Two Questions:

Oh, I don't get the Fentanyl friend for a while, which is very sad. Paramedic school is in my future, but not for a few years. ;) But thank you for the compliment. I just kept wishing I could do more other than hug her sister and daughter (I'm not paid staff, I can do that!)
 
If you believe anxiety may be a root cause then oxygen is not the answer for two reasons. One, its never a good plan to give a drug to see if it may help. You only give a drug with a specific goal in mind and possible reactions and preparations to treat those reactions. Second, if it is anxiety related the patient will now believe they need oxygen to get through another anxiety related problem. Plus a NRB mask will make anyone anxious, try strapping one on your face after taking a short jog or doing some jumping jacks.
 
NYBLS said:
If you believe anxiety may be a root cause then oxygen is not the answer for two reasons. One, its never a good plan to give a drug to see if it may help. You only give a drug with a specific goal in mind and possible reactions and preparations to treat those reactions. Second, if it is anxiety related the patient will now believe they need oxygen to get through another anxiety related problem. Plus a NRB mask will make anyone anxious, try strapping one on your face after taking a short jog or doing some jumping jacks.
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She just kept asking for help to breathe. I think this situation is that little gray area between what we are taught in class and what is going on in the situation. Like I said- nasal cannula or NRM if she wants help to breathe with a tiny bit of O2 to make her feel better? I'd call the MD for sure before administering anything unless the Paramedic oks it. But that just seemed like it would be the step I would take if she were in my truck and I had say. I mean, if someone is yelling "help me, I can't breathe!" Do you just ignore her? Her mental status was so messed up that our coaching sure didn't work.
 
I"m really not being facetious. I'm still in that separation of head vs. heart. I just would have liked her to feel like she was getting some help is all. Even if all someone did was throw a NC around her ears and called it good. But shoulda-woulda-coulda, right? :) I'm learning! I'm learning!
 
Amelia said:
couldnt you put the NRM on with a low flow of O2?
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I don't think this is actually possible because of the way a NRB works - oxygen fills up the reservoir, and then the patient inhales that. If the O2 isn't flowing at a high enough rate, the bag won't be inflated, and the patient won't have any air to breathe (well not really, because 1 of the vent flap thingies is usually removed, which stops it from being a true non-rebreather).
 
Who are really wanting to help in this situation? Who are you really trying to help feel better? The patient or yourself?
 
Amelia said:
She just kept asking for help to breathe. I think this situation is that little gray area between what we are taught in class and what is going on in the situation. Like I said- nasal cannula or NRM if she wants help to breathe with a tiny bit of O2 to make her feel better? I'd call the MD for sure before administering anything unless the Paramedic oks it. But that just seemed like it would be the step I would take if she were in my truck and I had say. I mean, if someone is yelling "help me, I can't breathe!" Do you just ignore her? Her mental status was so messed up that our coaching sure didn't work.
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Oxygen does not magically give someone their ability to catch their breath. Odds are if someone is yelling at you that they can't breathe, they are breathing just fine. Now if they can barely speak more than a few words you might have a problem. That would probably be a good time to assess your patient then. It might behoove you to listen to their lung sounds, if they are moving good air and have clear fields throughout and are satting well and are yelling at you? They probably don't need oxygen.

Also, now would be a great time to kill the placebo idea. There is no reason to administer a medication unless you want its actions. Oxygen is not a pain reliever nor an anti-anxiety agent. Oxygen is a drug like any other, and has indications. We don't give our patients tubes of glucose to make them feel better cared for either, right?
 
Thats very true. Learning through experience and those much wiser, eh?
 
Epi- her. Im a very selfless person as would indicate my husbands and boys clothes are clean and mine are neglected until I find no clean clothes (oh yeah- i need to take care of myself too) i just need to be ok with "theres nothing else I can do." But im hoping that in the "zone" ill feel differently. The ED is not my territory, shall we say?
 
Tigger said:
We don't give our patients tubes of glucose to make them feel better cared for either, right?
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luke_31 said:
1: oxygen doesn't need to be given if sats are normal in the ED. As an EMT you should never withhold oxygen from a patient who has those complaints.
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What exactly is the difference? If the ED is basing whether or not to provide oxygen only on spO2, why aren't we? For that matter do we really think the ED is basing their decision based purely on a number? Of course not. They assess the patient and determine what interventions are needed. EMS can do that too. I've said already, but if someone is yelling at you that they can't breathe, they can breathe just fine and need to be calmed down.

COmedic17 said:
2. Your not a doctor. You can't diagnose people. You can tell them the signs and symptoms, and they will understand what you are getting at. That's why you call cardiac "alerts" and stroke "alerts". You can alert the hospital to a POSSIBLE life threatening condition, but you can't diagnose it.
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Doctors do not have a monopoly over the term "diagnose." Call it what you will, but it's silly to say that EMS does not diagnose. If we didn't diagnose (definition: identify the nature of (an illness or other problem) by an examination of the symptoms), how are we justifying our treatments?

Flying said:
For this specific purpose, I would make a point on choosing a NC over a mask because the person is more likely to feel the flow of air at lower pressures, contributing to any placebo effect.

I find it fantastic that you are more in tune with the needs of the people who we transport than those who have been in EMS for x years. People will thank you for providing something tangible in terms of their treatment. (Some may appreciate our good buddy Fentanyl more, but that's another story.)
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Alternatively, when you provide an improper medication you are just practicing bad medicine. Oxygen is medication just like fentanyl is. Not to mention that not every patient will respond well to such a treatment. Perhaps placing oxygen on someone will only worry them more...

Amelia said:
Epi- her. Im a very selfless person as would indicate my husbands and boys clothes are clean and mine are neglected until I find no clean clothes (oh yeah- i need to take care of myself too) i just need to be ok with "theres nothing else I can do." But im hoping that in the "zone" ill feel differently. The ED is not my territory, shall we say?
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Sometimes you won't have the treatments the patient needs, sometimes the patient does not need any treatment. There is a distinct difference there.
 
Tigger said:
What exactly is the difference? If the ED is basing whether or not to provide oxygen only on spO2, why aren't we? For that matter do we really think the ED is basing their decision based purely on a number? Of course not. They assess the patient and determine what interventions are needed. EMS can do that too. I've said already, but if someone is yelling at you that they can't breathe, they can breathe just fine and need to be calmed down.


Doctors do not have a monopoly over the term "diagnose." Call it what you will, but it's silly to say that EMS does not diagnose. If we didn't diagnose (definition: identify the nature of (an illness or other problem) by an examination of the symptoms), how are we justifying our treatments?


Alternatively, when you provide an improper medication you are just practicing bad medicine. Oxygen is medication just like....
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The difference is about 9+ years of medical schooling.


Also, my protocol says ANYONE complaining of SOB or difficulty breathing gets atleast some 02.

In addition, Your confusing a field impression with an actual clinical diagnosis.

I can think someone has hyperkalemia due to other symptoms and field tests (vitals, EKG, etc),but until I have labs, all it is is a field impression of what I THINK is probably wrong. I do not have a ct scan. I can't diagnose a stroke. I can say someone failed the Cincinnati stroke scale, is hypertensive, and I am fairly certain they are having a stroke, but without a head scan I can not diagnose it.

So no. We do not diagnose. Our treatments are based off of a field impression of what's probably wrong, based on signs and symptoms. It is not definitive.
 
COmedic17 said:
The difference is about 9+ years of medical schooling.


Also, my protocol says ANYONE complaining of SOB or difficulty breathing gets atleast some 02.

In addition, Your confusing a field impression with an actual clinical diagnosis.

I can think someone has hyperkalemia due to other symptoms and field tests (vitals, EKG, etc),but until I have labs, all it is is a field impression of what I THINK is probably wrong. I do not have a ct scan. I can't diagnose a stroke. I can say someone failed the Cincinnati stroke scale, is hypertensive, and I am fairly certain they are having a stroke, but without a head scan I can not diagnose it.

So no. We do not diagnose. Our treatments are based off of a field impression of what's probably wrong, based on signs and symptoms. It is not definitive.
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That is a purely semantic argument. A doctor's diagnosis is not carved in stone either. Field impression, working diagnosis, whatever else you call it, it's all the same. You take the information provided to you and make an educated assessment as to what is causing the patient's issues. But I digress, this is not a fight worth having.

And spare us the "my protocol" argument, you can do better than that. Critical thinking, it's a thing. Assess your patients and treat appropriately. Most (if not all) protocols are prefaced with something along the lines of (borrowed from my book):

These protocols are guidelines and cannot be expected to cover all clinical conditions and patient variables. On occasion, patient presentations may be handled with some deviation by providers.
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Use clinical judgement. If you are justifying anything with "my protocols said so," you have not justified it at all.
 
I'm having a hard time finding it but at one of the big EMS conferences there were a bunch of MD's (that is Medical Doctor if you didn't know (sorry couldn't resist)) that said paramedics do diagnose. I'll keep looking because jems or emsworld did a thing on it.
 
You know what I should have sone is to ask the family to keep coaching her on her breathing. Im sure they were just as exhausted and stressed as she was. They probably needed some coaching too. I am very glad, however that she is ok and hopefully rested up.
 
And that's where I was confused- protocol vs common sense vs developing EMS critical thinking.
 
The whole bit with the oxygen is a bit silly, my fault for encouraging off-label use.

I've always liked the idea of having a diagnosis to work with. Ideally, every call gets a basic assessment/history, from which we gain a theory or idea that we base our logistical decisions on.
Our theory will never be refined by laboratory data, but we still decide to order our priorities with the information we have.

How do we justify not going L&S on every call when we say we cannot tell what is truly going on? It seems to be more reasonable to say based on x findings we can say that this person won't die within the minute, and would appreciate a slow and smooth ride to the hospital.

Sorry in advance for beating the horse.
 
ED Doctors diagnose all the time, and then the hospitalist comes along and gives another diagnosis, and then the PA discharges with a third diagnosis.

Use your assessment skills to create a WORKING diagnoais, use your clinical judgment to treat accordingly using protocols as a guideline. Act in the beat interest of your patient. You are a professional medical practitioner, have some respect!
 
Amelia said:
And that's where I was confused- protocol vs common sense vs developing EMS critical thinking.
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Use it all! There is no reason why any of that need by mutually exclusive.

You probably see my big point now, your assessment is the most important part. Don't measure yourself based on what you can or cannot provide for your patient.
 
I got it. :) Thanks guys. You're right, I need to trust my training and critical thinking more.
 
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