When to believe the pulse oxymeter, when not?

[flamingemt2011]

In answer to your diabetic question, yes, I would agree with that and the cardiac monitor, and any other piece of equipment. I see too many rookies who do not know how to assess, BECAUSE your only experience is from the text book, and you blindly trust the machines. All this technology is great, but you can't base your treatment solely on what the machines tell you. The machines should justify your treatment, not direct your treatment, EXAMPLES:

IDDM patient,unconscious, acetone breath, D-stick says 99 ?

21 year old, monitor shows VTach, but the patient has stable vital signs and no cardiac symptoms.

Trauam Patient very pale, diaphortic, and tachycardic but machine say B/P is 140/90.

Patient has been hogtied by PD and left in the prone position for 30 minutes, patient is hyperventilating, pulse ox says 100% (read positional asphyxia - death by EMS on merginet)

I am not opposed to machines, but you have to be able to know when the machines are wrong.

[DwayneEMTP]

DFIB, no, only the SPO2 values.

You know what was really weird? I remember that I'd started to have trouble talking, and felt kind of drunk and hungover, slurring my words a bit, which is why the other medic got involved, I think hoping to prove that I was drinking...but mostly the moment when I thought, "Holy shit! I'm one of my patients!"

The idea of medical providers not diagnosing and treating themselves became real to me then. Had I seen you in that condition I hope that I would have gone down the right path much sooner, but my role was to treat people, not get sick, so having something other than a bug I could shrug off just didn't even appear on my radar.

Good experience though. For the record, to those that may treat these in the future it was symptoms were sort of like having a really bad flu, at least the last few days, nausea, joints/skin ached, really bad headache, combined with being motion sick..a little dizzy, slower than usual when thinking, had to focus to pronounce words clearly...

Dwayne

[Vorenus]

I am not opposed to machines, but you have to be able to know when the machines are wrong.

I agree.

Still, you`re argument that you`d have to learn by treating pt. without machines beforehand kinda wrong in my book. You have to learn to differenciate before hitting the streets autonmously, otherwise you`d decline those pt. the best treatment available.

[flamingemt2011]

Negative Ghostrider: To go a littel more in depth, I hope that you have some kind of orientation/training plan for rookies, who have not had much patient contact. I would hope that means you are assigned to a competent veteran, who was around before we had all of these machines (yes most of this technology was not around until the late 80s-90's, or was around but was too expensive for EMS to use). If you were my partner, I would teach you to assess without machines first, by that I mean your initial exam should be about surveying the scene, eyeballing the patient from a distance (can not tell you how many times I have walked in and spotted a critical patient from across the room, while a rookie was asking history questions, and had not realized the patient was in dire straits). Simple vital signs, head to toe assessment, and having a good idea of what is probably wrong before you attach a machine. Then I let you play with the machines and confirm or rule-out what you think you have. I am not saying I would not let you touch the machine for 6 months, I am saying we just do basics first in the early minutes of the call.

[Just Plain Ruff]

Negative Ghostrider: To go a littel more in depth, I hope that you have some kind of orientation/training plan for rookies, who have not had much patient contact. I would hope that means you are assigned to a competent veteran, who was around before we had all of these machines (yes most of this technology was not around until the late 80s-90's, or was around but was too expensive for EMS to use). If you were my partner, I would teach you to assess without machines first, by that I mean your initial exam should be about surveying the scene, eyeballing the patient from a distance (can not tell you how many times I have walked in and spotted a critical patient from across the room, while a rookie was asking history questions, and had not realized the patient was in dire straits). Simple vital signs, head to toe assessment, and having a good idea of what is probably wrong before you attach a machine. Then I let you play with the machines and confirm or rule-out what you think you have. I am not saying I would not let you touch the machine for 6 months, I am saying we just do basics first in the early minutes of the call.

You sound like a sound and competent preceptor, I am the same way, you don't get to really do a lot until you can show me you know the difference between shit and shinola.

[tniuqs]

You should not be allowed to use a pulse-oximeter until you have run at least 100 respiratory calls, and have assessed all of those properly with just your ears, eyes, and brain. You should be able to approximate a pulse-ox reading without using it, then use the pulse-ox to prove your estimation. You will be a far better clinician if you follow that advice.

EPIC FAIL on all levels.

http://scholar.google.ca/scholar?q=studies+pulse+oximetry+vs+clinical+recognition+of+cyanosis&hl=en&as_sdt=0&as_vis=1&oi=scholart

[DFIB]

I see too many rookies who do not know how to assess, BECAUSE your only experience is from the text book, and you blindly trust the machines.

I might be able to buy that idea if all textbooks contained were a dissertation about how one should blindly trust the machines but since textbooks teach patient assessment beyond what the oxemeter reads then I am calling BS on this statement.

IDDM patient,unconscious, acetone breath, D-stick says 99 ?

Does the fact that he is IDDM mean that he is necessarily in a diabetic coma? Are there any other reasons for acidosis?

Trauma Patient very pale, diaphoretic, and tachycardia but machine say B/P is 140/90.

Can you think of any possible scenario where a patient would be pale, diaphoretic and tachycardic that are not hypovolemia? And even a hypovolemic patient can maintain his BP for some time. This is called compensated shock. A person would have to lose 30% or more of their blood for their systolic pressure to drop below 90 mmHg. A plummeting BP is a late sign. Also I would expect the distance between the systolic pressure and the diastolic pressure to become closer not further apart.

I am not opposed to machines, but you have to be able to know when the machines are wrong.

This we agree with.

[Vorenus]

Negative Ghostrider: To go a littel more in depth, I hope that you have some kind of orientation/training plan for rookies, who have not had much patient contact. I would hope that means you are assigned to a competent veteran, who was around before we had all of these machines (yes most of this technology was not around until the late 80s-90's, or was around but was too expensive for EMS to use). If you were my partner, I would teach you to assess without machines first, by that I mean your initial exam should be about surveying the scene, eyeballing the patient from a distance (can not tell you how many times I have walked in and spotted a critical patient from across the room, while a rookie was asking history questions, and had not realized the patient was in dire straits). Simple vital signs, head to toe assessment, and having a good idea of what is probably wrong before you attach a machine. Then I let you play with the machines and confirm or rule-out what you think you have. I am not saying I would not let you touch the machine for 6 months, I am saying we just do basics first in the early minutes of the call.

Who do you mean?

[DFIB]

DFIB, no, only the SPO2 values.

You know what was really weird? I remember that I'd started to have trouble talking, and felt kind of drunk and hungover, slurring my words a bit, which is why the other medic got involved, I think hoping to prove that I was drinking...but mostly the moment when I thought, "Holy shit! I'm one of my patients!"

The idea of medical providers not diagnosing and treating themselves became real to me then. Had I seen you in that condition I hope that I would have gone down the right path much sooner, but my role was to treat people, not get sick, so having something other than a bug I could shrug off just didn't even appear on my radar.

Good experience though. For the record, to those that may treat these in the future it was symptoms were sort of like having a really bad flu, at least the last few days, nausea, joints/skin ached, really bad headache, combined with being motion sick..a little dizzy, slower than usual when thinking, had to focus to pronounce words clearly...

Dwayne

I have had CO poisoning when I was about 6 years old. I fell asleep in the floorboard of a VW bug that had an exhaust leak and a hole in the floor.

I almost died and have been very sensitive to CO in the air every since. I get the exact same symptoms as you describe but at a very low concentration and begin vomiting.

Too bad that happened to me, who knows I might have been a genius.

Edited to insert

Edited December 13, 2011 by DFIB

[Eydawn]

Dwayne. For the love of God. CO2 is carbon DIOXIDE.

The shit that kills you is carbon MONOXIDE. CO. That's why it can attach to hemoglobin.

Sorry. That one kills me... had to nail it. Now I'll finish reading, and THEN I'll make a substantial reply... ;-)

Wendy

CO EMT-B

First of all, to Flaming: Man, it would be great if rookies got paired up with someone who knows their current practice AND had the experience of practicing before we had all these extra assessment tools available. That would be ideal, as long as the providers were up on current practice.

Unfortunately, my experience was that I was paired with a medic from the 70's whose opinion was "we don't need none of that book larnin. Stick an IV in em and let's take em to the hospital." And a lot of the older providers I encountered, who were preceptors, just simply didn't approach clinical practice very well. They gave medications without understanding them. They bullshitted a lot. So I would have to disagree with this model, based on my n=1 experience.

Now, as to the question of using the devices or not; I say absolutely, you need to be using every assessment tool available to you. It's your own dumb fault if you fail to integrate all parts of your assessment, including what you see, hear, smell, feel, and have as data output from your machine. If you just go with the numbers you see, and don't use critical thinking, then you're up the creek.

Get a number you don't trust? Do a manual assessment when applicable and/or change machines... Now, if you get a result on two different machines that you can't reconcile with your other assessments, file that contradiction in your brain and make sure that info is available to either medical control or whoever you're giving handoff to.

It's a lot more simple than 'treat the patient, not the monitor' or 'I don't need to do that because I have a monitor to tell me XYZ'- there can in fact be a happy medium, it just takes a little bit of work IMHO.

Wendy

CO EMT-B