Did this medic just not care or what?

[fiznat]

The pulse ox, alone, is meaningless. We don't throw patients on oxygen (or start any other treatment for that matter) on the basis of a single measurement. If you were concerned about this patient's oxygenation, why didn't you perform an respiratory assessment? It seems you had the opportunity, since you had already tried looking for an IV site.

Careful about how critical you choose to be about your instructors and preceptors. Utilize them for their knowledge, and don't feel bad about asking questions. If you want to know why this medic didn't think it was important to put the patient on oxygen, ASK him. Take the information you receive however you like, but the only way to truly understand how that decision was made is to ask the person who made it. Who knows, maybe you'll find out that there was more to it than you thought.

[usalsfyre]

A single saturation level of 92% in a longtime smoker with COPD probably wouldn't even show up on my radar. If it did, I'd check the probe first.

In the absence of increased dyspnea/a respiratory complaint or something related to a respiratory complaint this means positively squat.

How exactly could she have benefited from "some air" (for that matter wasn't she breathing "air")?

[usalsfyre]

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.

Agree more could have been done (IN fentanyl is a wonderful thing if it's available) but how does O2 play into her needs?

[spenac]

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.

[Bieber]

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.

[Richard B the EMT]

Perhaps not on target here, but I direct a question at the OP, 2Rude: Does the system you work in, or the local protocols, have anything on administering moisturized O2? While I cannot recall the last time I administered moisturized O2, New York State DoH requires that the supplies to do so are to be on board the ambulance.

[2Rude4MyOwnGood]

Sorry for leaving some info out of my original post. Keep in mind that im a student so im still learning! Thanks for all of the replies, ill answer them as best i can.

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.

Her presentation didnt change from when her SPO2 was 96%. When we arrived on scene she was supine on her couch, skin was pale and diaphoretic. Once in the unit she was placed in the POC, or semi Fowlers. I was unable to tell if there was any exertional dyspnea since she literally didnt do any moving on her own while in our care. She was able to speak full sentences and didnt complain of SOB. But her back pain became much worse with each coughing spell.

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.

My reason for asking about putting the patient on a NRB vs. NC is that i just wanted to make sure i was doing exactly what the medic wanted me to do. He wasnt exactly excited to have me back there with him so i wanted to make sure i did everything the way he wanted it to be done.

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?

The patient said that it was likely a slipped disk, something that she claimed had happened before. Great point about the anxiety causing her sat to go down, i hadnt thought of that. Her respiratory rate was 18 and regular when she wasnt coughing. I was looking to start an IV because the medic directed me to do so when we got her into the back of the unit. I listened to her lungs despite the medic not doing so and found that they sounded clear bilaterally.

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!

The patient denied any history of COPD, CHF, or emphysema. Her only meds were Abilify and Xanax. I didnt know that O2 could make the coughing worse, thanks for that info. So far in school its been drilled into our heads that everyone gets O2 and an IV, ill be sure to bring this case up in class this week.

And thank you Bieber for the lengthy reply! I didnt want to quote it and take up all that space but thats a very informative post. Im heading out the door for class in a few minutes but ill be back later to read it again.

Edited February 23, 2011 by 2Rude4MyOwnGood

[island emt]

Another quality post young jedi knight. +1

Bieber you are one of the few that obviously stayed awake and paid attention in class.

[tcripp]

Careful about how critical you choose to be about your instructors and preceptors. Utilize them for their knowledge, and don't feel bad about asking questions. If you want to know why this medic didn't think it was important to put the patient on oxygen, ASK him. Take the information you receive however you like, but the only way to truly understand how that decision was made is to ask the person who made it. Who knows, maybe you'll find out that there was more to it than you thought.

I couldn't offer a better suggestion other than you should be doing that for every call, whether you agree with the treatment or not. Get an understanding of why your preceptor handles each and every call. Carry this out with anyone you ride with. Any good medic will be happy to share with you their thought process. This will help you to understand how and why others do what they do so you have an good grasp of "oh, yes I was on the right track" vs "damn, I was just lucky this time" vs "I wish I had thought of that".

Every day should be a learning opportunity, regardless of what color patch you are sporting!

[Johnboy]

2R,

Your pt hx is very, very general. I am assuming her back pain was lower, considering she weighs 300 lbs. Upper back pain is a whole different animal, but you did not say. You have no documentation of lung findings, or her mental status. 96% sat in a morbidly obese pt is ok in my book, if they are standing up talking to me, holding a decent conversation. Does she have COPD, you didnt say, but one would have to assume she does because of your statement about her house being filled with smoke. Again, no lung sounds were disclosed. In COPD exacerbations, you have a respiratory alkalosis in the begining from hyperventilation, (compensation) followed by a steady rising hydrogen ion concentration as they worsen, so - your statement only carries so much weight with her Etco2 being 11. I am also assuming that you have placed this pt on the litter with her feet on it as well. If she is fat, guess what, all that adipose pushes his or her lungs up into her throat, hence the decreased sat. Treat the pt not the monitor, and please before bashing a seasoned medic, make sure you have your ducks in a row. I am sure he or she cares, this seems like nothing but drama on your part. I am sure he or she knows after 20 to 30 years of experience "sick or not sick".

JB