O2- supervisor's POV

[martor]

So a buddy of mine that works for a private forwarded me this email that he received from his supervisor (FYI small company mainly dialysis call) :

By now we should all know county protocols for administrating O2. Just today we had an EMT not give a pt O2 who was sating at 92%. Regardless of how you feel about it if the patient is sating at 92% at room air you give them Oxygen; 15 LPM via NRB. We are going to get flagged by county for that and if it happens a couple more times we will be flagged for investigation. Lets not forget the basics and perfect them. Every pt gets offered O2 from here on out if they refuse you write patient refuses O2. We are getting O2 cheaper now so everyone gets O2 why not? If you give them O2 you can write "Pt given O2 for comfort." If we need to get O2 every 3 days so be it. The one skill/ treatment we are allowed to administer so administer it. If you offer O2 and pt says they are ok you can say "I have to." Who is expert in BLS? Is it your pt? You can give them a cannula at 2LPM if you need to. Basically get belligerent with administering O2 to pts. You will never get chewed out for administering O2

I am have a pretty clear idea of how most of you will react, but the thing is what advice should I give him as far as handling this situation?
How would you handle the situation?

 

[Medic Tim]

O2 is a medication. With any medication there are indications for its administration. Giving a medication without an indication is a medication error. An spo2 reading of 92 means nothing by itself. There are numerous reasons why it will give a false high or low. Oxygen should be given based off of you evaluation/assessment. The spo2 is a small portion of that.....if you even have one.

I don't know about anyone else but a nrb is not comforting at all. They smell and it can be difficult to talk to the emt/medic. Same for a nasal with the addition of making your nose/throat dry.

 

[martor]

Thank you Medic Tim. I did inform him (yes it is somebody else, not a "my friend has a problem with..." situation) that an assessment is needed to administer anything.
I was aiming more toward the: How do you handle a supervisor that decided to push O2 "for comfort." I assume it is meant to increase the charge per transport.

 

[TomP]

So what about COPD pt's who rely on their hypoxic drive to breath and live in the low 90's? That email is ridiculous!

 

[Medic Tim]

My manager is a lower license than I am and I get questioned from time to time why I did something or didn't do something. What it comes down to is .... Was it in the best interest of the pt. There have been times I have had to get our CQI department and medical director involved( other times they reported me or flagged the call) as there was no way I was right. Most every time cqi and or the medical director agreed with what and why I did/didn't do something. This manager also expects us to follow protocols word for word with no deviation because it is the "doctors orders".

My advice would be to have him find out from the county if it is true they will be flagged for what he claimed and getting the medical director involved since ... You know.... YOu are giving the O2 under his license.

 

[Sublime]

So a buddy of mine that works for a private forwarded me this email that he received from his supervisor (FYI small company mainly dialysis call) :




I am have a pretty clear idea of how most of you will react, but the thing is what advice should I give him as far as handling this situation?
How would you handle the situation?

First things first this is a dialysis transfer service trying to make a buck in every way possible, I seriously doubt they care about the proper use of oxygen or patient care in general.

That supervisor sounds like a douche, probably wouldn't listen or believe you even if you provided him with solid undeniable evidence.

And last it is unfortunate but the way most ems schools teach is that everyone gets oxygen and that it's harmless. So this way of thinking is likely to be accepted by many.

 

[Aidey]

Out of curiosity what does the county protocol actually say? If the protocol is that stupid you can't really put all the blame on the supervisor.

 

[martor]

Thank you everybody. I will just send him a link to this thread so he will see the opinion of more experienced EMT.

It is a San Diego based company. No specific protocol on Oxygen administration. During my schooling, if you didn't administer O2 WHEN INDICATED then you failed the entire skill.

I would mind the email if it didnt include the "I have to.." and the "You will never get chewed out for administering O2." <_< *sigh*

 

[mycrofft]

Shhhhh enough.
Yeah, as above, what are the protocols?
And why does the "hypoxic drive" chestnut still emerge periodically?

 

[JPINFV]

Shhhhh enough.
Yeah, as above, what are the protocols?
And why does the "hypoxic drive" chestnut still emerge periodically?

I'm going to start teaching people to not give oxygen to smokers... you know, unless you want their cigarette to cause the oxygen to explode.

 

[mycrofft]

One way to turn that 7 min cigarette break into a thirty second one.

 

[Amberlamps916]

First things first this is a dialysis transfer service trying to make a buck in every way possible, I seriously doubt they care about the proper use of oxygen or patient care in general.

That supervisor sounds like a douche, probably wouldn't listen or believe you even if you provided him with solid undeniable evidence.

And last it is unfortunate but the way most ems schools teach is that everyone gets oxygen and that it's harmless. So this way of thinking is likely to be accepted by many.

Respect

 

[NYMedic828]

So what about COPD pt's who rely on their hypoxic drive to breath and live in the low 90's? That email is ridiculous!

I'm going to start teaching people to not give oxygen to smokers... you know, unless you want their cigarette to cause the oxygen to explode.

 

[medicdan]

OP, consider looking up and reviewing Medicare Fraud with your supervisor.

 

[martor]

OP, consider looking up and reviewing Medicare Fraud with your supervisor.

Again, not my supervisor. Thank you though.
I dont see a reason for fraud. The email said that in case pt refuses then to write it down.

 

[Akulahawk]

Again, not my supervisor. Thank you though.
I dont see a reason for fraud. The email said that in case pt refuses then to write it down.

So, they'll still end up billing medicare for something that isn't indicated. Medicare will probably end up denying that part of the claim. Once that starts happening, the company will likely do one of the following: eat the cost and still send medicare the claim for it in hopes of getting reimbursed occasionally or they'll send a bill to the patient in the hopes of getting paid for it.

 

[NYMedic828]

I'm far from informed on the matter but I believe here in NYC, administration of supplemental O2 is not a billable treatment. I don't think it has been for quite some time now in NY, primarily for the reasons in this thread.

I think BLS transports are actually flat rate. ALS im sure is itemized.

 

[DrParasite]

OP, consider looking up and reviewing Medicare Fraud with your supervisor.

BINGO!!!! if we put oxygen on everyone, we can bill the insurance company for it.

I know of one 911 service (that I never worked for) that used to do this back in the day... the director said "it's the only way we will make enough money to pay you well and afford nice trucks and equipment." very scary.

not only that, but it's a massive CYA decision: the company would rather be accused of putting oxygen on everyone who doesn't need it (with with less negative consequences), than not putting oxygen on someone who does need it (with more negative consequences). Shows how competent their EMS staff are.

 

[Clare]

the company would rather be accused of putting oxygen on everyone who doesn't need it (with with less negative consequences), than not putting oxygen on someone who does need it (with more negative consequences). Shows how competent their EMS staff are.

In my experience at least, it is far easier to determine between who needs oxygen and who does not. The patient who needs oxygen will be fairly obvious, whereas the patient who will be harmed by its administration is, up until recently, less obvious.

It was once explained to me that ischaemia and hypoxia are two different things and then it all made sense seeing as how there is a big push on to specifically reduce the amount of un-necessary oxygen given to patients who have stroke or myocardial infarction or myocardial ischaemia as well as reducing the overall amount of oxygen given that was not needed.

I cannot speak for how things used to be so I have nothing to compare it to, but in my time on ambulance oxygen is used quite conservatively and in very low doses; 2-3 lpm on nasal prongs.

 

[Chupathangy]

Martor, I almost started laughing uncontrollably when I read this post because I work for that company and I remember VERY well when I got that email. That caused a lot of unrest among the EMTs and ironically one EMT did get in quite a bit of trouble over it at the ED. And no, our Protocols do not state that we must place every low sating pt on high flow. Protocol says "O2 and/or ventilate prn" Sp02 monitoring is fairly new to San Diego EMTs and I wouldnt be surprised if they eventually remove it due to occurrences like this.