Oxygen

[Mattyirie]

Did my first ride yesterday as an EMT-B student and in 7 calls, i didn't administer oxygen once. Never felt the need. Every patient was vitally stable with adequate oxygen saturation. With the diagnostic tools available to me, perfusion appeared adequate as well. This goes against the generalization in basic class of "give everyone oxygen...it doesn't hurt" and I think I am OK with it. What is everyone else's opinion...?

Just a little background about me, I've taken a full year of anatomy and physiology and I feel I've grasped the concepts well enough to understand basic homeostatic physiology. I also have basic cell bio, pathophysiology, microbiology and a host of self directed research... BUT no field experience except in the hospital.

 

[usafmedic45]

Oxygen is only indicated when there is clinically demonstrable hypoxia (either via SpO2 or by overt clinical signs like cyanosis or pallor) or in cases of known or strongly suspected CO toxicity. With the exception of CO toxicity (where 15 L/min or more via a NRB is indicated until you get the patient to a hyperbaric facility), the lowest amount of oxygen necessary to achieve a saturation >90% is all that should be used.

O2 does do harm and it has been shown to worsen clinical outcomes when used inappropriately.

 

[NomadicMedic]

Your eduaction and understanding will help you in the field, but if you don't apply oxygen in your class/testing scenarios, expect to get dinged for it.

Most basic, and sadly, some advanced EMS classes are still taught with the hamfisted "Ug! Mongo put on oxygen" mentality.

 

[medichopeful]

What is everyone else's opinion...?

My opinion is you used your brain and didn't blindly follow protocols. You're gonna make an excellent provider!

 

[FFEMT427]

My opinion is you used your brain and didn't blindly follow protocols. You're gonna make an excellent provider!

I don't think protocols say anything about using our brains

 

[JPINFV]

I don't think protocols say anything about using our brains

In other words, EMS isn't a profession and needs to stop complaining about not getting to eat at the adult table in health care.

 

[FFEMT427]

In other words, EMS isn't a profession and needs to stop complaining about not getting to eat at the adult table in health care.

LOL sometimes it seems that way

 

[STXmedic]

My opinion is you used your brain and didn't blindly follow protocols. You're gonna make an excellent provider!

Don't you have to call med control to use that???

 

[medichopeful]

Don't you have to call med control to use that???

Only if you've already used the maximum amount allowed by standing orders! :rofl:

 

[MrBrown]

This stuff does my head in. I must applaud you for not being another one of the "oxygen can't do any harm" group, you sir are one of the few it seems. Makes me want to crack people around the bloody head with the oxygen tank, seriously.

Oxygen is only indicated for those who are acutely hypoxic (SpO2 < 95% on RA) the exception being those patients with COPD as they often have chronically low SpO2, lowest I've seen is in the high seventies.

Like with anything, clinical judgement is required; somebody who is blue in the face and struggling to breath but has an SpO2 of 100% clearly needs oxygen, somebody who has an SpO2 of 50% (arbitrary number) but who is pink, speaking in full sentences and well perfused doesn't need oxygen.

Hyperoxaemia/oxygen in supraphysiological amounts is really bad news for the following groups of patients and it's most important that oxygen should not be administered to them unless hypoxic: premature newborns, neonates, stroke, and myocardial infarction. The reasoning behind premature newborns, stroke and MIs is that oxygen in supraphysiological amounts causes small capilaries and arterioles to constrict which will reduce blood supply, for newborns I am told there is "some evidence" (none I have personally reviewed) that oxygen makes outcomes worse.

 

[ArcticKat]

The problem with education is that there is the School's way of doing things, then there is the real world way. Do it the way the school wants you to until you graduate...then you can treat your patients properly after that.

 

[the_negro_puppy]

I've even noticed a trend now with my service over the past 2 years of less and less oxygen being used. It used to be that everyone with active chest pain received NRB @ 15 l/m


Now we just titrate oxygen when it is needed. I.E acutely hypoxic/hypoxemic cardiogenic APO patients obviously get maximum oxygen, but a patient with nil DIB/shortness of breath maintaining good sats, clolour etc wont get any.

 

[BlakeFabian]

Yes, O2 is normally withheld until indicated. However, I don't completely agree with that. If you have a Pt who's in pain, dyspnoeic, or with any other complaint than you need to do something; anything. Simply putting them in your truck & monitoring vitals en-route isn't sufficient.

I almost always tell my Pt's something like, "Sir, I'm going to give you a little bit of Oxygen; not because you're in any kind of respiratory distress but because sometimes the Oxygen helps to diminish (pain, dyspnea, anxiety, etc...)

If that Pt believes that the 02 will help them then, in their mind, it's going to. Even if it doesn't relieve any actual symptoms, their mind tends to focus less on whatever complaint they have because they believe that your intervention is helping them.

On that note, NEVER say that (Insert intervention here) is GOING to help because, when it doesn’t; you’ll become a liar and lose the Pts trust & confidence.

 

[JPINFV]

Yes, O2 is normally withheld until indicated. However, I don't completely agree with that. If you have a Pt who's in pain, dyspnoeic, or with any other complaint than you need to do something; anything. Simply putting them in your truck & monitoring vitals en-route isn't sufficient.

Dyspnoeic is an indication of respiratory illness. Supplemental oxygen is appropriate, albeit a NRB is not necessarily required.

Patients who are in pain need pain medication, not magical air.

Patients with complaints need their complaints appropriately treated, which is not giving them magical air.

Why do you need to do anything? Benign neglect is completely appropriate in a lot of cases, especially when it comes to providing magical air and nothing else. If something must be done, why not give adenosine, or lidocaine, or naloxone, or any other drug. What makes the drug known as oxygen any more or less of a drug than lidocaine or naloxone or adenosine? Why do those drugs have indications that are more complicated than "give if ambulance is present"?

How are providers smart enough to know when to transport with lights and sirens, or when to give adenosine or lidocaine, or naloxone, but at the same time too incompetent to determine when to give supplemental oxygen?

I almost always tell my Pt's something like, "Sir, I'm going to give you a little bit of Oxygen; not because you're in any kind of respiratory distress but because sometimes the Oxygen helps to diminish (pain, dyspnea, anxiety, etc...)

Does the oxygen do it, or is it a placebo? Would sugar pills provide the same effect, and if so, why not just administer a sugar pill? It's cheaper.

If that Pt believes that the 02 will help them then, in their mind, it's going to. Even if it doesn't relieve any actual symptoms, their mind tends to focus less on whatever complaint they have because they believe that your intervention is helping them.

So if the patient thinks naloxone or adenosine or lidocaine will help them, will give them those drugs on command?

Does the patient believe supplemental oxygen will help them on their own accord, or do they believe so because you lied to them about it?

On that note, NEVER say that (Insert intervention here) is GOING to help because, when it doesn’t; you’ll become a liar and lose the Pts trust & confidence.

Why are you administering medications when you don't have enough confidence that the intervention is appropriate to tell them that it will work?

 

[CAOX3]

Simply putting them in your truck & monitoring vitals en-route isn't sufficient.

If its all that they require, thats what they recieve.

I dont need to look busy to justify my existence, if all they require is a ride then thats what they get.

 

[daj72]

Hyperoxaemia/oxygen in supraphysiological amounts is really bad news for the following groups of patients and it's most important that oxygen should not be administered to them unless hypoxic: premature newborns, neonates, stroke, and myocardial infarction. The reasoning behind premature newborns, stroke and MIs is that oxygen in supraphysiological amounts causes small capilaries and arterioles to constrict which will reduce blood supply, for newborns I am told there is "some evidence" (none I have personally reviewed) that oxygen makes outcomes worse.

Perhaps a stupid question, MrBrown, but evidence for the negativ supraphysiological effect is it available online ?

 

[BlakeFabian]

Dyspnoeic is an indication of respiratory illness. Supplemental oxygen is appropriate, albeit a NRB is not necessarily required.

Patients who are in pain need pain medication, not magical air.

Patients with complaints need their complaints appropriately treated, which is not giving them magical air.

I agree, and if I was putting across the motion of only providing O2 then I apologize. Of course, when 02 or another intervention is indicated then provide it. I was simply stating my opinion of what to do when there really aren’t any indicated interventions.

Why do you need to do anything? Benign neglect is completely appropriate in a lot of cases, especially when it comes to providing magical air and nothing else. If something must be done, why not give adenosine, or lidocaine, or naloxone, or any other drug. What makes the drug known as oxygen any more or less of a drug than lidocaine or naloxone or adenosine? Why do those drugs have indications that are more complicated than "give if ambulance is present"?

Simply transporting is completely appropriate when indicated. If that's all you want to do; go for it. In my opinion, It's better to always be doing something while in the back with your Pt instead of sitting still and merely checking vitals every 15 minutes.

This is the BLS section of the forum, so I'm assuming the poster would be on a BLS truck. Likewise, on a BLS truck the medications wouldn't be available unless tandem is called.

How are providers smart enough to know when to transport with lights and sirens, or when to give adenosine or lidocaine, or naloxone, but at the same time too incompetent to determine when to give supplemental oxygen?

You're misinterpreting what I'm trying to say.

Does the oxygen do it, or is it a placebo? Would sugar pills provide the same effect, and if so, why not just administer a sugar pill? It's cheaper.

Good idea. I'm simply saying, in my opinion, doing something is better than nothing.

So if the patient thinks naloxone or adenosine or lidocaine will help them, will give them those drugs on command?

Of course not. I stated O2 because it's a intervention with no side effects in low doses (In a normal, no interventions indicated patient.)

Does the patient believe supplemental oxygen will help them on their own accord, or do they believe so because you lied to them about it?

It's situation dependent. Sometimes the simple act of the BLS provider providing an intervention may convince the Pt that it's helping.

Sometimes, it's because of the white lie.

Why are you administering medications when you don't have enough confidence that the intervention is appropriate to tell them that it will work?

Because that's what I was taught. It's not because I lack confidence in my interventions; it’s because there's always those situations where your intervention won't have its anticipated effect on the Pt.

I was taught to never make promises in EMS. Saying “this WILL work” is a promise; Murphy’s Law is then begging to make that technician look like a fool.

Keep in mind, the original poster asked for our opinions. My entire posts are of my own opinions. I'm not saying it's the absolute best thing to do, I'm saying it what I think is right. If you disagree, then simply don't do what I do.

I've cared for my Pts this way for the last 2 years, and neither my director nor medical director have told me to stop.

 

[fast65]

I agree, and if I was putting across the motion of only providing O2 then I apologize. Of course, when 02 or another intervention is indicated then provide it. I was simply stating my opinion of what to do when there really aren’t any indicated interventions.



Simply transporting is completely appropriate when indicated. If that's all you want to do; go for it. In my opinion, It's better to always be doing something while in the back with your Pt instead of sitting still and merely checking vitals every 15 minutes.

This is the BLS section of the forum, so I'm assuming the poster would be on a BLS truck. Likewise, on a BLS truck the medications wouldn't be available unless tandem is called.



You're misinterpreting what I'm trying to say.




Good idea. I'm simply saying, in my opinion, doing something is better than nothing.



Of course not. I stated O2 because it's a intervention with no side effects in low doses (In a normal, no interventions indicated patient.)



It's situation dependent. Sometimes the simple act of the BLS provider providing an intervention may convince the Pt that it's helping.

Sometimes, it's because of the white lie.



Because that's what I was taught. It's not because I lack confidence in my interventions; it’s because there's always those situations where your intervention won't have its anticipated effect on the Pt.

I was taught to never make promises in EMS. Saying “this WILL work” is a promise; Murphy’s Law is then begging to make that technician look like a fool.

Keep in mind, the original poster asked for our opinions. My entire posts are of my own opinions. I'm not saying it's the absolute best thing to do, I'm saying it what I think is right. If you disagree, then simply don't do what I do.

I've cared for my Pts this way for the last 2 years, and neither my director nor medical director have told me to stop.

So what I'm gathering from your post is that you're going to give a drug that's not indicated, just because there's nothing else to do? If there's "no intervention indicated" then why are you providing oxygen, which is in fact an intervention?

It's not ok to lie to our patients and instill the belief that a little oxygen will solve their problems, like JPINFV said, it's not some magical drug. Lying to our patients reflects poorly on our profession, and it reflects poorly on the provider, I don't care how minor of a lie it is.

Believe it or not, not every patient we run across requires an intervention during transport. Some just require a thorough assessment and a monitoring of vital signs, no use providing a drug that they don't need just because you feel obligated to do something more. Providing oxygen when it's not indicated just because someone called 911 is a close-minded action and as such it gives me the impression that the provider lacks judgement and logical thinking. My $0.02.

 

[JPINFV]

Simply transporting is completely appropriate when indicated. If that's all you want to do; go for it. In my opinion, It's better to always be doing something while in the back with your Pt instead of sitting still and merely checking vitals every 15 minutes.

When you see your physician for a checkup, do you expect to be prescribed something even if no medication is indicated?

This is the BLS section of the forum, so I'm assuming the poster would be on a BLS truck. Likewise, on a BLS truck the medications wouldn't be available unless tandem is called.

Ok, why not insert a NPA or administer oral glucose or administer activated charcoal?

Good idea. I'm simply saying, in my opinion, doing something is better than nothing.

Why is doing something better than nothing? Since plenty of systems and services charge extra for the administration of oxygen, is causing the patient to have a larger bill (sometimes significantly larger (.pdf warnng)) worth the provider being able to say, "At least I did something"?

Of course not. I stated O2 because it's a intervention with no side effects in low doses (In a normal, no interventions indicated patient.)

Naloxone isn't going to cause side effects in a patient where it isn't contraindicated and in low doses.

However, let's switch back to EMT level interventions. NPAs don't have any major side effects when placed properly, and if the patient gags, it's easily reversible. Oral glucose and activated charcoal doesn't have any side effects in the doses administered if no contraindication is present. Why not administer those as well?

Why should the side effect profile matter when a drug is not indicated? The side effect of nothing (when indicated) is... wait for it... nothing.

It's situation dependent. Sometimes the simple act of the BLS provider providing an intervention may convince the Pt that it's helping.

Sometimes, it's because of the white lie.

Samuel Hahnemann would be proud.

Because that's what I was taught. It's not because I lack confidence in my interventions; it’s because there's always those situations where your intervention won't have its anticipated effect on the Pt.

I was taught to never make promises in EMS. Saying “this WILL work” is a promise; Murphy’s Law is then begging to make that technician look like a fool.

Fine, hedge the bet with "this should work." Of course saying "oxygen should help" when oxygen isn't indicated is a white lie. A white lie that could add to your patient's bill.

Keep in mind, the original poster asked for our opinions. My entire posts are of my own opinions. I'm not saying it's the absolute best thing to do, I'm saying it what I think is right. If you disagree, then simply don't do what I do.

It's not much of a discussion board if no discussion occurs. Why should any opinion, including mine, stand unchallenged if another poster sees reason to challenge it? I am neither infallible, nor afraid of defending my opinion, nor afraid of stating that I'm wrong when I'm wrong. By stating that this is simply your opinion in this manner, what are you afraid of?

I've cared for my Pts this way for the last 2 years, and neither my director nor medical director have told me to stop.

Ask your physician if he administers oxygen for no reason other than he hasn't thought of anything else to do in a patient where supplemental oxygen is not indicated. If he's not afraid of having his patients sit in the ED without supplemental oxygen while waiting for him to initiate treatment (for example, between being brought back and his exam, between his exam and the return of any laboratory tests, or any other delay), than what is EMS afraid of?

How often do you take a patient to the ED on supplemental oxygen only for the receiving RN discontinue oxygen therapy? If a continuous treatment is suddenly discontinued simply because there no longer is a "positive ambulance sign," then shouldn't that be an indication that something is deficient?

I'll end on this note. The absolute worst I've ever felt after handing over a patient to an RN on an emergency call was a patient where I justified placing an NRB because of "protocol." Why did I feel terrible about that?

...because I should be better than that.

EMS should be better than that.

We should be able to, and expected to, defend our interventions, regardless of how minor, based on the patient's condition and the results of our exam. By being unable to justify my intervention, I failed my patient that day. I failed EMS that day. I failed myself that day. Sure, I've had the entire, "Must complete exam before transporting priority patient down the street to the ED" tunnel vision patient, which no doubt had the potential to cause much greater harm than simply administering oxygen when it isn't indicated. However a rookie mistake and a consciously failing to think are two drastically different issues. A rookie mistake is much different to me than saying, "I administered a treatment that I could not justify."

The kicker? The RN didn't say anything negative to me either.

 

[BlakeFabian]

You both make valid points.

Let's just agree to disagree.