Did this medic just not care or what?

[2Rude4MyOwnGood]

We ran a call yesterday to a 60yr old female complaining of terrible back pain that his been going on for about a week. The last 3 days she claims only leaving her couch to walk no more than 5 steps in any direction. We enter the apartment which smells like cigarettes and old people, she has a nasty hacking cough and claims to only have smoked 3 cigs that day.

Pain is a 10 at this point, but has gone as low as 7 over the past few days. She was unable to move so we laid out the Grier stretcher and used her sheet to lower her on to it. Pateint likely weighed ~300lbs. Put her on the monitor and it showed that her 02 sat was 96, BP was 146/90. She claims to have a very low resting BP so the medics told her it might be caused by the stress of the situation and we'll figure it out as soon as we can. Monitor also showed a C02 reading around 11.

We got her to the unit and her cough certainly didnt decrease at all, but her back pain was her CC, and all she was worried about. The lead medics took over while i looked for a vein to stick. Neither myself or the medic could find a site that looked good enough to poke at so he began talking to her about her medications.

We are already en route to a hospital thats less than 10 minutes away by this point. 02 sat now read 92. I ask the medic "would you prefer a mask or cannula for her?". He looked up and said " i wouldnt worry about it, we're almost there". I was blown away by that comment.

This guy is a 30 year FF/Paramedic vet and he doesnt think that withholding oxygen is a big deal? Even if it wasnt her CC, she still could have benefitted from some air.

So i guess im just wondering what the hell happened here? Did he just figure that since we were so close to the hospital, oxygen wasnt important anymore? Does any of this sound a bit off to you too, or am i overthinking it?

[mobey]

Why do you feel this was the wrong decision?

Can you explain the decrease in the 02 sat once the pt was moved?

This is where REAL learning takes place, within critical thinking.

Please answer the questions to the best of your ability, and I will help build on your answers to get you on the same track as the medic.

[P_Instructor]

Complacency can kill a cat........more should have been done for her even though the complaint was only back pain. Be the patient advocate and work her needs whether complaint or not in certain circumstance. My opinion only.

[2Rude4MyOwnGood]

Why do you feel this was the wrong decision?

I felt that it was wrong because the medic was only treating her CC, she clearly had other issues. He never even listened to her lungs once. She was moving air, but not in a very healthy way, and we were fully equiped to change that.

Can you explain the decrease in the 02 sat once the pt was moved?

Im guessing that her sat went down because her coughing and respirations were not allowing for healthy gas exchange in the lungs.

This is where REAL learning takes place, within critical thinking.

Please answer the questions to the best of your ability, and I will help build on your answers to get you on the same track as the medic.

I was hoping to learn a lot from this medic since he has been doing it for so long, but he was definitely the type who doesnt really care that there is a medic student riding with him, he was never eager to explain things to me. It was like pulling teeth to get info from him

[46Young]

Did the pt's presentation change at all from when the SPO2 was 96%? You didn't mention how the pt was sitting upon arrival. What were her L/S? Did she exhibit any exertional dyspnea? Could she speak full sentences w/o having to catch her breath? Is it possible the pulse ox probe wasn't on correctly? How was the SPO2 waveform? I'd personally have given the pt a few liters via NC if their sat went down, but you have to remeber to treat the pt, not the monitor.

[Chief1C]

I've been in similar situations, where I felt the paramedic wasn't doing what should be done. However, in the case of whether or not to provide oxygen. I don't ask. I just do it. Three or four liters of oxygen would probably have improved her monitor readings. But even if that wasn't provided as a vital sign, I'd likely have given oxygen anyway, based on the respiratory symptoms. If the medic doesn't want to do anything, that's on him/her, but I at least do what I can to make the patient comfortable.

We enter the apartment which smells like cigarettes and old people

That's real professional.

[FireMedic65]

What do you think the cause of the back pain was? You think anxiety caused the decrease in Sp02? What was her rate/quality of breathing? What was on the monitor besides the co2? What was the rhythm? What makes you think she needed 2li of o2? Why were you looking to start an IV?

If the medic didn't listen to lung sounds and you though it should have been done, why didn't you listen? Why didn't you speak up for what you though the patient needed?

[JCFEMedic2112]

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!

[kevkei]

Well, for starters, maybe trust the higher level of care and the experience he brings to the table and perhaps it isn't simply a case of withholding the O2.

Based on what is presented here, I'd say it sounds like a chronic COPD pt and lower O2 sats may be normal. What is more of the history - meds, past medical history, etc. How about physical findings such as lung sounds? Underlying rhythm on the ECG?

Remember, not all patients need 'VOMIT' = Vitals, O2, IV, Monitor, Transport. Also remember the saying of treat the patient and not the monitor. Based on the O2 sats, was it clinically significant? Do you have the possibility of disrupting the 'hypoxic drive' if she is a COPDer?

As others have indicated, try using it as a learning experience and ask what their thought process was. It's not fair to assume what was going through their mind and questioning their decision making. You would probably find that their was a logical thought process.

[D.P.Gumby]

Well, for starters, maybe trust the higher level of care and the experience he brings to the table and perhaps it isn't simply a case of withholding the O2.

Based on what is presented here, I'd say it sounds like a chronic COPD pt and lower O2 sats may be normal. What is more of the history - meds, past medical history, etc. How about physical findings such as lung sounds? Underlying rhythm on the ECG?

Remember, not all patients need 'VOMIT' = Vitals, O2, IV, Monitor, Transport. Also remember the saying of treat the patient and not the monitor. Based on the O2 sats, was it clinically significant? Do you have the possibility of disrupting the 'hypoxic drive' if she is a COPDer?

As others have indicated, try using it as a learning experience and ask what their thought process was. It's not fair to assume what was going through their mind and questioning their decision making. You would probably find that their was a logical thought process.

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.