O2's Place in the Initial Assessment

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Big Poke

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Time to vent on a long standing pet peeve of mine...

It's the fact that the dicision to apply O2 in every NREMT/Non-NREMT assessment skills sheet falls in the "Breathing" category of the intitial assessment, and making a decision at that point is pass/fail criteria. The problem with this seems obvious, yet it has remained there as long as I've been in EMS. It ignores circulatory factors and vital signs as a means to determine hypoxia and poor perfusion. Here's a skills scenario you might get from a proctor:

PT is alert. C/C of severe lower abd pain. Respiratory indicators are WNL. PT denies difficulty breathing.

So at this point you know your guy is with it, he has a non-respiratory chief complaint, and he's having no diffculty breating. Would you give O2? No, of course not. But then you get to the C part of the ABC's and this is what you find:

Skin signs cool/pale/clammy. Radial pulses weak/thready. Tachycardic.

So he's shocky, possibly hinting at a GI bleed/sepsis patient, which indicates high flow O2. But per NREMT you just failed for choosing not to apply O2 when they wanted it addressed in the B section. Am I the only one who thinks it would be far more appropriate for O2 consideration to be placed at the end of your inital assessment, not right in the middle of it?
 
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Big Poke said:
Time to vent on a long standing pet peeve of mine...

It's the fact that the dicision to apply O2 in every NREMT/Non-NREMT assessment skills sheet falls in the "Breathing" category of the intitial assessment, and making a decision at that point is pass/fail criteria. The problem with this seems obvious, yet it has remained there as long as I've been in EMS. It ignores circulatory factors and vital signs as a means to determine hypoxia and poor perfusion. Here's a skills scenario you might get from a proctor:

PT is alert. C/C of severe lower abd pain. Respiratory indicators are WNL. PT denies difficulty breathing.

So at this point you know your guy is with it, he has a non-respiratory chief complaint, and he's having no diffculty breating. Would you give O2? No, of course not. But then you get to the C part of the ABC's and this is what you find:

Skin signs cool/pale/clammy. Radial pulses weak/thready. Tachycardic.

So he's shocky, possibly hinting at a GI bleed/sepsis patient, which indicates high flow O2. But per NREMT you just failed for choosing not to apply O2 when they wanted it addressed in the B section. Am I the only one who thinks it would be far more appropriate for O2 consideration to be placed at the end of your inital assessment, not right in the middle of it?
Click to expand...

Cool/pale/clammy with weak "thready" pulses doesn't necessitate the need for oxygen either. Cool pale and clammy skin is not a definitive sign of hypoxia (IE: hypoglycemia). Many people couldn't tell you a thready pulse from a weak pulse from a baseline for that patient. It's hard to feel a pulse on my grandmother does that mean she is chronically in shock?



Fact is oxygen administration isn't the problem, the entire methodology of the NREMT and EMS vocational programs country wide are the problem. They need to be abolished and replaced by practical educational programs.
 
You're definitely touching on the bigger problem here. What if with all of those signs given, you get to the vitals section (waaaay at the bottom of the assessment) and you find out they're sat'ing at 100% on room air? The majority of research points towards O2 still not being indicated. But NREMT would probably consider the use of a cannula fail criteria at that point.

I do agree that circulatory signs are not concrete indicators of hypoxia. But they CAN be in certain cases, which means they still need to be factored in the equation of giving oxygen. Your grandma might have a baseline that would appear "shocky" to the untrained EMS worker but, generally speaking, a healthy 25 y/o should never present like that unless somethings off.

What the cirriculum is teaching is that it never matters, O2 therapy can always be determined after merely assessing the patients breathing.
 
What if you just treated the patient based on clinical knowledge and experience and your own personal methodology of treatment that worked for both you and the patient effectively?

The fact is, in every EMS program you do what the book and state wants you to do to pass and then the next thing you do is throw all of that out the window.
 
Agree with the above.

Yea, it makes little sense in THIS scenario to apply O2 mid ABC assessment with the lack of obvious respiratory issues and before you get a baseline pulse-ox for trending. That's why the ED RN usually takes off 15L NRB off pretty much as soon as you walk in unless the patient clearly won't tolerate it.

And from the scenario provided, there still isn't a clear indicator that boosting their FiO2 is going to solve a darned thing.

EMS is high flow O for everything because it doesn't *usually* hurt anything... except for the free radicals and potentially hiding a progressing V/Q problem until it is critical. The latter is my biggest issue... in EMS protocols the early Oxygen intervention can preclude the discovery of an underlying pathology... and then it gets worse... and it becomes crisis time. I guess if it is 5 minutes to the ED door, that's not a problem for the patient most of the time, but it isn't 5 minutes a lot of places.
 
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It sounds like my original post may have been misleading. Mentioning the need for "high flow O2" after the circulatory findings is not my personnel feeling, it's what is typical of NREMT's expectation of treatment.

From a real-world personal standpoint, I'm very against the idea of giving certain treatment only because its the norm, or it "doesn't hurt anything". Like I said before, it ties into the bigger picture of all of this, which is the lack of evidence/result based medicine. I'm merely pointing out a fundamental flaw in the testing curriculum...the fact that circulatory indicators and vitals are not factored in prior to the decision to give O2.
 
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I'm pretty sure the critical fail criteria says something along the lines of "performs primary assessment prior to treating threats to ABCs" it doesn't say you have to do A then B then C. If a skills examiner fails you for the above scenario and you said you'd apply O2 when you did; they are just on a power trip.
 
There are two ways to approach this. The first is to say that, by not mentioning the frank skin signs (or by your not asking about them) during the "breathing" portion, relevant information was withheld. The second is to say that the initial assessment is meant to identify and treat immediate life threats, and while supplemental oxygen may be indicated in that patient, its absence is not a life threat, in the way it might be for a patient in severe respiratory distress.

Either way it has little bearing on reality. Most true initial assessments are completed in a few seconds, so most people sensibly treat after it's finished, rather than the textbook "treat as you go."
 
Big Poke said:
Time to vent on a long standing pet peeve of mine...

It's the fact that the dicision to apply O2 in every NREMT/Non-NREMT assessment skills sheet falls in the "Breathing" category of the intitial assessment, and making a decision at that point is pass/fail criteria. The problem with this seems obvious, yet it has remained there as long as I've been in EMS. It ignores circulatory factors and vital signs as a means to determine hypoxia and poor perfusion. Here's a skills scenario you might get from a proctor:

PT is alert. C/C of severe lower abd pain. Respiratory indicators are WNL. PT denies difficulty breathing.

So at this point you know your guy is with it, he has a non-respiratory chief complaint, and he's having no diffculty breating. Would you give O2? No, of course not. But then you get to the C part of the ABC's and this is what you find:

Skin signs cool/pale/clammy. Radial pulses weak/thready. Tachycardic.

So he's shocky, possibly hinting at a GI bleed/sepsis patient, which indicates high flow O2. But per NREMT you just failed for choosing not to apply O2 when they wanted it addressed in the B section. Am I the only one who thinks it would be far more appropriate for O2 consideration to be placed at the end of your inital assessment, not right in the middle of it?
Click to expand...

The NREMT skill sheets state that you must consider oxygen. It doesn't say that you have to apply it.

You should always consider it - the key is to knowing whether it is Clinically necessary.
 
Uh, the sheets say "failure to voice and ultimately provide appropriate oxygen therapy" is the fail criteria. Problem solved.

Breathing subsection is the most appropriate location for the oxygen point, but does not need to be applied until you've discovered the need for it. If there's no need, then just verbalize that you're INTENTIONALLY not giving oxygen (rather than just forgetting to). They need to know your wheels are turning inside.

Doing assessment out of order isn't a markdown. As long as you don't start doing secondary exam before treating ABC problems. They're not trying to have you be a robot...
 
AnthonyM83 said:
Uh, the sheets say "failure to voice and ultimately provide appropriate oxygen therapy" is the fail criteria. Problem solved.
Click to expand...

When did they change it?
 
If oxygen is not yet indicated after your airway and breathing assessment, then verbalize that you've considered it and decided against it. There is no rule that you can't reevaluate their condition and modify treatment as you gain more information.
 
I'm working off memory a bit. From what I can remember when doing NR skills, they always wanted it performed in B and not doing so was a fail. I could be wrong, and hopefully I am. Voicing that you're considering it but going to continue your assessment before making the decision to apply it would be appropriate.
 
Big Poke said:
I'm working off memory a bit. From what I can remember when doing NR skills, they always wanted it performed in B and not doing so was a fail. I could be wrong, and hopefully I am. Voicing that you're considering it but going to continue your assessment before making the decision to apply it would be appropriate.
Click to expand...

Performing it doesn't mean giving it to the patient. They want to make sure you know when during your assessment you apply it.

You can download the NREMT skill sheets here: http://www.emtsource.org/nremt_practical_skills.php
 
This is an issue with instructional limitations. Get enough other questions right, pass, and critique the question from the other side.
 
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