I did something dumb

[Righteous]

I had a patient with an O2 sat ranging from 82 to 89. I didn't give him any o2, very stupid. At the time my reasoning was

That he was talking to me.
That his respirations were 18
I asked him if he felt short of breath and he said no.

Looking back at the vitals after the transport it finally dawned on me.
My last place of work was laid back and I picked up some bad habits. Its no excuse though because I passed. National registry and I'm an emt I. I know that patients get o2 at any sat below 95. Hell I was thinking it as I was talking to him.

That mistake will never happen again. Guess I let non emergency transport make me lax. I just had to get this off my chest. Lol the look on the faces of whoever reads my pcr. This has to be onef my dumber emt moments.

 

[Sasha]

Don't depend on the O2 sat to tell you how your patient is doing. If breathing is unlabored, coloring is good, mental status is good, patient's not complaining of SOB I don't necessarily take the SpO2 to heart. It CAN be wrong. I have gotten readings in the low 80s because of cold hands or nail polish.

You can always OFFER O2, but if a patient is not SOB they are likely not to take it.

Was he obese? google Pickwickian syndrome/obesity hypoventilation syndrome, very interesting stuff. Normal for them to have low SpO2!

 

[Tincanfireman]

That he was talking to me.
That his respirations were 18
I asked him if he felt short of breath and he said no.

Treat the patient, not the box; there's a zillion reasons to explain an indicated low SPO2, and for all the reasons you listed above there's a better than even chance he was doing just fine without it. That said, it's good that you critique yourself and look for ways to improve your patient care. Kudos to you for that!

 

[VentMedic]

However, when a patient's SpO2 is very low for them, they may not realize how short of breath they are. You literally become altered to where you fail to recognize how sick you are and you may even appear to oriented to the standard questions. I see patients like this very often and it is a battle to get them to put their O2 back on. Once they do, no problem as they return to their true "normal" state.

There is also the term hypoxic euphoria that you might hear occasionally but it has varying degrees and implications depending on different situations.

If the SpO2 monitor does state a low reading one should do a very thorough assessment and give them some O2 to see if there is any change in their current mentation, color or other signs and symptoms.

If you document that low SpO2, you will also have to carefully document what action you took or why you didn't.

Also, what was the chief complaint of the call?

I let non emergency transport make me lax.

Too many fail to see the importance of non emergency transport and blow off the opportunities it holds for perfecting assessments. EMTs are sold that only 911 with the cool calls matter. Thus, those EMTs will suck at those calls as well. It is good you realize this now and you can go back and review what you learned in EMT and start to advance your education.

 

[MrBrown]

SPO2 is helpful, but not always accurate.

 

[Righteous]

Reason for call pt transport from nursing home to hospital to declott afv(I think it was afv?)

Pt history, blindness, dialysis, diabetic, hypertensive, epileptic

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I forgot to mention the emt at the hospital(I think they are just calledtechs) was mean muggin me pretty hard.

 

[MrBrown]

I forgot to mention the emt at the hospital(I think they are just calledtechs) was mean muggin me pretty hard.

He probably needs a schwaking. Treat the patient, not the machine.

There is nothing magic about oxygen and IV fluid, two treatments most ambo's give to patients who do not require them and in quantities that are supratheraputic or supraphysiological.

Infact, both in supraphysiologic quantities or given when not indicated can be harmful, even fatal in the wrong group of patients (IV fluid for a hypotensive cardiogenic edema for example).

 

[VentMedic]

He probably needs a schwaking. Treat the patient, not the machine.

There are exceptions. If one does not fully understand the disease process to be certain that number is or is not correct, one should error on the side of caution. It is easier to remove an oxygen device than it is to replace brain cells.

There is nothing magic about oxygen and IV fluid,

But yet both can be used to save a life.

Infact, both in supraphysiologic quantities or given when not indicated can be harmful, even fatal in the wrong group of patients (IV fluid for a hypotensive cardiogenic edema for example).

Let's not give this new EMT the wrong idea that he will kill someone by giving oxygen especially for a transport less than a few hours.

 

[MrBrown]

Point well taken; I did orignally write in that saying harmful or fatal might be a bit of a stretch.

Interestingly, research out of the UK seems to show that COPD patients who are delivered to ED by ambo's even with short transport times are more often than not hyperoxic and hypocapenic.

 

[Righteous]

Thanks for all the feed back. At the risk of sounding dumb, when is o2 contraindicated.

 

[MrBrown]

Thanks for all the feed back. At the risk of sounding dumb, when is o2 contraindicated.

The only truly dumb question is the question not asked.

Well, I can't think of when oxygen is absoutely contraindicated but VM might know ... paging VentMedic, paging VentMedic

There is a high degree of subjectivity around when oxygen is relatively contraindicated depending on your intepretation of various amounts of evidence (some more dubious than others), your education and the way your medical direction/medical oversight process works.

As I said before, there is nothing "magic" about oxygen and in times gone by (and still today, although to a lesser degree) it's enjoyed magic elixor-cure-all status like something out of a turn of the century drug store ad.

This really means it does not necessarily provide benefit (and in some patients may be harmful esp if allowed to cause hyperoxia or hypocapenia, such as in COPD patients). While you should not take this as an indication not to give a patient oxygen it just means that like anything, the good ole' ambo trick of "more is better!" does not necessarily ring true.

Good clinical judgement is required; for example you mention a patient who has an SPO2 of 89% well the SPO2 doesn't measure more important indicators of oxygen saturation at the tissue level so you need to look at your patient and use your brain; are they struggling to breathe? do they look cyanotic? are they using accessory muscles to breathe? what are thier breath sounds? how many words per breath can they speak? etc etc

Your best bet is to follow the protocols your medical director has authorised.

 

[VentMedic]

Point well taken; I did orignally write in that saying harmful or fatal might be a bit of a stretch.

Interestingly, research out of the UK seems to show that COPD patients who are delivered to ED by ambo's even with short transport times are more often than not hyperoxic and hypocapenic.

The hypoxic drive has been well discussed and there are theories that have been around for at least 2 decades as to why the CO2 may climb. As well, only about 5% of all COPD patients are even CO2 retainers by the definition mentioned in EMT books. Should oxygen be withheld from all COPD patients incase one of them happens to be part of that 5%? Would you even withhold O2 from one of the 5% if they were short of breath, their oxygenation level is in question or they may have a problem that hinders delivery at the tissue level such as sepsis?

 

[VentMedic]

Well, I can't think of when oxygen is absoutely contraindicated but VM might know ... paging VentMedic, paging VentMedic

Infants who have cyanotic heart defects with ductal dependent lesions.

Even at that, they may get some oxygen for extremely low SpO2 (<70%) once the meds (PGE1) are initiated to keep the PDA open. If the SpO2 gets too high, we will reduce them to 16% Oxygen by mixing in more Nitrogen.

 

[MrBrown]

The hypoxic drive has been well discussed and there are theories that have been around for at least 2 decades as to why the CO2 may climb. As well, only about 5% of all COPD patients are even CO2 retainers by the definition mentioned in EMT books. Should oxygen be withheld from all COPD patients incase one of them happens to be part of that 5%? Would you even withhold O2 from one of the 5% if they were short of breath, their oxygenation level is in question or they may have a problem that hinders delivery at the tissue level such as sepsis?

No not at all. Most COPD patients are being issued with a little brightly coloured card from thier eh .... oxygenologist? no that's not right, um, lets go with pulmonologist, that will detail the specific flow rate and SPO2 they have been found to respond best to.

 

[VentMedic]

No not at all. Most COPD patients are being issued with a little brightly coloured card from thier eh .... oxygenologist? no that's not right, um, lets go with pulmonologist, that will detail the specific flow rate and SPO2 they have been found to respond best to.

Okay, let's take the stereotype COPD patient as an example and you mentioned an SpO2 of 89% earlier.

The SpO2 of 89% may stay the same but depending on what is going on with the patient at that time that causes the Oxyhemoglobin Curve to shift will affect the PaO2.

http://www.ccmtutorials.com/rs/oxygen/page06.htm

That script given by the doctor is for the patient who is "normal" for his condition since CMS will not allow us to qualify the patient for home O2 in an acute disease state. That would be too easy.

Good site:
http://www.ccmtutorials.com/rs/oxygen/index.htm

 

[rhan101277]

Blood pressure can also affect SPO2, also the person being hypothermic or hyperthermic can effect the way hemoglobin binds to oxygen.

 

[46Young]

Thanks for all the feed back. At the risk of sounding dumb, when is o2 contraindicated.

Perhaps (disclaimer ) in the occurence of carpal pedal spasm in an otherwise healthy individual with a Hx of anxiety and panic attacks and presenting as such, or someone with an onset of hyperventilation caused by emotional stress, with no other significant medical findings evident.

 

[CAOX3]

Lung sounds?

 

[VentMedic]

Perhaps (disclaimer ) in the occurence of carpal pedal spasm in an otherwise healthy individual with a Hx of anxiety and panic attacks and presenting as such, or someone with an onset of hyperventilation caused by emotional stress, with no other significant medical findings evident.

Why?

Ventilation and oxygenation are very different. For hyperventilation you would need a reduction in PaCO2 which is difficult to determine in the field. Even with ETCO2 you may have to look for causes for the gradient but you would not know the PaCO2. Tachypnea would be a more appropriate term and there can be many causes including hypoxia. Respiratory distressed patients, especially children, will breathe rapidly in an attempt to lower their rising PaCO2 or increase their decreased PaO2. DKA patients will be tachypneic and will actually be "hyperventilating" by lowering their PaCO2 to increase the pH. A patient with a pulmonary emboli can also hyperventilate with some decrease in PaCO2 while trying to maintain their PaO2. The same for people with a spontaneous pneumothorax which may not always be the classic totally decreased breath sounds on one side. Tall skinny runners are prone to this happening. Septic will be tachyneic and will try to lower their PaCO2 while their body's pH is dropping. I would not consider withholding O2 on any of these patients unless all medical causes are eliminated as a possibility. Even emotional events can lead to a serious medical problem either neuro or cardiac with an increase in BP.

As well, some people when emotionally stressed will breathe rapidly but very shallow, thus they actually "hypoventilate" or reduce their CO2 elimination ability.

 

[MrBrown]

Important things I have learnt which may of benefit here

Oxygenation and ventillation are two totally seperate physiologic processes

The amount of oxygen inspired does not equal the amount that will enter the bloodstream

There is nothing magic about oxygen meaning it is not clinically beneficial in every patient

Very high flows (15lpm for everybody) is also not required in every patient