Skills Final

[chaz90]

What state is this? Pulse Ox is not always reliable.

Don't overthink the NR. For testing purposes, the SpO2 is what they say it is.

 

[Mariemt]

What state is this? Pulse Ox is not always reliable.

then treat the patients symptoms. This is elementary basic EMT stuff. During testing you can ask for a pulse ox reading.

 

[Sandog]

then treat the patients symptoms. This is elementary basic EMT stuff. During testing you can ask for a pulse ox reading.

In the previous post that I quoted, you alluded that in your state, you determine your O2 therapy based on SPO2 readings. If this is the case it is a bad practice at best.
Your thinking explains why SPO2 monitoring is not in the scope of basic in many states.

 

[Mariemt]

In the previous post that I quoted, you alluded that in your state, you determine your O2 therapy based on SPO2 readings. If this is the case it is a bad practice at best.
Your thinking explains why SPO2 monitoring is not in the scope of basic in many states.

Our state (Iowa) does titrate oxygen levels based on patient need and spo2 readings.
What is bad practice is throwing o2 on every patient. O2 is a drug.

 

[Mariemt]

In the previous post that I quoted, you alluded that in your state, you determine your O2 therapy based on SPO2 readings. If this is the case it is a bad practice at best.
Your thinking explains why SPO2 monitoring is not in the scope of basic in many states.

Titrating o2 is also standard in AHA curriculum and is now in the nremt registry bank of questioning. Bad practice? Your opinion

 

[Sandog]

Just my opinion perhaps. I think more harm can be done from withholding O2 due to erroneous SPO2 readings than can arise from needless administration of O2.

Although pulse oximeters are nearly ubiquitous in health care, some users may question which patients should be monitored, and how often. Unless clinicians both understand and follow established guidelines, pulse oximetry can be misused or overused, further straining resources.3, 4

Several studies show that there's a knowledge deficit about pulse oximetry among medical and nursing staff.5-7 In one study, researchers administered a 17-question survey on pulse oximetry to 442 nurses, physicians, and respiratory therapists; the respondents' mean score was just 66%.6 Another study of 50 nursing and medical staff found "an alarming deficit" in their understanding of pulse oximetry.7

http://www.nursingcenter.com/lnc/CE...906000-00037&Journal_ID=54030&Issue_ID=863636

 

[Mariemt]

Just my opinion perhaps. I think more harm can be done from withholding O2 due to erroneous SPO2 readings than can arise from needless administration of O2.





http://www.nursingcenter.com/lnc/CE...906000-00037&Journal_ID=54030&Issue_ID=863636

Read my last post carefully... base on patient NEED and spo2 reading.
If your pulse ox is reading 99 but your patient is cyanotic, let's rethink this.

There are many, many studies out there supporting o2 titration. It is now being taught in all classes, EMR and above. Too much o2 can be just as dangerous as not enough, but you can't tell if you're giving too much, only not enough.
You have signs of low o2. Dusky nails etc.
I can put all sorts of links supporting this, but I already did for the one that applied to the thread. I link the nremt site.
You can argue this one until you are blue in the face, I will give you o2 then. .
We put a pulse ox on our patient, but also assess their lips, nails etc etc. .
The pulse ox is a tool, a tool in our assessment, not a diagnosis. Its reading is considered with o2 therapy.
To say titrating o2 is bad practice is irresponsible of you. To put o2, a drug on all patients is equally irresponsible.

 

[hogwiley]

Titrating o2 is also standard in AHA curriculum and is now in the nremt registry bank of questioning. Bad practice? Your opinion

It was explained to me by a medical director that the potentially harmful effects of giving o2, or too much o2 prehospital when its not really needed usually pale in comparison to the effects of even mild hypoxia, and a pre hospital environment is such that its not always possible to continuously ensure the person isn't suffering from hypoxia.

I understand its kind of taken as a badge of sophistication among EMS personnel to complain about excessive o2 administration, and SOME of the people doing the complaining may even have some understanding of the physiological processes that underpin these arguments. I suspect most probably don't, and some of these people can possibly do more harm than good by withholding o2.

If some systems don't trust EMTs to check blood sugar, why would they trust them to titrate o2 administration on patients experiencing a medical emergency, based on possibly unreliable spo2 readings?

 

[chaz90]

If some systems don't trust EMTs to check blood sugar, why would they trust them to titrate o2 administration on patients experiencing a medical emergency, based on possibly unreliable spo2 readings?

Poor practices and policies in one area doesn't justify ignorance in another. As mentioned previously in this thread, oxygen is not withheld just due to SpO2 values. Pulse oximetry is a tool that, when correlated with clinical findings, allows us to judiciously administer O2 to those who need it. Slapping oxygen on every patient you transport because "Hey, hypoxia is bad and sometimes patients are hypoxic" is as bad as giving 4 mg of Zofran to every patient because sometimes people are nauseous. Changing research and culture that teaches us previously held beliefs about the complete safety and benefits of O2 are wrong leads to changes in medicine.

 

[Mariemt]

It was explained to me by a medical director that the potentially harmful effects of giving o2, or too much o2 prehospital when its not really needed usually pale in comparison to the effects of even mild hypoxia, and a pre hospital environment is such that its not always possible to continuously ensure the person isn't suffering from hypoxia.

I understand its kind of taken as a badge of sophistication among EMS personnel to complain about excessive o2 administration, and SOME of the people doing the complaining may even have some understanding of the physiological processes that underpin these arguments. I suspect most probably don't, and some of these people can possibly do more harm than good by withholding o2.

If some systems don't trust EMTs to check blood sugar, why would they trust them to titrate o2 administration on patients experiencing a medical emergency, based on possibly unreliable spo2 readings?

you also didn't read where I stated spo2 is tool. It is not just a badge of sophistication, the state wants to know why o2 is being used. State is looking at use of o2. O2 is over used and can be harmful. Your spo2 looks normal but the patient's nails look dusky? Use o2. O2 titration is now in the nremt testing and skills. There is a reason for this argument .

 

[Mariemt]

It was explained to me by a medical director that the potentially harmful effects of giving o2, or too much o2 prehospital when its not really needed usually pale in comparison to the effects of even mild hypoxia, and a pre hospital environment is such that its not always possible to continuously ensure the person isn't suffering from hypoxia.

I understand its kind of taken as a badge of sophistication among EMS personnel to complain about excessive o2 administration, and SOME of the people doing the complaining may even have some understanding of the physiological processes that underpin these arguments. I suspect most probably don't, and some of these people can possibly do more harm than good by withholding o2.

If some systems don't trust EMTs to check blood sugar, why would they trust them to titrate o2 administration on patients experiencing a medical emergency, based on possibly unreliable spo2 readings?

the systems don't trust EMTs to take blood sugar? Or they find it unnecessary?
Our system we take blood sugars, a lot! On diabetics, stroke like symptoms, all altered status... you wouldn't believe how many people presenting as strokes are hypoglycemic.
I do know it is taught that if they altered but alert enough for glucose to go ahead and give oral glucose in systems that don't check bgl

 

[Mariemt]

Poor practices and policies in one area doesn't justify ignorance in another. As mentioned previously in this thread, oxygen is not withheld just due to SpO2 values. Pulse oximetry is a tool that, when correlated with clinical findings, allows us to judiciously administer O2 to those who need it. Slapping oxygen on every patient you transport because "Hey, hypoxia is bad and sometimes patients are hypoxic" is as bad as giving 4 mg of Zofran to every patient because sometimes people are nauseous. Changing research and culture that teaches us previously held beliefs about the complete safety and benefits of O2 are wrong leads to changes in medicine.

I love this post.

 

[hogwiley]

Poor practices and policies in one area doesn't justify ignorance in another. As mentioned previously in this thread, oxygen is not withheld just due to SpO2 values. Pulse oximetry is a tool that, when correlated with clinical findings, allows us to judiciously administer O2 to those who need it. Slapping oxygen on every patient you transport because "Hey, hypoxia is bad and sometimes patients are hypoxic" is as bad as giving 4 mg of Zofran to every patient because sometimes people are nauseous. Changing research and culture that teaches us previously held beliefs about the complete safety and benefits of O2 are wrong leads to changes in medicine.

I understand and even agree with these points. I also have seen patients brought into the ER with no oxygen on or a couple liters NC, and their spo2 is checked and its like low 80s or high 70s. It can make for an ugly scene when the Paramedic or EMT then has to explain why this is the case.

A recent example was a patient having seizures brought in. The medic was asked what her o2 was and he looked at his partner and asked....his partner says uuuh, it was like 93. Well, it wasnt 93 when they brought her in, it was 83. He was being judicious in his use of 02, meanwhile his patient is hypoxic while hes focusing on all this other stuff like starting a line etc, which is probably a good example of why so many of these crazy board certified emergency room physicians who write EMT books keep saying be generous with the o2 til you get em into the ER.

 

[chaz90]

A recent example was a patient having seizures brought in. The medic was asked what her o2 was and he looked at his partner and asked....his partner says uuuh, it was like 93. Well, it wasnt 93 when they brought her in, it was 83. He was being judicious in his use of 02, meanwhile his patient is hypoxic while hes focusing on all this other stuff like starting a line etc, which is probably a good example of why so many of these crazy board certified emergency room physicians who write EMT books keep saying be generous with the o2 til you get em into the ER.

Was the patient truly hypoxic though? Pulse oximetry swings both ways. Don't assume high sats are accurate until evaluated, and definitely don't assume low sats truly are low until evaluated as well. I do typically put post-ictal patients on 2 LPM O2, but just because their SpO2 was showing 83% doesn't mean it truly is. If the patient was fully alert, not complaining of any SOB, had normal skin color and was complaint free, I would troubleshoot the heck out of my pulse ox before assuming they were that hypoxic. Did the patient have poor peripheral circulation? Did she have nail polish on? This could have been an error by the medic too of course, but I'm just playing Devil's advocate.

 

[Mariemt]

I understand and even agree with these points. I also have seen patients brought into the ER with no oxygen on or a couple liters NC, and their spo2 is checked and its like low 80s or high 70s. It can make for an ugly scene when the Paramedic or EMT then has to explain why this is the case.

A recent example was a patient having seizures brought in. The medic was asked what her o2 was and he looked at his partner and asked....his partner says uuuh, it was like 93. Well, it wasnt 93 when they brought her in, it was 83. He was being judicious in his use of 02, meanwhile his patient is hypoxic while hes focusing on all this other stuff like starting a line etc, which is probably a good example of why so many of these crazy board certified emergency room physicians who write EMT books keep saying be generous with the o2 til you get em into the ER.

That's not titrating o2 that's not paying attention.. sorry you have bad medics.
Actually you will see a change in the EMT books. In 2012 changes were made to the EMT curriculum to begin titrating o2 and have affected the nremt testing and AHA guidelines as I have mentioned earlier.
Books are catching up and amendments are being made in classes to reflect it. So your crazy board certified phycisians have changed their minds, a long time ago.

 

[Mariemt]

Was the patient truly hypoxic though? Pulse oximetry swings both ways. Don't assume high sats are accurate until evaluated, and definitely don't assume low sats truly are low until evaluated as well. I do typically put post-ictal patients on 2 LPM O2, but just because their SpO2 was showing 83% doesn't mean it truly is. If the patient was fully alert, not complaining of any SOB, had normal skin color and was complaint free, I would troubleshoot the heck out of my pulse ox before assuming they were that hypoxic. Did the patient have poor peripheral circulation? Did she have nail polish on? This could have been an error by the medic too of course, but I'm just playing Devil's advocate.

when he said one medic looked at the other and said "uh" I believed it had nothing to do with titrating o2.

M

 

[hogwiley]

Was the patient truly hypoxic though? Pulse oximetry swings both ways. Don't assume high sats are accurate until evaluated, and definitely don't assume low sats truly are low until evaluated as well. I do typically put post-ictal patients on 2 LPM O2, but just because their SpO2 was showing 83% doesn't mean it truly is. If the patient was fully alert, not complaining of any SOB, had normal skin color and was complaint free, I would troubleshoot the heck out of my pulse ox before assuming they were that hypoxic. Did the patient have poor peripheral circulation? Did she have nail polish on? This could have been an error by the medic too of course, but I'm just playing Devil's advocate.

The patient did have an altered LOC, but that could have been the case regardless of whether they were hypoxic. They didn't look well, but not flat out cyanotic. They did have nail polish on, spo2 was rechecked using the ear lobe and it was still low.

I think part of the reluctance to do away with the liberal application of o2 is the worry that it could then result in pressure to not give it, or a general loss of concern over the consequences of not using it when it should be used. You will have EMTs erring on the side of not giving it, and then getting distracted with other things or getting tunnel vision, as was likely the case with the example I gave.

Really, I have no dog in the fight, if there even is a fight, I just see that there is a potential downside to discouraging the use of o2 too much.

 

[Mariemt]

The patient did have an altered LOC, but that could have been the case regardless of whether they were hypoxic. They didn't look well, but not flat out cyanotic. They did have nail polish on, spo2 was rechecked using the ear lobe and it was still low.

I think part of the reluctance to do away with the liberal application of o2 is the worry that it could then result in pressure to not give it, or a general loss of concern over the consequences of not using it when it should be used. You will have EMTs erring on the side of not giving it, and then getting distracted with other things or getting tunnel vision, as was likely the case with the example I gave.

Really, I have no dog in the fight, if there even is a fight, I just see that there is a potential downside to discouraging the use of o2 too much.

well as with any assessment, a patient who is unstable will likely need o2 and assessments should be done every 5 minutes or less. Checking lips, nail beds, spo2 etc should be part of every assessment whether it be 5, 10 or 15 minutes. Tunnel vision shouldn't be an excuse. The reason o2 use is being looked at is because of the damage that's being found. All of us know the dangers of o2 over use in a newborn and young infant.. the danger is in all ages .. maybe I have just been further educated in it as I run with ALS units and its been a topic of many of our continued education, but I do work a lot with our classes for EMT and it is now being taught. So I dunno. I've seen the research. I understand it and I know how to treat my patient based on my assessment, along with the pulse ox tool provided. Not alone in itself.

 

[Sandog]

you also didn't read where I stated spo2 is tool. It is not just a badge of sophistication, the state wants to know why o2 is being used. State is looking at use of o2. O2 is over used and can be harmful. Your spo2 looks normal but the patient's nails look dusky? Use o2. O2 titration is now in the nremt testing and skills. There is a reason for this argument .

Are you a medic, or basic? I just retook my skills testing for my 2 year recert, and we use NREMT skills guidelines for testing. Nowhere was titration even mentioned.

I may only be a basic but I have a good deal of molecular biology background to understand what O2 titration entails, sounds neat and is a good idea, but the advantages are just not justified in comparison to the rare, very rare occasion that someone is harmed by O2.

I would love to see some real data showing all this harm that O2 has done, and I mean over a large sample, not a few out of a million. Can you show that?

 

[Mariemt]

This is the nremt page itself explaining the new aha guidelines. It does mention o2 with cardiac. Changes took place in 2012

https://www.nremt.org/nremt/about/2010_aha_guidelines.asp

Here's the nremt page about it.