When to believe the pulse oxymeter, when not?

[DwayneEMTP]

I truly believe that having a preceptor that made me define my expectations before being allowed to apply any technology changed everything about me as a provider.

Still in my head I develop my theory, if only a knee jerk quickie, before putting on the O2, monitor, SPO2, capnography, etc. I think it's made me much stronger. Maybe not as strong as those that use then at the same time as developing a theory, but pretty good still.

The many if not most of the most significantly ill medical patients I've treated while doing remote medicine I've discovered before they were reported to me. Diaphoretic, inappropriately anxious, speech off, noticed that they stumbled over nothing, distant look when part of a conversation, etc.

I find that to be really uncommon characteristic in a medic. I used to say, "Hey! What are you doing? Don't you see that guy? Go and get him!" But now understand that mostly remote medics don't see much until someone hits the ground. I'm nothing special, but I do attribute my desire and ability to develop hands off suspicions to being forced to develop a working diagnosis without the aid of technology.

Again, not saying that my way is the best way, or that machines are useless. But in the remote arena at least I think it's a strong approach.

Wendy....Potato, potaato... :-)

Point taken...thanks.

Dwayne

[flamingemt2011]

Wendy I agree with you whole heartedly, and I must agree that in many systems orientation consists of "theres your truck, and you have a call holding". I am speaking specifically to new medics with little experience. You have to walk before you crawl, but rookies tend to lean on the machines too much. I agree, as you progress and fine tune your assessment skills, you may jump to the fancy machines quicker, or as a first tool. I imagine when you learned to drive your parents started you off in a parking lot, or a road that had little traffic, they did not dump you out on an interstate at rush-hour on day 1.

And yes, there are too many oldfarts in this industry who are incompetent and lazy.

[Vorenus]

Yeah, a mix of of both is obviously best.

I try to maintain that rountine: I do my physical assessment, do the anamnesia and stuff, while my partner is applying the monitoring on the patient (when I`m the senior/leading provider at scence). That way, when you`re through with your assessment and anamnesia, you`ll have everything you need to determine a possible therapy/treatment plan.

This defers with certain groups of patients of course, still I think it`s not a bad concept.

Although fairly new in this profession, too, I try to teach the bascis to trainees, too, when I have shifts with them.

Most important thing is too get them to acknowledge the importance of a proper anamnesis. I`ve got some trainees who grabbed straightforward for the med package (I let them do most of the stuff mostly) - that`s when I unobstrusively ask them wether they have asked that and that question, to get them on the right path again.

Edited December 13, 2011 by Vorenus

[tniuqs]

And yes, there are too many oldfarts in this industry who are incompetent and lazy.

And all the young ones are competent and motivated ... omg you have so many stereotypical opinions you should be in the Guinness book of world records .

[armymedic571]

Wendy I agree with you whole heartedly, and I must agree that in many systems orientation consists of "theres your truck, and you have a call holding". I am speaking specifically to new medics with little experience. You have to walk before you crawl, but rookies tend to lean on the machines too much. I agree, as you progress and fine tune your assessment skills, you may jump to the fancy machines quicker, or as a first tool. I imagine when you learned to drive your parents started you off in a parking lot, or a road that had little traffic, they did not dump you out on an interstate at rush-hour on day 1. And yes, there are too many oldfarts in this industry who are incompetent and lazy.

Incompetent and Lazy? Maybe... Maybe Not! Ones over usage of diagnostics can be causative of many different factors.... Now that I think of it, I really had nothing intelligent to add to this conversation.

[Bernhard]

Whow, great discussion! Thank you!.

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're not getting the point of my posting. Beside that: our EMS bought pulse oxymeters around 10 years after they bought me (very cheap, I have to admit), and we already did have oxygen in those days.

As a EMT-B I find Pulse Oximetry to be a very useful tool although it really doesn't influence my treatment that much. At our level we pretty much give everyone a little O2 except when otherwise contraindicated.

Well, that's somewhat the point. Should we really do this? Guidelines say, that too much O2 (>98%) will be not good - so I usually now leave O2 away now even in myocard infarct and stroke settings when SpO2 measures 94-98%. That said, my experience with the unexpected false-low reading in case#1 and the very bad signal in case#2 gave me something to think about the reliability of the pulse ox readings.

I'm still remembering old days when O2 was given to practically every patient. Having no problem with accepting new guidelines, I simply have a problem with believing a tiny tool dangling from someone's finger to be exact about a delta of 1%. And sorry, no, flamingemt2011, I don't believe that you are able to have even this accuracy.

Exactly, since we are stepping back from the old "O2 can`t hurt"-attitude, SpO2 measuring is even more important.

Yep, but I still am a bit unsure what the thing is really telling me, if it shows 98% (OK) instead of 99% ("too much"). Well...yes on the street I don't have a real issue with that (the 60% reading WAS an issue), but Dwayne simply got me thinking...

Displayed pulse matches manually measured pulse. Clinical correlation. If there's a waveform on the pulse ox, then the waveform is regular and not hitting the upper or lower limits.

I think, those basic rules make a lot of sense and I will take them over in all their shortness, remembering I already heard them somewhere but confess, I did not follow the pulse/waveform criteria. Thank you very much (BEorP too for mentioning the waveform criteria first)!

What other point of care testing can we use to titrate treatment, or do we just go with a NRB for everyone?

I think, that's the other real point, even if we can't trust on total accuracy, we can monitor changes. My question #3 actually was targeting to this answer, thank you for having it that quick. Plus, a pulse oxy is a great basic monitor device when you have not much space or have to move the patient (crash rescue, steep stairs) where a full ECG would get in the way.

(Dwayne & DFIB: glad you survived your experience - I continue to hear about such incidents, so maybe Dwaynes prophecy is correct).

Note: any spelling and grammar errors made intentionally for identifying purposes only.

[DwayneEMTP]

And all the young ones are competent and motivated ... omg you have so many stereotypical opinions you should be in the Guinness book of world records .

Don't be hatin' just cause all of us youngsters make you old shitheads look incompetent.

Plus, I think it's friggin' hilarious that you saw yourself in that post! Me? I had no idea what he was talking about...

Dwayne

[mobey]

As a EMT-B I find Pulse Oximetry to be a very useful tool although it really doesn't influence my treatment that much. At our level we pretty much give everyone a little O2 except when otherwise contraindicated.

Wouldn't it be contraindicated in every patient that is not hypoxic since it contributes to production of free radicals? (I do realize that it is only really a problem at high concentrations... just a point of context)

Running 100 respiratory calls will definitely make you a better clinician considering you do the proper workup and have a good feedback system but saying that the only way to learn to use oximetry is by running calls indicates that you think we all are idiots and incapable of learning through didactical training.

Quoted for emphasis

[thrutheashes]

This topic takes me back to something that I have believed for quite some time. As providers we need to rely loess on our toys, and rely more on our training, education, and instincts. The old mantra says "treat the patient, not the equipment" and I believe that 100%. We as a profession need to put EMPHASIS on our assessments, and use our technology as a backup, and not the other way around. I know it's an easy trap to fall into , and I've been there myself, though it is something Iconsistently try to work on.

[tniuqs]

Don't be hatin' just cause all of us youngsters make you old shitheads look incompetent.

Plus, I think it's friggin' hilarious that you saw yourself in that post! Me? I had no idea what he was talking about...

Dwayne

I found this entire thread rather amusing, very atypically stayed out of this on,e placing it under "it amuses me category" well until I saw the extra stupid post, them's fighting words LOL.

Could it be that over the years the posts and the links in delivery of oxygen, the in-depth posts by some of the "old" <just coughed a big loogie type respiratory terrorists> the research presented by the ones that are "incompetent" and not to forget "incontinent" and have "ED issues with gay porn" have perhaps altered some of the through processes of those youngish farts on this topic, ok well some it appear's a light came on.

Most seriously when I started as an RRT I had a wheeled cart to push the pulse ox around on, or go change a transcutaneous P02 probe to a new site to prevent burns <insert a weak feeble laugh> from pushing that cart .

Now they fit in me damn pocket and so small without my spectacles on that I loose them, needing a lanyard around my neck so it doest get lost in my rolls of phat..

But this is where I differ in opinion, these are extremely valuable tools, the blinky coloured LED light thing, the pulse number and that other number are far more in depth that what most bedside practioneners in EMS actually understand or what its telling them ! This as the understanding of "content and capacity" light contamination, recognition of blood dyscrasias, or motion artifact, flash through some of my slowed but still semi active synapses .

Rarely are the numbers misleading, the recognition that they are accurate readings from some of the posts is again rather hilarious from where I sit in my rocking chair gazing empty minded out the window .

Fact of the matter is we do treat the machines .. for example if you do not have a monitor at a code just what drug does one use ? Do a pulse check or a stethoscope for an anti arrhythmic or TNK ? ..... bah LMFAO.

We give blood based on machines ?

We use antibiotics based on machines ?

We do ventilator changes based on machines ?

We place in stents based on machines ?

Its only in EMS where this old "Myth" of treat the patient not the machine still has its throwback to the dark ages.

cheers