Forgot oxygen

[daughteroftheking]

I recently had a 63 year old male complaining of dizziness and nausea. Bp was found to be 190/110 and pulse 83. The pulse ox did not work, which is probably why I forgot the o2. Was this critical? I rechecked bp en route and it was 170/100 (a student took it the first time) bgl was 115.
It was pretty hot in his office when we got there and he said he always had problems with heat. He said he also ate salmon that day which always makes him feel sick. Only medical history was hypertension which was managed by meds - he took his meds that day as well.
Any thoughts on the benefits of o2 in this situation or possible diagnosis?

 

[Veneficus]

he should probably take his meds.

 

[daughteroftheking]

Sorry...I didn't make that clear. He took his meds the day of the call.

 

[Martyn]

I recently had a 63 year old male complaining of dizziness and nausea. Bp was found to be 190/110 and pulse 83. The pulse ox did not work, which is probably why I forgot the o2. Was this critical? I rechecked bp en route and it was 170/100 (a student took it the first time) bgl was 115.
It was pretty hot in his office when we got there and he said he always had problems with heat. He said he also ate salmon that day which always makes him feel sick. Only medical history was hypertension which was managed by meds - he took his meds that day as well.
Any thoughts on the benefits of o2 in this situation or possible diagnosis?

Sorry, but the why would the pulse ox not working make you forget the oxygen?

 

[Veneficus]

There is not enough info to reasonably form a diagnosis, but with a BP that high, I am suspect if he really is taking his meds as directed or if his BP is "controlled" on his current medication regiment.

vascular occlusion, hemorrhage, HTN crisis, hyperthyroid, and neoplastic disease immediately come to mind. (in no particular order)

I don't think the lack of oxygen was a critical event.

 

[Sasha]

I recently had a 63 year old male complaining of dizziness and nausea. Bp was found to be 190/110 and pulse 83. The pulse ox did not work, which is probably why I forgot the o2. Was this critical? I rechecked bp en route and it was 170/100 (a student took it the first time) bgl was 115.
It was pretty hot in his office when we got there and he said he always had problems with heat. He said he also ate salmon that day which always makes him feel sick. Only medical history was hypertension which was managed by meds - he took his meds that day as well.
Any thoughts on the benefits of o2 in this situation or possible diagnosis?

What about this call makes you feel that oxygen was indicated?

 

[NYMedic828]

We need to stop teaching people that every last patient needs oxygen...

With hypertension and supposed compliance with his meds, something is off. Either he did not take them or its time to see his primary care physician.

Excessive heat makes a lot of people dizzy/nauseated. Does not mean they need o2. Its not a respiratory problem and oxygen makes some people more nauseous.

He ate salmon, which always makes him feel sick... Seriously? I know it makes me feel sick every time, but hey im gonna eat it anyway.

With my limited knowledge compared to a guy like ven, id say he didn't take his meds and he feels sick because of the salmon/heat.

 

[EMT John]

We need to stop teaching people that every last patient needs oxygen...

With hypertension and supposed compliance with his meds, something is off. Either he did not take them or its time to see his primary care physician.

Excessive heat makes a lot of people dizzy/nauseated. Does not mean they need o2. Its not a respiratory problem and oxygen makes some people more nauseous.

He ate salmon, which always makes him feel sick... Seriously? I know it makes me feel sick every time, but hey im gonna eat it anyway.

With my limited knowledge compared to a guy like ven, id say he didn't take his meds and he feels sick because of the salmon/heat.

Agreed. +1

Salmon makes me sick. I think I'm going to go have some salmon. :rofl:

 

[Martyn]

We need to stop teaching people that every last patient needs oxygen...

With hypertension and supposed compliance with his meds, something is off. Either he did not take them or its time to see his primary care physician.

Excessive heat makes a lot of people dizzy/nauseated. Does not mean they need o2. Its not a respiratory problem and oxygen makes some people more nauseous.

He ate salmon, which always makes him feel sick... Seriously? I know it makes me feel sick every time, but hey im gonna eat it anyway.

With my limited knowledge compared to a guy like ven, id say he didn't take his meds and he feels sick because of the salmon/heat.

I totally agree with this, however, our protocols state:

Cardiovascular Emergencies
[FONT=Arial,Arial][FONT=Arial,Arial]Stroke, CVA, TIA, Hypertensive Crisis [/FONT]
[FONT=Arial,Arial]1. Size up the scene. [/FONT]
[FONT=Arial,Arial]2. Formulate a General Impression. b. Begin oxygen administration (see Airway Management Protocol). [/FONT]
[FONT=Arial,Arial]3. Assess Mental Status (AVPU). [/FONT]
[FONT=Arial,Arial]4. Assess Airway and Breathing. [/FONT]
[FONT=Arial,Arial]a. Begin oxygen administration or ventilation (see Airway Management Protocol). [/FONT]
[FONT=Arial,Arial]5. Assess Circulation. [/FONT]
[FONT=Arial,Arial]a. Begin oxygen administration (see Airway Management Protocol). [/FONT]
[FONT=Arial,Arial]6. Assess Vital Signs [/FONT]
[FONT=Arial,Arial]7. Perform Blood Sugar Test. [/FONT]
[FONT=Arial,Arial]8. Determine AMPLE. [/FONT]
[FONT=Arial,Arial]a. If patient is Hypo/Hypertensive (see Diabetic Emergency Protocol) [/FONT]
[FONT=Arial,Arial]9. Determine need for ALS/Priority transport. [/FONT]
[FONT=Arial,Arial]a. Any patient with signs/symptoms of stroke, CVA, TIA, or hypertensive crisis is considered to be an ALS preferred transport. [/FONT]
[FONT=Arial,Arial]10. Begin transport, or assist ALS if needed. [/FONT]
[/FONT]

 

[NYMedic828]

I totally agree with this, however, our protocols state:

Unfortunately in almost all areas BLS protocols don't allow for much leniency.

Our protocls state somewhere "these are guidelines not meant to replace good clinical judgement"

As a provider, if you feel treatment is not warranted or could even be harmful under the protocol you are supposed to follow, don't do it. But, make sure you have the knowledge to justify your actions should you come into question.

 

[TatuICU]

HTN meds (especially B blockers)+ excessive heat + fish= anyone nauseated. Excessive heat can place severe stress on your body and that stress can raise your blood pressure. Your body is simply not as efficient a machine at certain temps which also places greater stress on the heart.

Protocol people may say something to you I guess, I see someone has already posted the monkey sheet for some reason as if it has any bearing on this particular pt.

No difficulty breathing, no evidence of hypoxia (labored breathing, skin signs, AMS, etc). Don't worry about it dude. No biggie. You won't forget to assess for the need next time because you know you forgot this time. Every day you will think you screwed up or will have truly screwed something up and every next day you'll be better for it. That's what being a good provider is. Self examination, experience and continuing education.

 

[NYMedic828]

You won't forget to assess for the need next time because you know you forgot this time. Every day you will think you screwed up or will have truly screwed something up and every next day you'll be better for it. That's what being a good provider is. Self examination, experience and continuing education.

+1 Well said.

Id rather a provider who is willing to admit they did wrong and learn from it than a provider who thinks they did right, all the time.

 

[TatuICU]

I totally agree with this, however, our protocols state:

protocols are guidelines which health care providers use in addition to their critical thinking skills and situational awareness to render to the best possible care to their patients given the situation.

If your protocols state for EMT-Bs to c-collar and LSB a fall from standing position (as a lot that I've seen do) in a pt with CHF who simply can't breathe in a supine position what would you do then?

Guidelines my friend, guidelines.

 

[Christopher]

I totally agree with this, however, our protocols state:

If your patient did not have a functional nose and your protocols state to place a nasal cannula on them if their SpO2 was 92-94%, would you be in trouble for not using a nasal cannula?

If your patient did not have a right arm and your back pain protocol required a blood pressure in both arms, would you be in trouble for not acquiring a right sided BP?

If your protocol insisted you punch old women on Tuesdays........well, we probably would follow that one without question.

Please, please, please do not replace sound clinical judgement with blind adherence to protocols.

And being an EMT-Basic does not mean you can't use clinical judgement to supplement protocol!

Pulse oximeters are not a measure of oxygenation, ventilation, respiration, or perfusion but rather a measure of bound hemoglobin in the peripheral capillaries (they don't even directly measure bound oxygen).

Thus the quantitative value can be used as an indirect measurement of oxygenation IF AND ONLY IF it correlates with your physical examination and your clinical judgement.

If your physical exam and clinical judgement show the patient does not require supplemental oxygen...you shouldn't place them on supplemental oxygen.

Use SpO2 as a trending tool for oxygen therapy rather than a go/no-go for oxygen. You'll be doing your patients a great service.

Besides, the number of patients who actually need oxygen from EMS is shrinking as more and more studies come out showing the potential harm from hyperoxemia.

Did you miss anything or mess anything up? Absolutely not.

You were simply using clinical judgement without giving yourself credit!

 

[Martyn]

Just to put away the can of worms I opened, I agree, I agree, I agree...got it? However, my original question was to do with the OP's comment:

The pulse ox did not work, which is probably why I forgot the o2.

My question is just because the pulse ox was forgotten/not used, why did this make the OP 'not' use O²? Does this mean that even with cyanosis present if the pulse ox is not working you are still gonna 'forget' O²?

 

[daughteroftheking]

Reply

Sorry! I wasn't too clear on forgetting the oxygen. In a non-respiratory emergency, I tend to judge how much o2 is needed based on pulse ox reading. There was no immediate indication for o2 on this one
I now know that I should rely more on overall patient condition. I learned a lot from this call

 

[JPINFV]

I totally agree with this, however, our protocols state:

By chance, are your protocols online, and if so can you link them?

 

[JPINFV]

protocols are guidelines which health care providers use in addition to their critical thinking skills and situational awareness to render to the best possible care to their patients given the situation.

If your protocols state for EMT-Bs to c-collar and LSB a fall from standing position (as a lot that I've seen do) in a pt with CHF who simply can't breathe in a supine position what would you do then?

Guidelines my friend, guidelines.

Depends. I can post links to protocols that requires any deviations from the protocol to require a medical control consult. Of course this is a place where the "paramedics" are supposed to use the machine interp on 12 leads and call medical control on STEMIs since it's medical control's job to tell them to go to a hospital with a cath lab.

 

[TatuICU]

Depends. I can post links to protocols that requires any deviations from the protocol to require a medical control consult. Of course this is a place where the "paramedics" are supposed to use the machine interp on 12 leads and call medical control on STEMIs since it's medical control's job to tell them to go to a hospital with a cath lab.

Sounds like a place with very little respect for their employees.

 

[JPINFV]

Sounds like a place with very little respect for their employees.

It's a county wide protocol. It's funny because on one hand there's virtually no written BLS protocols (911 calls are always get paramedics, but since there are no private company paramedics most SNF calls are BLS) and some of their other protocols are relatively liberal (i.e. restraint policy, especially since a neighboring county requires all patients on a hold to be restrained). Yet other parts of the protocol are written in a very cook book manner, even with the current rewrite that loosened the wording a bit.