality and quantitiy of life a decade or more later.

Quite a price to pay to make yourself feel like you are doing something while you figure out what is going on in my opinion.

What I think makes that morally unacceptable is you are performing that treatment not for the patient, but for yourself.

We don't advocate giving Epi to every cardiac arrest patient because it has no short term harm and might do something. That very treatment dates back to the 1600s.

Considering the length of time that was part of consensus and that fact the AHA despite no study showing benefit in 40 years still uses it despite other society recommendations to stop using it should severely limit your respect for "consensus guidlines."

P.S. this is collective "you" not directed at Melclin personally.

 

[Melclin]

In response to this and your earlier post regarding high concentration o2.

Many of the guidlines have not changed for reasons other than the preponderance of evidence.

Not least of which is tradition and many providers who no matter what or how much evidence you present have the mental fortitude to admit prior recommendations were ineffective or wrong.

The EBM justification to this is usually to say the studies were small or "inconclusive." One of my favorites is "there is no harm in the short term."

Because it is saying just because in the short term there is subclinical harm while I have the patient, I don't really care what the subsequent patient condition may be.

No I don't agree on this point. I don't believe the idea of short term shot gun style approaches in this instance are based on the idea of ignoring sub-clinical harm that ends up being someone else's problem. I think its based on the idea that the harm may be non-existent or not clinically significant in short term application that is discontinued quickly if found to be unnecessary, but that it may be helpful if needed and initiated early. Probably doesn't hurt, might help. Maybe there are some providers kicking around thinking, "I don't care how much damage I do, as long as it doesn't become my problem", but I doubt that the British Thoracic society sat around giggling about it being 'the doc's problem', while they cleaned their rigs and went on the next call

It is based on a long outdated concept of acute disease.

Major society recommendations are consensus. Consensus does not make something correct. It does mean a compromise everyone can live with has been reached.

30 years ago if you stood up and said "backboards cause harm, do no good, and I am not using it. " You would have been sent to hell as a terrible clinician. You would not be following the "expert society guidlines." You would be no less wrong.

Once you get over the ineffective "emergency save lives now!" mentality and start looking down the trail a bit, you start to realize that some of those emergency now treatments reduce quality and quantitiy of life a decade or more later.

Quite a price to pay to make yourself feel like you are doing something while you figure out what is going on in my opinion.

What I think makes that morally unacceptable is you are performing that treatment not for the patient, but for yourself.

We don't advocate giving Epi to every cardiac arrest patient because it has no short term harm and might do something. That very treatment dates back to the 1600s.

Well....we sorta do. By we I mean the field..not us.

Considering the length of time that was part of consensus and that fact the AHA despite no study showing benefit in 40 years still uses it despite other society recommendations to stop using it should severely limit your respect for "consensus guidlines."

P.S. this is collective "you" not directed at Melclin personally.

I agree with most of what you're saying generally and in principle, but I feel it misses the point I was actually trying to make. I'll try to explain myself a little better.

For the record, I don't actually agree with putting O2 on this pt.

My point though was that I've noticed that people here have a tendency to overreact a little when they think they smell blind adherence to old school EMS doctrine. Rage, rage, rage about how absurd they think that idea/treatment to be. I think often the severity of the negative reaction has more to do with anger about the perceived adherence to an archaic status quo, than anything to do with EBM.

Take O2 admin for example. When people see a person say, "I put X amount of O2 on a pt whose SpO2 was Y", there is usually a pretty steady stream of people saying how stupid it is to do that (lets be honest, sometimes it is, but we're not talking about those times) and I'm sure you'd agree some of those discussion have become pretty heated. Judging by the strength of the reaction, you'd think there must be an overwhelming body of evidence showing just how awful it is to do such a thing. But there isn't. In fact, I'd say in an odd sort of way that reaction might even be to do with our own little quasi-expert opinion consensus we've developed within the community of EMT-Life; an opinion just as keen at rejecting O2 as others might be at keeping it.

I happen to agree with that opinion. I was simply warning against exactly what you are talking about. About the band wagon being hard to turn around once it gains a little momentum.

Most of all my point was simply this: While I dont think the application of O2 in this circumstance was right, I also don't think its correct to call it wrong, given the current state of the evidence base and the recommendations that exist (whatever one may say about the peak bodies, their recommendations have to be respected to a degree. We can't all be experts in all fields enough to throw out the guidelines of many often respected and experienced experts in each field).

 

[Veneficus]

I think we mostly agree on all the principles, we are just not communicating in an optimal way.

I was not speaking about the use of O2 in this case at all.

I will admit that I am a bit zealous about doing things based on "wrote protocol."

This comes not from just my US experience, but my world wide medical experience of watching patient slip through the cracks of guidline based medicine.

I think it originates from a flawed thinkng. That idea is that if you are following the rules you must be doing the right thing for the patient regardless of the need or outcome.

Now while that kind of thinking is not unique to US EMS, because of US EMS history and integration with the US fire service, which is very strongly paramilitary, it becomes very difficult to change that style of thinking. The most effective means is to consistently and adamantely take issue with it.

you'd think there must be an overwhelming body of evidence showing just how awful it is to do such a thing. But there isn't. In fact, I'd say in an odd sort of way that reaction might even be to do with our own little quasi-expert opinion consensus we've developed within the community of EMT-Life; an opinion just as keen at rejecting O2 as others might be at keeping it.

I agree this is definately the case. But I am not sure it makes it wrong.

There are multiple podcasts and blogs by various experts on a variety of EMS and critical care issues that advocate their points and do not readily accept counter points and in some notable cases do not even acknowledge them.

On the specific matter of O2, I would say there is very appreciable evidence when you look at all of the different medical specialties that have dealt with this topic showing that emergent use of high flow O2 is not a reasonable treatment.

I would offer yet again, the Emergency Medicine community asa world-wide whole, no matter the specialty involved focuses only on all or nothing studies that are only done in the emergency environment.

I strongly feel this is a deletorious approach, not one demonstrating of expertise. Many emergency treatments and patients cannot be studies. A hyperbolic example is CPR. We cannot have a control group of those who will not have CPR performed on them. But in more reasonable research, it is aways difficult for a variety of reasons. That limits the very ability to gather research. To then turn around and say there isn't "a lot," or "definitive" evidence while failing to acknowledge or extrapolate studies and evidence from other specialties is not simply disingenious, it is entirely self serving.

but I doubt that the British Thoracic society sat around giggling about it being 'the doc's problem', while they cleaned their rigs and went on the next call

I doubt they did that too. But I do not think it is outrageous to think that sat around and said "these decisions are too complex to put in the hands of EMS providers so we will create our guideline on the side of administering treatment as opposed to withholding it."

given the current state of the evidence base and the recommendations that exist (whatever one may say about the peak bodies, their recommendations have to be respected to a degree. We can't all be experts in all fields enough to throw out the guidelines of many often respected and experienced experts in each field).

While I agree with this, and personally defer to guidelines when I am not in the know, I have also been burned by following those guidelines in certain cases to the detriment of the patient.

The question then becomes not "should we follow the guidelines" but "how do we interpret and integrate these guidlines in practice?"

 

[Hunter]

The question then becomes not "should we follow the guidelines" but "how do we interpret and integrate these guidlines in practice?"

Better way to put it I think... Or maybe not better but easier for the people who swear by protocols, "which ones do we follow based on evidence and presentation, and which parts apply to THIS patient".
By "this" I don't mean the patient that was originally discussed but whatever patient you have in front of you, no better yet whom ever you have in front of you.

And I don't think anyone here would say "Don't follow protocol!" Because that would get you fired.

 

[Veneficus]

And I don't think anyone here would say "Don't follow protocol!" Because that would get you fired.

I know many agencies require providers to follow protocols like they are baking a cake. One step before the other, always in the same order and always all the steps.

I actually worked for one once. Briefly. We do not miss each other...

But I would say it is more common today to choose which part of the protocol you are using. Sometimes using multiple ones or parts of multiple ones. Even switching between them.

I am not suggesting not following your standing orders. Simply to be better at applying them.

 

[Melclin]

I think we mostly agree on all the principles, we are just not communicating in an optimal way.

Oh well, we'll disagree about something one day, mate. We just have to keep trying

I was not speaking about the use of O2 in this case at all.

I will admit that I am a bit zealous about doing things based on "wrote protocol."

This comes not from just my US experience, but my world wide medical experience of watching patient slip through the cracks of guidline based medicine.

Fair point. I suppose I'm coming from the opposite position (and considerably less experience all round it has to be said). I see many aspects to our system, both EMS and local healthcare in general, that would be greatly improved by an increased focus on guidelines. Mostly to overcome the basic fact that not everyone can be experts in everything but also to tackle to ridiculous inefficiencies, mostly logistical and communication related, that could easily be fixed if the stakeholders sat down and agreed on how things should be done.

I think it originates from a flawed thinkng. That idea is that if you are following the rules you must be doing the right thing for the patient regardless of the need or outcome.

Now while that kind of thinking is not unique to US EMS, because of US EMS history and integration with the US fire service, which is very strongly paramilitary, it becomes very difficult to change that style of thinking. The most effective means is to consistently and adamantely take issue with it.



I agree this is definately the case. But I am not sure it makes it wrong.

There are multiple podcasts and blogs by various experts on a variety of EMS and critical care issues that advocate their points and do not readily accept counter points and in some notable cases do not even acknowledge them.

On the specific matter of O2, I would say there is very appreciable evidence when you look at all of the different medical specialties that have dealt with this topic showing that emergent use of high flow O2 is not a reasonable treatment.

I would offer yet again, the Emergency Medicine community asa world-wide whole, no matter the specialty involved focuses only on all or nothing studies that are only done in the emergency environment.


I strongly feel this is a deletorious approach, not one demonstrating of expertise. Many emergency treatments and patients cannot be studies. A hyperbolic example is CPR. We cannot have a control group of those who will not have CPR performed on them. But in more reasonable research, it is aways difficult for a variety of reasons. That limits the very ability to gather research. To then turn around and say there isn't "a lot," or "definitive" evidence while failing to acknowledge or extrapolate studies and evidence from other specialties is not simply disingenious, it is entirely self serving.

Again a good argument. I strongly agree with seeking and considering evidence from outside your speciality. I'm often asked why I read a lot of surgical and general practice/primary care literature. "How is that relevant?", they ask. How will I know unless I read it", I reply.

I doubt they did that too. But I do not think it is outrageous to think that sat around and said "these decisions are too complex to put in the hands of EMS providers so we will create our guideline on the side of administering treatment as opposed to withholding it."

Well they aren't EMS specific. Just emergency specific. But you could make the same point for nurses of junior doctors who manage these pts initially.

While I agree with this, and personally defer to guidelines when I am not in the know, I have also been burned by following those guidelines in certain cases to the detriment of the patient.

The question then becomes not "should we follow the guidelines" but "how do we interpret and integrate these guidlines in practice?"

Truth.

If you happen to have a list kicking around and its easy to copy and past, have you got a set of references or resources RE detrimental effects of O2 from other specialities that I may not have read? I think its probably time I gave O2 another and more thorough look. It's been a while since I really looked at the literature on the topic.

 

[Veneficus]

If you happen to have a list kicking around and its easy to copy and past, have you got a set of references or resources RE detrimental effects of O2 from other specialities that I may not have read? I think its probably time I gave O2 another and more thorough look. It's been a while since I really looked at the literature on the topic.

Start with Robbin's and Guytons. Since there is stuff in there about it it must be at least 5 years old.