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All of this seems reasonable, but I think the hypoxic drive comment deserves mention: it's been pretty thoroughly debunked. Only a portion of COPD'rs are chronic CO2 retainers who could even putatively adapt to chronic hypercarbia and loose any impetus to breathe besides hypoxic drive. Even among that subset, several studies (can't find the list of citations right now unfortunately) have failed to find a decrease in respiratory rate due to oxygen administration, although they have revealed an increasing acidosis, and I've yet to see any reliable reports of apnea due to O2. Simply put there is no evidence that the hypoxic drive takes over in these patients, results in a decreased respiratory drive when exposed to high FiO2, or explains any of the pathology seen in COPD. Also the idea that cerebral chemoreceptors become totally “non-responsive” to rising levels of CO2 seems rather odd, as most other receptors/control systems will exhibit adaptation in the form of a changed “set-point” rather than complete abandonment of regulation. I do not believe any evidence exists to suggest that there is a loss of responsiveness of chemoreceptors to changes in CO2. That said, there is evidence of hypercarbia and acidosis following O2 administration in COPD patients, but this has nothing to do with decreased respiratory rate due to "hypoxic drive." Similarly, there is now evidence of increased mortality due to over-oxygenation of COPD patients in the prehospital environment (http://www.bmj.com/content/341/bmj.c5462.abstract), so your concerns are perhaps correct, but not because of the hypoxic drive.

I agree, treat the patient, not the machine, first of all, and secondly, 92 percent could very well be where she lives all of the time. Plus, we do not know what her meds were. Does she have emphysema? CHF? Coughing is only going to be exacerbated by some nice cold, dry, oxygen being introduced to her already irritated upper airway. Coughing could certainly be the source of her back pain if she has had some really bad bouts in the last few days. Making her cough more is going to make her hurt more. Oxygen will do many many things, however, one thing it will never, ever do is cure coughing. Whether the pain is from coughing or not, either way, it s going to make the patient really hurt bad if we make her cough more. I agree with the medic, I would not have placed her on oxygen with the information as provided here. It would have caused her more pain with the likely increased coughing. With all of that said, the Preceptor should have taken the time to explain his reasoning for his choices with you. Precepting is a verb, it does denote that you actually do something. Very good questions!

Well, it looks like I showed up a little late to this conversation, everyone seems to have answered this the same way I would have. But I'll just reiterate what's already been said, and that is to treat the patient, not the monitor. Like some others have mentioned, in the absence of physical signs/symptoms of respiratory distress an SpO2 reading of 92% isn't particularly worrisome. Oxygen, despite what we have heard, is NOT a benign treatment and it isn't for everyone, though many of us--including myself--live under blanket protocols that dictate that oxygen should be maintained at certain saturations (95% of above for me) or that it should be applied to every patient under the sun. This is unfortunate and hopefully on its way out, because we're seeing now that oxygen therapy can in fact be detrimental to certain patients, ironically the ones we've long presumed needed oxygen the most (i.e. AMI patients, and I believe also COPDers). Unfortunately, if your EMT program was similar to mine, you probably just learned the bare minimum of oxygen therapy (that is, never withhold oxygen), and that "all patients get oxygen". Even in my paramedic program, oxygen therapy was not covered as in depth as it should have. It's our natural instinct to have that knee-jerk reaction to vital sign readings that are outside of the "normal" range we're taught in the classroom, but it's important to recognize the difference between benign vital sign aberrations and malignant vital sign aberrations. What I mean by that is that you have to look at the whole picture, including and especially the patient's presentation. That means differentiating between acute illness and chronic illness. The truth is, many if not most of the patients we deal with on a daily basis have chronic conditions that they've lived with for a long time. We're not there to treat those, not unless they're the cause of today's emergency. During my internship, there were a couple of times where we were called to a patient with a LOT of underlying medical conditions that made me want to treat them for it, and something my preceptors really hounded me about was differentiating between the chief complaint and those underlying medical conditions. Yeah, there's a lot of patients with some serious problems, but what did they call EMS for TODAY? What is their medical emergency? In this case, is it this patient's chronically low SpO2 levels, or is it back pain? The next thing you need to ask yourself is what NEEDS to be treated, and what doesn't need our treatment. Yeah, you can opt to place this patient on oxygen, but what's the end goal? If she's in respiratory distress, it obviously needs to be treated. But if she isn't in any sort of distress, what do you think is going to be done in the emergency setting about her chronically low SpO2 readings? That's a long term condition that isn't going to be corrected by the ER, not if it's not her acute complaint today. So you can put oxygen on her, but I guarantee you if she doesn't have any respiratory complaints, the ER doc is going to say, "Yep, you've got chronically low SpO2 readings, you need to stop smoking and follow whatever regimen your general practitioner has set for you, and we're going to treat your emergency condition, the back pain, today." You're going to find, or perhaps have already found, that many patients live with high blood pressure, with problems ambulating and taking care of themselves, and many other conditions that we simply cannot treat and are not here to treat. So a patient's got high blood pressure, big whoop. What did they call EMS for TODAY? If it's for symptoms relating to that blood pressure, then it's probably time to do something about it. If not, then that's okay. It DOES need to be treated, but I'm not the one to do it. Another example would be a patient complaining of, say, an extremity injury whose EKG shows atrial fibrillation WITHOUT rapid ventricular rate or signs/symptoms of cardiac instability. Yeah, they need to get that treated, but that's also something they've probably lived with for a while, and if they're not having any symptoms from it, then I'm just gonna monitor it and treat for their chief complaint. We're not out to solve every medical problem our patients have, we're there to treat their EMERGENT conditions. And it sucks and it's hard to see somebody with a medical problem that we can't or shouldn't treat, but the sad truth is that many of the patients you'll have are in a bad way without the emergency they called us for. Your job is to differentiate between the emergency condition--their chief complaint--and the other stuff that we just can't fix in the field or even in the ER. I WILL say, in your defense, that anecdotally I've found that oxygen can help to some limited degree to relieve pain and nausea, so if you think the patient might have benefited from some oxygen in THAT respect, I'll agree with you. However for the sake of raising her pulse ox alone, I think you've got to look at the bigger picture.

Ok women is obese. If I understand what was written she was placed supine. Thank about what happens with all that adipose material. What does it put pressure against? _________ . Which in turn puts pressure on__________, which leads ultimately to a lower spo2 reading. What could you have tried that might have changed the spo2 w/o adding o2? As to pain management well not being there it is hard to say whether right or wrong but I will say it seems pain management by EMS needs great improvement.