When will O2 truly help?

[HERBIE1]

A litre or more of RL is also pretty good for a hangover since dehydration is usually a key factor in feeling like $hit.

Put on a nasal cannula and hang a litre and a half, and you'll be good to go.

Naaa...... Just kidding... I'd never do that!

Nasal? NRB.

Thiamine and Dextrose, PRN too...

Or so I am told...

[VentMedic]

See what I mean, Brandon?

Because one is an EMT-B using a textbook written at the 8th grade level does not mean one has to think like an 8th grader. And that goes for the 10th grade level Paramedic text book also.

Unless you have the education, assessment skills and diagnostic, your medical director will not be able to write complex guidelines for you and thus you will have to make do with the protocols he/she gives you.

Unless you can assess for certain the patient with a broken extremity is "hyperventilating" due to anxiety and not a fat embolism, you may have to error one providing significant O2 in attempts to alleviate their feeling of not being able to catch their breath. The same might be true for the patient with a headache. Imagine what would happen if there is already some cerebral swelling and we not put their face in a paper bag or a plastic mask with little to no O2 flow. Imagine what rebreathing CO2 could do to that person's brain. There are also many theories of thought of the various types of cerebral ischemia and O2 therapy.

It is sad when some do want to over simplify some concepts and that my post is considered over the top by the Herbies of EMS. Is it little wonder why we get such "education" in EMS as "CPAP pushes lung water" and "lido numbs the heart". We also get all those great EMS/Fire station stories like "I've never seen it work on this or that". Yet, they are only with the patient for a few minutes and have no lab values to support what they are saying. Most don't know what happens to the patient 5 minutes after they are dropped off at the ED. Thus, are their "observations" useful for those who may have 30 - 60 minutes to spend with the patient for transport?

The other factor to consider is the research itself. Often when forming the bases for one concept something else pops up. Look at how NaHCO3 was deemed not useful in the primary phase of ACLS nor did it change the acid/base balance when given down the ETT but did find uses elsewhere. What about NRBM and decompression sickness? Hasn't that concept been revisited but after extensive research on other applications? How about Albuterol and hyperkalemia? Who would have thought a side effect could become a treatment? What about acetylcysteine, the anedote for Tylenol overdose? Who would have thought it had so many uses and some of which were discovered through research for something else. Sometimes we look at research with tunnel vision and don't always see what it has actually proven.

If some were to start recognizing there is a whole lot more to medicine, even at a very basic (not meaning EMT- level, there would be little argument against advancing the education for EMS providers. We need to stop dummying down the material and get EMS providers to become thinkers rather than just recipe readers. Getting one to think about basic concepts such as the formula for oxygen carrying compacity lays the foundation for you to critically consider the literature and what others are talking about. If you understand a few of these basic concepts you can then ask the appropriate questions of other healhcare professions including your medical director and know when some are just spouting what they saw on TV with such great shows as Third Watch or Trauma and believe that to be science. Too often some in EMS fail to establish a line of communication with their own medical director to find out why he/she wrote the protocol in such a way that you are questioning it. It is your medical director's license you are working under, not mine. I am just giving you a broader picture to think about.

I do not have a degree(s) either, However, I did sleep at a holiday inn express last night! That has to count for something right?

Respectfully,

JW

It also helps if your wife, the Anesthesiologist, is there.

Edited November 14, 2009 by VentMedic

[Jwade]

Because one is an EMT-B using a textbook written at the 8th grade level does not mean one has to think like an 8th grader. And that goes for the 10th grade level Paramedic text book also.

Unless you have the education, assessment skills and diagnostic, your medical director will not be able to write complex guidelines for you and thus you will have to make do with the protocols he/she gives you.

Unless you can assess for certain the patient with a broken extremity is "hyperventilating" due to anxiety and not a fat embolism, you may have to error one providing significant O2 in attempts to alleviate their feeling of not being able to catch their breath. The same might be true for the patient with a headache. Imagine what would happen if there is already some cerebral swelling and we not put their face in a paper bag or a plastic mask with little to no O2 flow. Imagine what rebreathing CO2 could do to that person's brain. There are also many theories of thought of the various types of cerebral ischemia and O2 therapy.

It is sad when some do want to over simplify some concepts and that my post is considered over the top by the Herbies of EMS. Is it little wonder why we get such "education" in EMS as "CPAP pushes lung water" and "lido numbs the heart". We also get all those great EMS/Fire station stories like "I've never seen it work on this or that". Yet, they are only with the patient for a few minutes and have no lab values to support what they are saying. Most don't know what happens to the patient 5 minutes after they are dropped off at the ED. Thus, are their "observations" useful for those who may have 30 - 60 minutes to spend with the patient for transport?

The other factor to consider is the research itself. Often when forming the bases for one concept something else pops up. Look at how NaHCO3 was deemed not useful in the primary phase of ACLS nor did it change the acid/base balance when given down the ETT but did find uses elsewhere. What about NRBM and decompression sickness? Hasn't that concept been revisited but after extensive research on other applications? How about Albuterol and hyperkalemia? Who would have thought a side effect could become a treatment? What about acetylcysteine, the anedote for Tylenol overdose? Who would have thought it had so many uses and some of which were discovered through research for something else. Sometimes we look at research with tunnel vision and don't always see what it has actually proven.

If some were to start recognizing there is a whole lot more to medicine, even at a very basic (not meaning EMT- level, there would be little argument against advancing the education for EMS providers. We need to stop dummying down the material and get EMS providers to become thinkers rather than just recipe readers. Getting one to think about basic concepts such as the formula for oxygen carrying compacity lays the foundation for you to critically consider the literature and what others are talking about. If you understand a few of these basic concepts you can then ask the appropriate questions of other healhcare professions including your medical director and know when some are just spouting what they saw on TV with such great shows as Third Watch or Trauma and believe that to be science. Too often some in EMS fail to establish a line of communication with their own medical director to find out why he/she wrote the protocol in such a way that you are questioning it. It is your medical director's license you are working under, not mine. I am just giving you a broader picture to think about.

It also helps if your wife, the Anesthesiologist, is there.

Vent,

1. So, curious, what exactly do you say to those people when you hear the above highlighted responses?

Yes it does.......I have no problems asking her opinion. Why would I? Cardiac Physiology background, Medical School, Anesthesia Residency, managed the TICU.....Deals with Respiratory Physiology every day of the week! .Wealth of knowledge.

I know where my comfort zone is and where it is not.....( NICU is not ) That is why they have NICU nurses and RRT's! I respect those professionals immensely....

Respectfully,

JW

Edited November 15, 2009 by Jwade

[VentMedic]

Vent,

1. So, curious, what exactly do you say to those people when you hear the above highlighted responses?

It becomes difficult when teaching CPAP or mechanical ventilation to those who have no college A&P and who don't understand the concepts of preload or afterload. I can explain alot of concepts relying on some of the principles FFs learn in the fire academy but when only given 30 minutes ot 1 hour to teach them everything they should know about CPAP or basic pharmacology, I still refuse to over simplify. It just gets tiring hearing "I've always heard this" or "This is what our instructor said". Usually the word instructor says it all as the person may not have any education beyond the certificate they are teaching and thus, they do not know how to explain basic hemodynamics or pharmacological principles themselves. Teaching over all the hearsay or "the way we learn it in the street" can be challenging.

Let me toss back your earlier comments about how the basic O2 calculations are not useful in EMS education. This is now something I will have tossed back at me when teaching a class as "don't need that crap as EMS providers".

....I really know all those nice little calculations and while certainly useful in an ICU setting, they are pretty pointless in the majority of EMS calls.....

I was initially speaking from a very basic point of view, and in the scenario HERBIE presented, the H& H ideally should be dealt with first. I even ran this thread by the SICU Trauma Surgeon / Intensivist today, and he said, " 1. The Placebo effect is unknown,

Some will now get this idea that these fundamental explanations of showing how O2 affects the body are pointless as you with some impressive education said so and they will shut off the learning process for these basic concepts as just extra BS. It is through the lack of understanding of a few basic concepts that lead to a break down in EMS education. Instead knowing how O2 is carried, O2 content, the difference between delivered O2 and that in the blood, and the basic formulas for how O2 devices deliver an expected amount of O2, some will just rely on memorizing note cards. Example: 2 L NC = 28% O2. Unfortunately that note card fails to mention "at rest for a 75 kg person breathing normal VTs of 500 at a rate of 12".

These simple forumalas can also disprove the "placebo" effect. If one was just using compressed air, you might have an argument for the placebo effect but even 1 liter of oxygen can change the content for PaO2 in the blood. When one reads the literature, they will notice that we categorize or measure with relatively small increments when discussing some FiO2 and PaO2 relationships. This is expecially true with neurological studies as we run tight parameters for PaO2, FiO2, BP and SjvO2.

But, many will now call O2 a "placebo" and that will not be correct as more research would be needed to know if even a small increase in PaO2 could have a calming effect on someone by affecting other physiological factors since we do know O2 can bring about various chemical/physiological changes in the body. The study would have to be done against a true "placebo" of compressed air.

Thus, we now have one more piece of hearsay about O2 being a "placebo" or "a couple of liters does nothing" that will have to be explained to EMS providers.

Edited November 15, 2009 by VentMedic

[melclin]

Let me toss back your earlier comments about how the basic O2 calculations are not useful in EMS education. This is now something I will have tossed back at me when teaching a class as "don't need that crap as EMS providers".

A tutor assisting us with some giving sets the other day followed up a talk we had from a nurse on drip calculations, by saying in the broadest accent I've heard in a while (roughly equivalent to Bubba's southern drawl) "Now, forget all that crap. In Ambulance we have two drip rates: s**t loads..and none". I laughed and thought of you for some reason.

[slymedic1]

Going to have to agree with John here, valid point as it may be, the idea of Oxygen in any amount being enough to even temporarily fix an anemic state is almost obsurd, If your patient needs oxygen give it to them wow what a post

[tniuqs]

[VentMedic]

Going to have to agree with John here, valid point as it may be, the idea of Oxygen in any amount being enough to even temporarily fix an anemic state is almost obsurd, If your patient needs oxygen give it to them wow what a post

However, for the benefit of the new EMT(P)s, if you read or hear "history" of anemia, that does not necessarily mean it is still true in present day. Many medical conditions can cause anemia and then improve as that condition has been treated. As well, they may be receiving regular treatment or even blood transfusions to deal with this problem. Don't let that word "anemia" distract you from still attempting to treat the shortness of breath and for doing a thorough assessment to look for acute causes.

[Jwade]

However, for the benefit of the new EMT(P)s, if you read or hear "history" of anemia, that does not necessarily mean it is still true in present day. Many medical conditions can cause anemia and then improve as that condition has been treated. As well, they may be receiving regular treatment or even blood transfusions to deal with this problem. Don't let that word "anemia" distract you from still attempting to treat the shortness of breath and for doing a thorough assessment to look for acute causes.

Vent,

I would like to think even new EMT-P's, RN's, RRT's would still be doing a complete assessment regardless of the situation.

As this thread has finally come full circle to illustrate that, YES, one has to eventually treat any and all underlying acute conditions, which is exactly what I said in my first posts.....Albeit a little too basic for some of the brain trust in here!

Respectfully,

JW

[chbare]

However, we are still discussing the question about who benefits from oxygen therapy? I think we can say, yes some patients will benefit from supplemental oxygen. However, how much they benefit from the said therapy may be a better concept to discuss. Going back to an anemic patient; There is little doubt that increasing the partial pressure of oxygen will in fact increase the content of arterial oxygen in these patients (assuming no diffusion or oxygen movement problems exist). However, as pointed out earlier the actual impact on content of arterial oxygen is rather small.

In addition, we must also appreciate the difference between hypoxemia and hypoxia. There exist very important considerations and implications associated with these two concepts.

Take care,

chbare.