O2 Almost killed my patient.

[NPO]

We were dispatched to an acute care facility for an 80-something year-old male complaint of SOB. Upon arrival he was upright in bed with no current complaints. He was sat-ing 98-99% on 1lpm O2. While I took a report from the nurse my partner grabbed an updates set of vitals. All within normal limits. A short time later the patient complained of SOB and sure enough o2 sat was down to 93% and dropping. I consulted with the nurse out of professional curtesy, as it was still his patient. He told me under no circumstances should the oxygen be turned up to more than 1lpm due to the patients COPD, and that much O2 could kill him.

Now, I assume the nurse has more education than I do at my present point in my career, but can 2lpm really kill a COPD patient?

I ordered an RT from the facility for the patient and he received a breathing treatment before being transported.

I'm not an "everyone needs O2" kinda guy. In fact fewer than half of my patients present with a reason for oxygen, but this guy was symptomatic.

 

[AnthonyTheEmt]

If your patient is complaining of sob, and his sats are low, you give them oxygen regardless of if they have COPD. High flow oxygen over a long period hurts patients with COPD, but not short term exposure to it. but if they're complaining of sob, give them o's

 

[joegrizzly]

Look up hypoxic drive in COPD patients. Basically what the nurse was getting at is that in copd patients, the stimulus to breath is reversed to low levels of o2. Even with this cool tid bit of physiology, o2 is never witheld from a patient in EMS. Good call on the RT in my book, granted I'm just an EMT-Bandaid; but I do not believe 2 lpm of or greater o2 in the short term would be an extreme threat to a patient. Granted our guide lines in CA is to never withold o2, but I would love to hear a respone from a RT or medic on the issue of transporting a patient with a Hx of copd with hypoxic drive.

 

[NPO]

I did in fact ask the RT. She chuckled and said. "I've been doing this a while and I've never seen that happen."

Here in Cali I can't monitor o2 sat as a basic because I'm not educated enough to read numbers apparently. So I made for darn sure he was good to go before loading him up.

 

[JPINFV]

Here in Cali I can't monitor o2 sat as a basic because I'm not educated enough to read numbers apparently.

Reading and interpreting are two different things. On that note, "withholding" and "not indicated" are also two different things, and as long as EMTs keep equating the two I can't really argue that they should be interpreting a percent saturation.

 

[DesertMedic66]

I did in fact ask the RT. She chuckled and said. "I've been doing this a while and I've never seen that happen."

Here in Cali I can't monitor o2 sat as a basic because I'm not educated enough to read numbers apparently. So I made for darn sure he was good to go before loading him up.

A lot more counties in SoCal are allowing EMTs to monitor SpO2. I'm in a super restrictive county and we can do SpO2.

 

[VFlutter]

Here in Cali I can't monitor o2 sat as a basic because I'm not educated enough to read numbers apparently

Well to be honest you are most likely not educated enough to effectively monitor SpO2. SpO2 is more than just reading a number. Not that I think it shouldn't be allowed but I can see the argument.

 

[mycrofft]

Had such a pt before, wearing a MASK, not a nasal cannula. Cranking it to 6 lpm made quite a difference, they gave us the pt because they thought she was dying...and she was. Iatrogenically.

SOMe people still teach about the COPD/drive boogeyman. Maybe the MD wrote an order?

DO MD orders ever get relayed to transport techs, or just generic instructionsf rom the facility which might hopefully embody the MD's order?

 

[Veneficus]

SOMe people still teach about the COPD/drive boogeyman. Maybe the MD wrote an order?

I think it is like many things in EMS, while true, it is exceedingly rare, and somebody once saw it, had a cousin who saw it, heard that a long ago retired paramedic saw it, etc, and now it is given more ugency than it really deserves.

As you know, I hunted down this rare pathology on purpose, to see if it does exist, and I was shown it. A long term care facility is the most likely place EMS will see this. But it is still very rare.

I would imagine that the 1lpm order was written by a MD based on ABG and normal resting requirements on this patient.

I would also think (or at least I want to believe) that the MD may have believed that if the patient needed an increase in O2 from this 1 LPM baseline, that the patient may need to be evaluated for either an acute exacerbation or another acute pathology like pneumonia.

I cannot imagine she wrote anywhere on the chart not to increase o2 past 1lpm because the patient would die.

DO MD orders ever get relayed to transport techs, or just generic instructionsf rom the facility which might hopefully embody the MD's order?

Even if they are relayed, I would suspect most EMS providers would not follow them and mention some line about them not being an emergency doctor, medical control, etc.

Usually, you get a brief verbal report/instructions, and a really big stack of paperwork that would take ages to sort through. Some with outdated information.

 

[mycrofft]

"Even if they are relayed, I would suspect most EMS providers would not follow them and mention some line about them not being an emergency doctor, medical control, etc"

Holy CR^P.

I always liked the line "Well, they're in MY vehicle now and I have to treat them as I see fit".

If I'm on the litter, I'm bailing at that point.

 

[systemet]

Even with this cool tid bit of physiology, o2 is never witheld from a patient in EMS.

I routinely withhold oxygen from my altered mental status patients who have good saturation. I routintely withhold oxygen from my ACS patients, and my STEMIs who have a saturation of > 92%, and lack significant work or breathing or dyspnea, etc.

A lot of my patients don't get O2.

Am I awesome? Yes, probably.

 

[Akulahawk]

I routinely withhold oxygen from my altered mental status patients who have good saturation. I routintely withhold oxygen from my ACS patients, and my STEMIs who have a saturation of > 92%, and lack significant work or breathing or dyspnea, etc.

A lot of my patients don't get O2.

Am I awesome? Yes, probably.

No, you are not withholding oxygen from your patients. You are not giving oxygen because it is not indicated. If you are withholding oxygen from your patients, that would mean that oxygen is indicated and you are not giving it. One of those means that you are utilizing good judgment, the other means that you clearly are not.

 

[Aidey]

No, you are not withholding oxygen from your patients. You are not giving oxygen because it is not indicated. If you are withholding oxygen from your patients, that would mean that oxygen is indicated and you are not giving it. One of those means that you are utilizing good judgment, the other means that you clearly are not.

If he did that I think it would mean he is asphyxiating all of them...21% O2 FTW! :lol::lol::lol:

 

[Akulahawk]

If he did that I think it would mean he is asphyxiating all of them...21% O2 FTW! :lol::lol::lol:

Yes, that would be the ultimate withholding oxygen from your patients…:blink::blink::blink:

I think, of course, I think what he really means is that he is withholding supplemental oxygen. But I think we already knew that.

 

[Aidey]

Just because I'm a CL doesn't meant I can't be a smart arse too.

 

[systemet]

I think, of course, I think what he really means is that he is withholding supplemental oxygen. But I think we already knew that.

That is, indeed, what this poster meant. Aside from a couple of quickly recognised and corrected esophageal intubations, I have generally managed not to withhold too much of that 21%.

 

[joegrizzly]

I routinely withhold oxygen from my altered mental status patients who have good saturation. I routintely withhold oxygen from my ACS patients, and my STEMIs (Our STEMI protical is NRB @ 15lpm, but hey, thats my county) who have a saturation of > 92%, and lack significant work or breathing or dyspnea, etc.

A lot of my patients don't get O2.

Am I awesome? Yes, probably.

Well look at you life saver, you saver of lives you. My statement applies to how as a whole and by the book, EMS is taught to never withhold o2 from a patient. I should have added it earlier but I was hoping the magical words of "as indicated" would have fallen some where in the department of common sense. I did not mean start bagging and jam the o2 bottle down a patients throat for every illness or fall. If your patient is throwing good sats and it is not in your protical, by all means withhold o2 and eat your heart out kid. Thank you for pointing out my mistake and allowing me to correct myself.

 

[systemet]

Well look at you life saver, you saver of lives you.

Thanks!

My statement applies to how as a whole and by the book, EMS is taught to never withhold o2 from a patient.

And mine reflected my general irritation at the amounts of times I see people putting oxygen on perfectly healthy people for no apparent reason other than some other perpetuated institutional superstition.

Maybe you do this, maybe you don't. And if you don't, great. If I came across as arrogant or confrontational, then my apologies, it wasn't my intent.

I should have added it earlier but I was hoping the magical words of "as indicated" would have fallen some where in the department of common sense.

You'd be surprised how often people seem to administer oxygen without first engaging common sense.

Thank you for pointing out my mistake and allowing me to correct myself.

For what it's worth, I wasn't trying to start an argument. All the best.

 

[systemet]

In the spirit of having a discussion, versus the argument that this is, unfortunately, likely to become:

I see something bolded about giving a NRB @ 15 LPM to everyone with a STEMI up there -- are you sure that's a good idea?

 

[Aidey]

I don't think you can claim that is "as a whole and by the book" since the whole high flow O2 for everyone has been going out the window for a while now. Titrating O2 to SpO2 has been increasingly common for a while. Unfortunately there are still enough "15 lpm O2 via NRB for everyone" people out that it is necessary to specify what you mean.