another O2 question, unconscious, sorry in advance if...

[anichka]

sorry if this specific scenario has been asked about before. I have browsed this forum for a few years but only just signed up to find out this answer! I searched but there are a LOT of threads on O2!!

Had an eval today (I am an EMT-B student right now) and failed because I did not give the pt the proper O2 therapy.

Unconscious 30ish male, fall from a one-story building (his roof). Airway patent & clear, chest equal rise and fall, resp 16, skin w/p/d, lung sounds clear, BP 122/p, pulse 80ish, PERRLA. No obvious blood loss, some slight bruising on right temple and right upper abd.

I did not treat with O2 initially because I didn't feel it was indicated. The pt became responsive (but disoriented) during my 60 second head to toe and said "it hurts breathe." I started him on O2 then, a nasal cannula, 4 lpm, since he was not short of breath or anything else.

I searched my county protocol book and can't find anything that says what I should have done. What is the proper oxygen therapy in this situation?

**** Edited to add, this was just an EVAL so no harm done. I really want to understand what the proper treatment should have been, so I know what to do if/when I face this in real life. I don't want to wait till my next EMT class to find out, although I will surely ask my instructors for clarification if I don't reach an understanding before then. Thank you! ***

 

[teedubbyaw]

Pretty much everyone gets an NRB for EMT-B testing. That's how I remember it. Is it right? Nope.

 

[TransportJockey]

Pretty much everyone gets an NRB for EMT-B testing. That's how I remember it. Is it right? Nope.

This. It's stupid and inaccurate... but until some of the idiots doing the teaching and writing the evals are gone or get themselves better educated, it's the way it is.

 

[anichka]

So what would be the proper "real life" answer in this situation? I could give two pieces of poo about the test - I will take it again until I pass it (or they tell me to stop trying).

I want to know what is the right thing to do since I can't find protocol guidance.

 

[CriticalCareIFT]

Classroom stuff is still in the prehistoric age. For EMT testing it would be NRB at 15LMP or BVM at 15LMP, and everyone gets oxygen for testing purposes.

 

[teedubbyaw]

I think what you did was fine. It's possible he may not have needed it, though. Use your tools and what you know. Is he perfusing? Is he working to breath? Double check those lung sounds. Get an SpO2. Why is he SOB? *insert assessment* I'll stop there.

 

[anichka]

Okay, thank you for your responses.

We don't check SpO2 (no oximeters at our level) so I have to go with what I can see, hear, and feel. I had doubts too that I should even put him on the cannula, to be honest, but I figured that since I had an indication that he may have some difficulty/chest discomfort, to go with it (at least, I felt I could justify it).

He was not actually SOB and I suspected the "it hurts to breath" was more related to the bruising on his upper abd area, but he was also disoriented and unable to answer my SAMPLE questions...

 

[Akulahawk]

sorry if this specific scenario has been asked about before. I have browsed this forum for a few years but only just signed up to find out this answer! I searched but there are a LOT of threads on O2!!

Had an eval today (I am an EMT-B student right now) and failed because I did not give the pt the proper O2 therapy.

Unconscious 30ish male, fall from a one-story building (his roof). Airway patent & clear, chest equal rise and fall, resp 16, skin w/p/d, lung sounds clear, BP 122/p, pulse 80ish, PERRLA. No obvious blood loss, some slight bruising on right temple and right upper abd.

I did not treat with O2 initially because I didn't feel it was indicated. The pt became responsive (but disoriented) during my 60 second head to toe and said "it hurts breathe." I started him on O2 then, a nasal cannula, 4 lpm, since he was not short of breath or anything else.

I searched my county protocol book and can't find anything that says what I should have done. What is the proper oxygen therapy in this situation?

**** Edited to add, this was just an EVAL so no harm done. I really want to understand what the proper treatment should have been, so I know what to do if/when I face this in real life. I don't want to wait till my next EMT class to find out, although I will surely ask my instructors for clarification if I don't reach an understanding before then. Thank you! ***

When someone says that it hurts to breathe, they're going to likely breathe shallow. This means lower ventilation/air movement, so at the EMTB level, you're going to want to put the patient on 15L by non-rebreather mask. Since they're teaching to the lowest common denominator, they probably figure that if an EMT determines that oxygen is needed, the EMT should just default to 15LPM by mask and call it good... so, at least for testing purposes, put 'em on lots of oxygen. In this scenario, they may have been wanting you to apply the oxygen when you recognized that this guy fell off a roof...

Real world with this patient? I'd probably start low and reassess frequently because of the potential for hypoventilation. If I'm the attendant, I'm going to direct my partner to apply the oxygen as I continue my trauma assessment. Probably the only things I'll address myself as I find them are immediate life threats. I can have my partner(s) do other tasks for me as I need them done. I normally don't like to stay on-scene on trauma calls, so I'm going to want to transport relatively soon. This means that I'm going to do my assessment, get the patient packaged appropriately, and into the ambulance in an expeditious manner. At that point, I'm going to reassess and do a more detailed exam, and get going.

On the whole, in a real-world sense, I don't see that you did anything glaringly wrong. However, as many have stated, testing is not real world.

 

[Av8or007]

EMT/AMFR class is wrong about o2 - nrb @15 is not good for all.

You probably did the right thing. An nc @ 2-6 is usually fine if you need o2.

In absence of spo2 you will sometimes have to error on the side of hyperoxygenation (unfortunately) but still - assess and treat your pt.

Just for interest sake, the newest guidelines actually consider it mandatory to monitor SpO2 during oxygen administration.

Oxygen is not benign and can be harmful in certain patient populations. It is a powerful medication with indications, contraindications and cautions.

Patients with ischemic events such as MI or Stroke as well as patients at risk of Type II respiratory failure (e.g. copd'rs) are at particular risk from hyperoxia induced adverse events, including pulmonary complications, ROS mediated adverse effects and ischemia reperfusion injury.

SpO2 provides a way to determine the need for oxygen therapy in the absence of any clinical signs (i.e. cyanosis or severe respiratory distress).

Low concentration oxygen should be administered if the SpO2 is <94% if the patient is NOT at risk for hypercapnic (type II) respiratory failure, and titrated to maintain spo2 BETWEEN 94-98%.

SEVERE respiratory distress, profound shock states, and major trauma should receive high concentration oxygen. (THE EVIDENCE MAY CHANGE, ESPECIALLY WITH OXYGEN THERAPY).

If the pt is at risk of type II respiratory failure, then LOW concentration oxygen should be administered using nasal prongs or a ~28% venturi mask (ideal) IF and ONLY IF saturation is <88% or severe respiratory distress is present.
Patients with COPD often have normal spo2 values between 88-92%, and administration of high concentration O2 to these patients can be detrimental. If saturation is <85% then high concentration oxygen should be used.

Oxygen is NOT beneficial and may cause harm in non-hypoxemic MI patients, and has been shown to worsen outcomes for non-hypoxemic stroke patients with mild to moderate strokes.

OXYGEN IS NOT: a pain drug or a "cure all".
It is a MEDICATION used to treat hypoxemia.

See:

http://www.brit-thoracic.org.uk/Guidelines/Emergency-Oxygen-use-in-Adult-Patients.aspx

And for some simpler reading:

http://www.ems1.com/columnists/mike-mcevoy/articles/1308955-Can-oxygen-hurt/

 

[anichka]

@Akulahawk, yes, the impression I got was that they did want me to put him on oxygen after noting the fall. Of course, testing is different than real life and I always look to the evaluator to confirm that what I am reading in the situation (e.g., vitals, lung sounds, etc.) is what they want for the scenario. I know if I had an indication there was trouble with breathing, I would have done it earlier but I didn't think there was. BUT, I think I understand where this all comes from now.

@Av8or007 Thank you so much for all that to chew on! I had read some of that info from the other O2 threads and am delving into it now. I wonder if they will start to let us monitor SpO2 eventually. They intentionally keep oximeters off the BLS units in my county b/c they don't want us to rely on them instead of our own senses.

p.s Akulahawk, I think I recognize you from allnurses.com as well...?

 

[Av8or007]

that's the problem with some basic life support services. they seem to think that it is OK to give oxygen indiscriminately without having a pulse oximeter to check the persons oxygen saturation.

You will probably hear the saying treat the patient not the monitor. As long as you don't take it to literally it is very true. What it is saying is that the pulse oximeter or any other diagnostic tool is just a another tool for you to build your clinical assessment. Be a clinician and assess your patient.
Anyone who says BLS can't 'think' or be a clinician has got some issues...

At the same time if something doesn't seem "right" with the patient even though they are stable and you're getting weird vital signs or pulse ox numbers this is a clue that something else may be going on - never ignore the diagnostic equipment but do not blindly follow the numbers.

The trick is to take the numbers you're getting from your vital signs and integrate that number with the appearance and your physical assessment and history of the pt.

Your own senses (sadly) do not include the ability to read the oxygen saturation of anyone you see (this would be cool though).

If it makes you feel any better though I've got the same issue up here in Canada. Our first response agency does not carry pulse oximeters.
The difference is that many people carry their own pulse oximeter and this is allowed even though is not "officially" endorsed.

 

[Akulahawk]

I forgot to add that I don't necessarily agree with teaching that everyone that needs oxygen should get 15L by NRB. Of course, I was taught a little differently, but they didn't have such a drive to simplify things either back then. For us, oxygen was basically a 2-6L or 15L deal, depending upon patient presentation, and only if the patient needed supplemental oxygen. My training as a Paramedic continued that in greater depth.

As stated above, oxygen is a drug, and can be harmful if given inappropriately.

 

[Akulahawk]

@Akulahawk, yes, the impression I got was that they did want me to put him on oxygen after noting the fall. Of course, testing is different than real life and I always look to the evaluator to confirm that what I am reading in the situation (e.g., vitals, lung sounds, etc.) is what they want for the scenario. I know if I had an indication there was trouble with breathing, I would have done it earlier but I didn't think there was. BUT, I think I understand where this all comes from now.

@Av8or007 Thank you so much for all that to chew on! I had read some of that info from the other O2 threads and am delving into it now. I wonder if they will start to let us monitor SpO2 eventually. They intentionally keep oximeters off the BLS units in my county b/c they don't want us to rely on them instead of our own senses.

p.s Akulahawk, I think I recognize you from allnurses.com as well...?

Yes, I'm on allnurses too.

 

[Medic Tim]

something to keep in mind. If you are going to take the NREMT test...I believe they now teach titrated O2 and not 15l NRB for everything....I may be wrong though

 

[CriticalCareIFT]

something to keep in mind. If you are going to take the NREMT test...I believe they now teach titrated O2 and not 15l NRB for everything....I may be wrong though

Based on their skills sheet critical area still is ____ Failure to voice and ultimately provide high concentration of oxygen

https://www.nremt.org/nremt/downloads/E201 Trauma Assessment.pdf

For testing they cannot fail you if you gave NRB at 15, so like I said on Basic testing it comes down to 2 choices NRB or BVM at 15.

 

[Medic Tim]

Based on their skills sheet critical area still is ____ Failure to voice and ultimately provide high concentration of oxygen

https://www.nremt.org/nremt/downloads/E201 Trauma Assessment.pdf

For testing they cannot fail you if you gave NRB at 15, so like I said on Basic testing it comes down to 2 choices NRB or BVM at 15.

Just looked up the medical skill sheet... it reads

Failure to voice and ultimately provide appropriate oxygen therapy. while the Trauma one still requires NRB. I thought when they made the change it was to both medical and trauma.

I get what you are saying though. If you go right to the NRB you will most likely pass.
I just hate that students are taught 1 thing in school and expected to do another in the field.

 

[Mariemt]

I had 7 stations on my EMT b skills. I passed them all first try.

I did NOT use o2 on any of my pts. While they said you can fail by not using appropriate O2 therapy, I felt not using O2 was the right therapy.
My medical was chest pain, previous heart attacks. I immediately did the basic crap and then I asked the evaluator for the O2 sat. It threw her off a second and she said "95". I then stated "i do not feel the need to start my pt on any O2 at this time but reserve the right to change my mind "
The pt was pink, warm, dry and not struggling to breathe.

Trauma assessment was a fall with head injury. I did all the normal stuff and again asked my evaluator for O2 sat. He was not surprised and said 98..

I said the pt does not have any cyanosis, sob or any indication of distress, I feel overoxigenating this pt could cause more harm than good and reserve the right to add O2 on my detailed exam.

That evaluator said it was the best he had ever seen and strongly believed in titration.

It isn't about throwing O2 on, it is about correct usage.

 

[Mariemt]

Just looked up the medical skill sheet... it reads

Failure to voice and ultimately provide appropriate oxygen therapy. while the Trauma one still requires NRB. I thought when they made the change it was to both medical and trauma.

I get what you are saying though. If you go right to the NRB you will most likely pass.
I just hate that students are taught 1 thing in school and expected to do another in the field.

I didn't on trauma and got 43 out of 43 points. Its about proper usage.

 

[anichka]

I didn't ask that question - maybe it would have changed the evaluator's mind - but I have a strong suspicion that her answer would have been "you don't know that" or "you won't know that in the field" or something along those lines.

I *did* verbalize that I did not think it was necessary AND why I did not, but that was obviously not the expectation in this situation... regardless, I have a a better feeling about what I should do when I encounter that situation in real life.

 

[anichka]

I also have the feeling that it is probably subjective to who is evaluating you.

I think that if it had been a couple of the paramedic who are teaching us, my response may have been deemed appropriate. Nevertheless, I will know for the next eval time, err on the side of O2.