To O2 or not to O2

[Kdellicker]

One of the guys I run with, we went to class together and got our certification together, is very adamant about putting O2 on everyone! Last night we had a run "Victim of a fall". After asking some questions I had concluded that it was possible rib fx & or bruising of the liver. Either way, something I could not see. When we checked the pt's O2 and Pulse, Pulse WNL (Within Normal Limits) O2 was 97% and BP was WNL. Lungs were clear and normal RE. RR 22. I suggested maybe holding off on Oxygen as it would be unnecessary given O2 Saturation was 97%. If someone is uncomfortable why shove a NC up their nose and why strap a NRB to their beak. If there is a downward trend in pt's O2 sat then yes you should put on Oxy but I just don't see putting O2 on every single person that enters the ambulance. And He is convinced that O2 has pain relieving property's.... I'm not sure.... Maybe he knows something I don't. Any input would be appreciated guys! And thanks for letting me Join ya'lls forum.

 

[VFlutter]

Oxygen administration is a topic that usually gets me fired up. This has been discussed over and over again on this forum so I will keep it simple.

Oxygen is a medication. Every medication has an indication. Oxygen's indication is hypoxemia (Sp02<90ish%). Giving a patient who is not hypoxemic is a medication error and improper use.

You would not give atropine to a patient in normal sinus rhythm nor would you give nitro to a patient without chest pain. Oxygen is no different.

Oxygen does not have magical qualities. It does not relieve pain, reduce nausea, or decrease anxiety.

Oxygen is not benign. Hyperoxemia can cause harm in certain patient populations.

NRBs should only be used on patients in severe respiratory distress after failure to maintain oxygen saturation with lower Fi02.

To put it bluntly your partner does not sound like the sharpest tool in the shed and should pick up an A&P book

 

[Wayfaring Man]

In my training with MFRI, it was stressed that every single patient gets O2. All of them. Every patient. From the sick person to the boo-boo finger, we're putting them on O2. For our internship rides, if the lead provider declines O2 we need to document that we "considered" it. The want us to oxygenate everyone, likely because of the risk-reward ratio. If we give someone O2 who doesn't need it, nothing will happen but maybe a headache. If we don't give it to someone who needs it, welp.

By protocol, everyone should get O2. But realistically, it's not everyone. There are cases where it's definitely a yes, and some where it's pretty much a no. Low O2 sat? Absolutely, even if they're fine, just to CMA. Trouble breathing? Of course, but the Medic usually takes those calls for us. Diminished lung sounds? Yeap. Chest pain? Probably, but again, medics take those over. Heavy bleeding? Yeah probably. Pain? Depends, but likely, just as a placebo if nothing else. Garden variety sick person? Maybe! It's a judgment call.

I agree with Chase that it's a medication with indications and should be treated as such. But the training a lot of guys are receiving right now, including myself, is to give O2 to every single person. There is also a strong implication that if we don't have O2 in the documentation, then when we get a chart review it's going to not end up well for us. I'm not a seasoned veteran or an experienced EMT, and I don't have a great depth of clinical judgment to lean on, so while I have not given O2 more than I've given it, I still consider it for a lot of calls.

Incidentally, our training is also to go straight to high-flow O2 at 15LPM via NRB unless the patient cannot tolerate it. Protocol gives us more flexibility but I was taught to go straight to the mask.

 

[Rialaigh]

Oxygen administration is a topic that usually gets me fired up. This has been discussed over and over again on this forum so I will keep it simple.

Oxygen is a medication. Every medication has an indication. Oxygen's indication is hypoxemia (Sp02<90ish%). Giving a patient who is not hypoxemic is a medication error and improper use.

You would not give atropine to a patient in normal sinus rhythm nor would you give nitro to a patient without chest pain. Oxygen is no different.

Oxygen does not have magical qualities. It does not relieve pain, reduce nausea, or decrease anxiety.

Oxygen is not benign. Hyperoxemia can cause harm in certain patient populations.

NRBs should only be used on patients in severe respiratory distress after failure to maintain oxygen saturation with lower Fi02.

To put it bluntly your partner does not sound like the sharpest tool in the shed and should pick up an A&P book

I echo this but would like to emphasize a point that is difficult to distinguish in the field but should be a huge teaching point.

Oxygen is a medication. Every medication has an indication. Oxygen's indication is hypoxemia (Sp02<90ish%). Giving a patient who is not hypoxemic is a medication error and improper use.

In the world we practice in COPD is a very VERY common occurrence as are CO2 Retainers. The optimal 02 level for these patients varies greatly patient to patient. Because there has to be something taught I think generally in the hospital setting and in the field protocol is taught to titrate O2 to keep the patients SPo2 level above 92%.

However

For these CO2 retainers many of them live at home at SPo2 levels far below 92% and function on a daily basis with these diminished O2 levels. When I am dealing with a COPD patient, especially an elderly patient, I base whether I give oxygen on 2 things mainly, the first being work of breathing, and the second being level of alertness. If the patient is alert and oriented and has no increased work of breathing and no lethargy, then even if their O2 sat is 85% I will try and get by with 2L nasal cannula (or even nothing).

I am starting to see more medical journal articles out there on the use of prehospital oxygen in C02 retainers and the negative effects associated with it including increased Cpap use and increased ventilator use associated with a higher rate of respiratory failure outcomes resulting in death or disability. It does not take much, 45 minutes on a non rebreather needlessly for a CO2 retainer is more then enough time to start causing a dramatic increase in CO2 and a lethargic state requiring either very careful titration of O2 at the hospital or more commonly Cpap.



If you think that you don't run into that many COPD/CO2 retainer patients then think again. I would say on any decently busy EMS unit you will likely see several a week. Keep this in mind when titrating your O2 on the truck. Place more emphisis on mental status and alertness, and work of breathing, do not focus on SPo2 for these patients.


To close with a little story, I interned at a Pulmonology office my senor year of high school. Spent a couple days a week there with a Dr. for about 4 months seeing patients and looking at labs and imaging with him. He would frequently see COPD patients who would come from home on 2L-4L of oxygen via nasal cannula. These patients lived fairly quality lives at home, no running or athletics for them and they got out of breath easily but with some medication and proper O2 management they were able to avoid hospitalizations and enjoy life at home. These patients would frequently come in with O2 sats below 85%. It is not because they were hypoxic, it is because that is where they live all the time. If you put a non rebreather on one of these patients for several hours you would find them unconscious and needing to be intubated and placed in the CCU on a vent.




That is my long post for the month, if anyone needs to correct me please do, I certainly don't know everything and rarely know much at all. If you want to read an article or two on prehospital O2 use in CO2 retainers I have several bookmarked away that are good.

 

[Rialaigh]

In my training with MFRI, it was stressed that every single patient gets O2. All of them. Every patient. From the sick person to the boo-boo finger, we're putting them on O2. For our internship rides, if the lead provider declines O2 we need to document that we "considered" it. The want us to oxygenate everyone, likely because of the risk-reward ratio. If we give someone O2 who doesn't need it, nothing will happen but maybe a headache. If we don't give it to someone who needs it, welp.

By protocol, everyone should get O2. But realistically, it's not everyone. There are cases where it's definitely a yes, and some where it's pretty much a no. Low O2 sat? Absolutely, even if they're fine, just to CMA. Trouble breathing? Of course, but the Medic usually takes those calls for us. Diminished lung sounds? Yeap. Chest pain? Probably, but again, medics take those over. Heavy bleeding? Yeah probably. Pain? Depends, but likely, just as a placebo if nothing else. Garden variety sick person? Maybe! It's a judgment call.

I agree with Chase that it's a medication with indications and should be treated as such. But the training a lot of guys are receiving right now, including myself, is to give O2 to every single person. There is also a strong implication that if we don't have O2 in the documentation, then when we get a chart review it's going to not end up well for us. I'm not a seasoned veteran or an experienced EMT, and I don't have a great depth of clinical judgment to lean on, so while I have not given O2 more than I've given it, I still consider it for a lot of calls.

Incidentally, our training is also to go straight to high-flow O2 at 15LPM via NRB unless the patient cannot tolerate it. Protocol gives us more flexibility but I was taught to go straight to the mask.

Read my above post, there is a LOT of risk involved with giving a LARGE patient population increased (or any) amounts of O2. This is a big learning curve for EMS to learn to titrate oxygen to work of breathing and level of alertness and not to a number.

 

[fma08]

Does the patient need oxygen?

If yes, give them oxygen.

If no, don't give them oxygen.

:deadhorse:

 

[Aidey]

In my training with MFRI, it was stressed that every single patient gets O2. All of them. Every patient. From the sick person to the boo-boo finger, we're putting them on O2. For our internship rides, if the lead provider declines O2 we need to document that we "considered" it. The want us to oxygenate everyone, likely because of the risk-reward ratio. If we give someone O2 who doesn't need it, nothing will happen but maybe a headache. If we don't give it to someone who needs it, welp.

Here is how you document that*.

Pt maintained SpO2 of 97% on 21% oxygen via inhalation.

* Please note you shouldn't actually do this unless you are looking to deliberately piss someone off.

 

[Mariemt]

The nremt now recognizes o2 titration. The text books have not all caught up but any instructor worth their salt should be following aha guidelines for o2 titration for chest pain at the very least.

Guess what boys and girls? The nremt has questions about o2 and contraindications.

We even monitor levels per protocol with codes, head injuries and everything else.

 

[Christopher]

In my training with MFRI, it was stressed that every single patient gets O2. All of them. Every patient. From the sick person to the boo-boo finger, we're putting them on O2. For our internship rides, if the lead provider declines O2 we need to document that we "considered" it. The want us to oxygenate everyone, likely because of the risk-reward ratio. If we give someone O2 who doesn't need it, nothing will happen but maybe a headache. If we don't give it to someone who needs it, welp.

Nails on a chalkboard...ouch.

You should question everything taught at MFRI, because it has been a solid decade since O2 for everybody was acceptable. Actually, I've never heard of that in particular being acceptable medical practice (O2 via NRB for all "sick" people has only recently died off).

By protocol, everyone should get O2. But realistically, it's not everyone. There are cases where it's definitely a yes, and some where it's pretty much a no. Low O2 sat? Absolutely, even if they're fine, just to CMA. Trouble breathing? Of course, but the Medic usually takes those calls for us. Diminished lung sounds? Yeap. Chest pain? Probably, but again, medics take those over. Heavy bleeding? Yeah probably. Pain? Depends, but likely, just as a placebo if nothing else. Garden variety sick person? Maybe! It's a judgment call.

I doubted that MD's protocol really was "give O2 to everybody", and as far as I can tell from my read of the 2012 and 2013 protocols this is not the case. I would challenge anyone to show you where the protocols require you to do this.

I agree with Chase that it's a medication with indications and should be treated as such. But the training a lot of guys are receiving right now, including myself, is to give O2 to every single person. There is also a strong implication that if we don't have O2 in the documentation, then when we get a chart review it's going to not end up well for us. I'm not a seasoned veteran or an experienced EMT, and I don't have a great depth of clinical judgment to lean on, so while I have not given O2 more than I've given it, I still consider it for a lot of calls.

We QA 100% of our calls, and a big thing we look for is inappropriate use of treatments, which includes O2. You get in as much trouble for not documenting a need as you would for not applying it when appropriate.

Incidentally, our training is also to go straight to high-flow O2 at 15LPM via NRB unless the patient cannot tolerate it. Protocol gives us more flexibility but I was taught to go straight to the mask.

Man it makes me cringe, but I guess if they're handing this out to you and expecting you to meet this standard...how can we blame the providers?

From a training side, we've had lots of problems with EMT's from MD who move to our area that have a really poor handle on being a clinician and spend a lot of time slaving over our protocols ("BGL is an ALS procedure" and other nonsense).

If MFRI is really spreading, "O2 for everybody," then I may have to change my tactics to acknowledge this fundamental deficiency in their whole EMS education. Scary, scary, scary.

 

[Tigger]

I agree with Chase that it's a medication with indications and should be treated as such. But the training a lot of guys are receiving right now, including myself, is to give O2 to every single person. There is also a strong implication that if we don't have O2 in the documentation, then when we get a chart review it's going to not end up well for us. I'm not a seasoned veteran or an experienced EMT, and I don't have a great depth of clinical judgment to lean on, so while I have not given O2 more than I've given it, I still consider it for a lot of calls.

When all you have is a hammer, everything looks like a nail.

There is pretty much no reason to consider oxygen on a patient that does not present with any respiratory difficulties.

It is acceptable as an EMS provider to provide no interventions on the way to the hospital. If something isn't indicated, don't go looking for ways to make it indicated.

 

[TheLocalMedic]

When all you have is a hammer, everything looks like a nail.

There is pretty much no reason to consider oxygen on a patient that does not present with any respiratory difficulties.

It is acceptable as an EMS provider to provide no interventions on the way to the hospital. If something isn't indicated, don't go looking for ways to make it indicated.

^This

 

[jwk]

In my training with MFRI, it was stressed that every single patient gets O2. All of them. Every patient. From the sick person to the boo-boo finger, we're putting them on O2. For our internship rides, if the lead provider declines O2 we need to document that we "considered" it. The want us to oxygenate everyone, likely because of the risk-reward ratio. If we give someone O2 who doesn't need it, nothing will happen but maybe a headache. If we don't give it to someone who needs it, welp.

By protocol, everyone should get O2. But realistically, it's not everyone. There are cases where it's definitely a yes, and some where it's pretty much a no. Low O2 sat? Absolutely, even if they're fine, just to CMA. Trouble breathing? Of course, but the Medic usually takes those calls for us. Diminished lung sounds? Yeap. Chest pain? Probably, but again, medics take those over. Heavy bleeding? Yeah probably. Pain? Depends, but likely, just as a placebo if nothing else. Garden variety sick person? Maybe! It's a judgment call.

I agree with Chase that it's a medication with indications and should be treated as such. But the training a lot of guys are receiving right now, including myself, is to give O2 to every single person. There is also a strong implication that if we don't have O2 in the documentation, then when we get a chart review it's going to not end up well for us. I'm not a seasoned veteran or an experienced EMT, and I don't have a great depth of clinical judgment to lean on, so while I have not given O2 more than I've given it, I still consider it for a lot of calls.

Incidentally, our training is also to go straight to high-flow O2 at 15LPM via NRB unless the patient cannot tolerate it. Protocol gives us more flexibility but I was taught to go straight to the mask.

I don't even know who or what MFRI is but clearly they're clearly they're a menace. What you're being taught is way more than stupid - it's dangerous.

 

[VFlutter]

I don't even know who or what MFRI is but clearly they're clearly they're a menace. What you're being taught is way more than stupid - it's dangerous.

I am assuming Medical First Responder something. Probably less education than a Boy Scout.

I wish these people could see the ABGs of the patients they bring in on NRBs. On the other hand most of them probably do not even know what an ABG is let alone have ability to comprehend even the basic concepts of them.

 

[chaz90]

I am assuming Medical First Responder something. Probably less education than a Boy Scout.

I'm afraid I found it, and it's worse than what you feared.

http://www.mfri.org

Yet another organization that makes it abundantly clear where they place their priorities and still manages to hold great sway over EMS stagnation. Sadly, this sort of attitude seems far too common based on some of the backwards EMS I've seen from our southern neighbors...

 

[Wayfaring Man]

For what it's worth, we also had the instructor doing the "in the field, you probably should not give oxygen to everyone" shtick. So there is an understanding. The entire state of Maryland is not doing it that way, nor would I advocate for doing it that way. I haven't given O2 more than I've given it because there's no reason to O2 someone in most cases. I was just providing a possible rationale for where the OP's partner might have developed the "O2 everyone" idea.

I doubted that MD's protocol really was "give O2 to everybody", and as far as I can tell from my read of the 2012 and 2013 protocols this is not the case. I would challenge anyone to show you where the protocols require you to do this.

Indications:
All medical and trauma patients.

Precautions:
Never withhold Oxygen from those who need it.
Should be given with caution to patients with COPD.
Simple or partial rebreather face masks must be supplied with a minimum 6 lpm
Non-rebreather face masks must be supplied with a minimum 12 lpm.

Contraindications:
None.

Dosage:
Adult: Administer 12-15 lpm with NRB mask or 2-6 lpm via nasal cannula, unless otherwise directed.
Child: Administer 12-15 lpm with NRB mask or 2-6 lpm via nasal cannula, unless otherwise directed.

Also page 27, General Patient Care:

c) Administer oxygen as appropriate:
1) Administer oxygen at 12-15 lpm via NRB mask to all priority 1 patients (including COPD).
2) Administer oxygen at 12-15 lpm via NRB to all priority 2 patients (including COPD) experiencing cardiovascular, respiratory, or neurological compromise.
3) Administer oxygen at 2-6 lpm by nasal cannula or 6-15 lpm mask delivery device to ALL other priority 2 and priority 3 patients with no history of COPD.
4) Priority 3 patients, with a history of COPD or patients with chronic conditions, should receive their prescribed home dosage of oxygen. If patients are not on home oxygen, they should receive oxygen at 2-6 lpm nasal cannula or 6 lpm mask delivery device, if indicated.

Emphasis original.



Again, like I said, I don't personally advocate this practice. It's very much a "everything looks like a nail" situation and furthermore even if it weren't dangerous, it would be wasteful and inconvenient to the patient. But they're my protocols, so I need to be aware of them and able to justify myself with them.

 

[Christopher]

c) Administer oxygen as appropriate:
1) Administer oxygen at 12-15 lpm via NRB mask to all priority 1 patients (including COPD).
2) Administer oxygen at 12-15 lpm via NRB to all priority 2 patients (including COPD) experiencing cardiovascular, respiratory, or neurological compromise.
3) Administer oxygen at 2-6 lpm by nasal cannula or 6-15 lpm mask delivery device to ALL other priority 2 and priority 3 patients with no history of COPD.
4) Priority 3 patients, with a history of COPD or patients with chronic conditions, should receive their prescribed home dosage of oxygen. If patients are not on home oxygen, they should receive oxygen at 2-6 lpm nasal cannula or 6 lpm mask delivery device, if indicated.

I guess I can see how that could be read that way, it looks more like what to use when you find you need O2. There was another table listing SpO2 and other findings with what O2 was appropriate.

Scary to think this stuff is still in protocols this way, because like I said we get a decent number of MD providers rolling thru our department and have a rough time getting them on board with EMS.

 

[Wayfaring Man]

I guess I can see how that could be read that way, it looks more like what to use when you find you need O2. There was another table listing SpO2 and other findings with what O2 was appropriate.

Scary to think this stuff is still in protocols this way, because like I said we get a decent number of MD providers rolling thru our department and have a rough time getting them on board with EMS.

Yeah, this is the way it's written and while I take it to mean "this is how you oxygenate a patient who needs it" that "ALL priority 3 patients. . . " thing with a NC is blatant. I don't agree with it but I'm not the ME. At the end of the day, I don't give a treatment that I don't think is necessary and I don't withhold a treatment that I think is necessary and I feel I can back that up, but I can understand how some people might struggle with that based on "protocol says. . . "

Can you elaborate on what you mean about having a rough time getting them on board with EMS?

One of the issues we have in MD is that all our career firefighters are EMTs, which is usually a good thing except that sometimes you get firefighters staffing ambulances who want nothing to do with EMS. But that's neither here nor there.

 

[Bullets]

here is how you document that*.









* please note you shouldn't actually do this unless you are looking to deliberately piss someone off.

oh im using this!

 

[Christopher]

Can you elaborate on what you mean about having a rough time getting them on board with EMS?

The vast majority slave over the protocols with little to know understanding of how anything actually works. Lots of "aspirin is a blood thinner" cookbook medicine, which doesn't really fly. Most seem lost when they realize the expectation is you're not just a first aider who drives a taxi.

A number have benefited from retaking an EMT course in NC. We take it as fact that with an EMT you're already proficient in acquiring BGL's (and don't say ridiculous crap like "it is an ALS skill"), BIAD's, 12-Lead acquisition, numerous medications (excepting naloxone, which is "relatively" new), and protocols which exist as a floor and not the ceiling.

A few of them did not care for our Con Ed which wasn't just rereading a textbook..."but NREMT doesn't say that!"

One of the issues we have in MD is that all our career firefighters are EMTs, which is usually a good thing except that sometimes you get firefighters staffing ambulances who want nothing to do with EMS. But that's neither here nor there.

I work in an area where all career firefighters possess an EMT or higher, and my department requires Paramedic (note: we have 16 non-administration employees). The folks who tend make the worst EMT's are those who were made to take it to continue employment. For the most part they're all pretty good. Early on in their transition we made part of their continued competency evaluation include ride time with the EMS services.

That being said, a number of our better paramedics came from the fire side and got "bit by the bug" during their clinical time with us.

 

[unleashedfury]

The idea of giving Hi Flow 02 to every patient is as old as johnny & roy. yet we still beat people over the head with 02 is for everyone LOTS of it too. what the hell why don't we just bag mask everyone cause that's high flow 02 and we can ensure the quality/quantity of respirations.

oxygenation is a BLS skill its one of the few medications you may administer as a EMT-Basic and we can't get that right half the time. we want to advance the field for better practicioners, better patient outcomes and become more proficient as clinicians yet we continue to follow old outdated protocols. and standards. so we look like a bunch of friggin monkeys with needles and we wonder why

In my years I've learned that not everyone needs 02, and its acceptable to just toss someone in the back of the buggy and drive take a set of vitals or 2. and call it a day. Not everyone fits the bill for prehospital interventions. If you got a patient experiencing leg pain. and cannot ambulate requesting EMS do they need oxygen? or anything we can do prehospital most likely not. a simple ride over to the ED is all they need. or an urgent care center if your protocol allows.

Don't withhold 02 from those who need it, but its not for everyone. follow the SP02 saturations guide. but if the patient is acutally experiencing distress treat your patient. I've seen patients with low 02 sats mid 80's but that's where they live should I dump them on 15LPM 02 via NRB mask? nope.