BLS Skills -- What Should We Add?

[EpiEMS]

I think it is valuable for how simple it is to evaluate but at the same time I think 1/10 EMTs (if even) actually understand what they are measuring.

Furthermore, in my experience it is irrelevant to most EMTs treatment. Half the time they get an O2 sat of 98-100% and I still walk in to find the patient on oxygen.

Worse still, they check baseline saturation while the patient is on oxygen.


Side note, I know more than a handful of paramedics who are equally bad...

I've the same problem where I'm at, but it's usually FD that has the pt on oxygen unnecessarily. Broadly, I can't see pulse ox for BLS being "bad" (or at least, have a deleterious effect on patient care) unless a BLS provider shows up to a CO poisoning and doesn't give O2 just because the "sats look good."

 

[NYMedic828]

I've the same problem where I'm at, but it's usually FD that has the pt on oxygen unnecessarily. Broadly, I can't see pulse ox for BLS being "bad" (or at least, have a deleterious effect on patient care) unless a BLS provider shows up to a CO poisoning and doesn't give O2 just because the "sats look good."

Exactly.

We walk a fine line in EMS for both paramedic and EMT level care with what we allow under-educated providers to perform.

As you stated it isn't directly a bad thing in the absence of misunderstanding but it can potentially be. Kind of like giving narcan just because its benign except for the one that time we slam an amp into someone and they start vomiting and throwing punches.

I also constantly see people obtain an O2 sat on a patient who has been out in the winter and immediately puts them on O2 when they get a low reading.

 

[EMT B]

I'm not sure BLS needs pulse-ox.

why?

 

[EpiEMS]

Exactly.

We walk a fine line in EMS for both paramedic and EMT level care with what we allow under-educated providers to perform.

As you stated it isn't directly a bad thing in the absence of misunderstanding but it can potentially be. Kind of like giving narcan just because its benign except for the one that time we slam an amp into someone and they start vomiting and throwing punches.

I also constantly see people obtain an O2 sat on a patient who has been out in the winter and immediately puts them on O2 when they get a low reading.

No argument from me on these points. I also tend to think that we get into this problem because of the lack of basic science, math, and reading skills of far too many providers. Not to mention the limited degree of education provided in EMS provider courses on the science rather than the skills.

 

[NYMedic828]

No argument from me on these points. I also tend to think that we get into this problem because of the lack of basic science, math, and reading skills of far too many providers. Not to mention the limited degree of education provided in EMS provider courses on the science rather than the skills.

To once again reference the pulse-ox issue, in regards to your math comment, I don't think many people actually understand percentages either...

Everyone seems to think you can exceed a saturation of 100% :blink:

 

[Christopher]

To once again reference the pulse-ox issue, in regards to your math comment, I don't think many people actually understand percentages either...

Everyone seems to think you can exceed a saturation of 100% :blink:

You can exceed a partial pressure of 100 mmHg, which is usually where the confusion exists.

 

[NYMedic828]

You can exceed a partial pressure of 100 mmHg, which is usually where the confusion exists.

Not with a non rebreather at sea level though...

 

[Christopher]

Not with a non rebreather at sea level though...

At sea level we're working with 760 mmHg of "air pressure", 20.95% of which is oxygen. So at sea level we'd have a partial pressure of 159 mmHg O2 on "room air". QED

I was referring to PaO2 when I said you could "exceed a partial pressure of 100 mmHg".

 

[abckidsmom]

To once again reference the pulse-ox issue, in regards to your math comment, I don't think many people actually understand percentages either...

Everyone seems to think you can exceed a saturation of 100% :blink:

Exceeding 100% only works on putting forth effort. According to some bosses I've had.

 

[systemet]

Not with a non rebreather at sea level though...

Actually, you can. Sea level is 760 mmHg. Room air, FiO2 ~ 0.2 gives you about 150mmHg of O2 in ambient air. This decreases slightly due to humidification in the upper airways. PaO2 tends to be around 100 mmHf due to V/Q mismatching and anatomic shunting (e.g. Thebesian veins, bronchial system return).

Lets say our NRB approaches FiO2 1.0, which it probably doesn't, we get an alveolar concentration of ~ 670 mmHg, allowing for humidification ( PH2O ~ 50 mmHg) and alveolar CO2 (~ 40 mmHg), we've now got a good gradient to markedly exceed a PaO2 of 100 mmHg. A rough guide for predicting PaO2 is that it shoild be something around 500 * FiO2. In fact we look at the PaO2 / FiO2 numbers for assigning patients to ALI / ARDS.

Of course, additional oxygen beyond SpO2 100% does little to improve arterial O2 content, as I'm sure you're aware, and saturated hemoglobin doesn't eliminate hypoxia if there's issues of stagnancy, e.g. regional ischemia, hypotension, or disorders of hemoglobin, e.g. anemia, CO or cellular poisoning.

 

[usalsfyre]

I agree with NYMedic, you categorically can not exceed an SpO2 of 100%. Won't happen.

PaO2 is a different matter however .

 

[mycrofft]

Pulse oximetry without instruction is like giving someone an oboe without lessons and tablature. Makes noise, maybe a little imitative music, but not properly played.

 

[Bullets]

I've the same problem where I'm at, but it's usually FD that has the pt on oxygen unnecessarily. Broadly, I can't see pulse ox for BLS being "bad" (or at least, have a deleterious effect on patient care) unless a BLS provider shows up to a CO poisoning and doesn't give O2 just because the "sats look good."

Wait, if a patient has good saturation and no complaints why would I give them oxygen? Just because their CO Alarm went off?

Also find me a meter that accurately measures CO levels...

 

[mycrofft]

Wait, if a patient has good saturation and no complaints why would I give them oxygen? Just because their CO Alarm went off?

Also find me a meter that accurately measures CO levels...

Especially after banging around in an ambulance in in a jump bag. Pulse Ox probes are notorious for being damaged.

 

[Tigger]

I have yet to meet a CNA that I liked.

I like my girlfriend's mom, but she's the only CNA I've ever liked.

What do you actually need humidified oxygen for? Odds are the patient doesn't need as much oxygen as the providers want to give them anyway. It may be beneficial for a trach'd patient but its really not necessary in our setting.

If the patient is on humidified oxygen, I try to keep them on it for comfort's sake.

IIRC correctly it was added to the "new" NREMT EMT curriculum.

 

[systemet]

I agree with NYMedic, you categorically can not exceed an SpO2 of 100%. Won't happen.

PaO2 is a different matter however .

ha ha ... I'm an :censored:. I jumped in and answered the question that no one was asking. My apologies to NYMedic, I thought that we were talking PaO2.

Reading comprehension for the win!

 

[EMT B]

Pulse oximetry without instruction is like giving someone an oboe without lessons and tablature. Makes noise, maybe a little imitative music, but not properly played.

how is it being used, and how should it be used?

 

[NYMedic828]

how is it being used, and how should it be used?

Its being used a number to document on a report and as a means of having definitive measure of whether the patient is perfusing adequately or not (which it is far from), and furthermore if they require oxygen/ventilation.

Instead, it takes a deeper understanding of

FiO2
PaO2
SpO2
Bohr Effect
Oxygen disassociation curve
Hypoxic conditions
Histotoxic conditions
Carbon Monoxide poisoning (and general hazmat realistically)
Factors affecting the probe itself and its accuracy.
How the device actually acquires a measurement
plethysmography


Theres just a lot more to it then 90% of the EMS providers out there grasp...


We also tend to use it more as a qualitative measurement than a quantitative one. It can and should be used as both. A pulse-oximeter is the only tool we carry to actually measure (statistically) whether or not our oxygen therapy has done anything and if we need to give more, less or none.

 

[VFlutter]

how is it being used, and how should it be used?

Many Basics are told something like "Spo2 must be above 93" and that is it. They are not taught anything beyond chasing a number. They do not understand what a pleth wave is, what is normal and what is just noise, latency in pulse ox readings, common causes for erroneous readings, etc. Also, the "NRB @ 15Lpm on everyone" mentality.

Some examples of lack of understanding (Not just EMTs, this happens in the hospital as well)

*Recording an spo2 of 82% on a patient with Raynauds with no signs of distress
* Hooking a patient up to a NC and switching to a NRB because sats don't come up in the first minute.
*Bumping up the flow on a COPD patient who is always 90% on 2L NC just to get to 93%

 

[EMT B]

FiO2
PaO2
SpO2
Bohr Effect
Oxygen disassociation curve
Hypoxic conditions
Histotoxic conditions
Carbon Monoxide poisoning (and general hazmat realistically)
Factors affecting the probe itself and its accuracy.
plethysmography

Theres just a lot more to it then 90% of the EMS providers out there grasp...

where might one go looking for more info on this stuff? (other than google..)