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BVM vs RSI (Was ketamine in trauma - better options)

htaed_rd at 123mail.org htaed_rd at 123mail.org
Fri Dec 23 04:15:10 GMT 2005


On Thu, 22 Dec 2005 19:01:23 -0800, "Ashton Treadway"
<napthene at gmail.com> said:
> Hi, Tim:
> 
> No harm, no foul. For my part, I'm sorry I derailed things like this.
> 
> Because you clearly have a strong opinion on this particular topic,
> let me ask you this: do you believe that the issues with prehospital
> pulse oximetry derive from:
> 
> 1. Fundamental problems with the hardware and/or method of determining
> oximetry ("hardware" issues),

Sometimes the equipment allows for a quick, clear, and accurate
measurement of oxygen saturation.

Often, especially in an unstable patient, there will be physiological
reasons that delay or prevent a clarity - agitation, poor circulation
due to pallor or low hemoglobin, ...


> 2. Misuse, misapplication, lack of training, or other "software"
> issues on the part of EMS providers, or

There is the paradox of the one thing research shows oximetry to be
useful for in the emergency setting being covert hypoxia.

So the most important use would be in confirming the appropriateness of
not applying oxygen after nothing else indicates that oxygen is needed.

The best way to use oximetry, in my opinion, is to fully assess the
patient first. 

If they appear to need oxygen do not delay it.

If you already know that you are going to give high flow oxygen by mask,
what benefit is there from a room air sat, or even a sat on oxygen?

After everything else is done is the time when oximetry is appropriate.

Too many people use it as a substitute for a good assessment.

There are paramedic schools that just want to process students, rather
than teach them.

They want to get by with an acceptable pass rate, rather than develop an
understanding of assessment, of treatment, or of iatrogenic
complications.

Touching the patient has become something repulsive in the eyes of many.

The pulse is assessed by using the oximeter, which gives a nice number
that does not require one to count or multiply.

With the discussions of should medics use RSI, or even intubate, it is
important to have excellent assessment skills, an ability to provide
care even when everything is malfunctioning.

There are people who will refuse to do anything without a reading from a
machine - whether it is a physician refusing to treat CHF until after a
BNP measurement or a medic, nurse, or doctor refusing to give oxygen
without a room air sat.

We have become technology dependent.

The technology is supposed to serve us, not restrict us.

I know many people who apply the oximeter as they are giving oxygen.

I do not really have a problem with this - it isn't delaying care.

I know some who will withhold oxygen, until after a sat, from an
obviously short of breath patient - that is a big problem.

It seems to be occurring more frequently. 


> 3. A combination of both factors

A bit of a combination, but the reliance on it prior to treatment
decisions is the biggest problem, when it does occur.


> And, following on from that, do you think these problems are solvable?

Well, I think that the entire educational system is broken and needs to
be remade.

Start over.

Start with the research, explain what science is.

Add in basic patient care and assessment in a step by step fashion.

Develop excellent BLS skills before moving on to ALS.

At each step relate it to research.

The scientific method is the alternative to magic, witchcraft, or
religion as medicine.

Talk about the major studies - what was done well, what was not done
well, what could be done to improve the study when redesigning it, ...

We have too many treatments that have no evidence to support their
prehospital use, so why are they being used by medics?

The same is true in hospital and in hospital studies do not apply to
prehospital use very well, but they do provide theories for further
research.

QA of medics focuses so much on a few easily measured items that can fit
on a small QA form - SpO2, oxygen, IV, ECG, blood sugar, ... but how
many really are appropriate for that patient?

There are protocols that insist that lidocaine be given for PVC's beyond
6/minute, or couplets, ... but no evidence of benefit.

There are protocols that make it very difficult, in some places, to
treat pain - yet all of the research states that we are undertreating
pain.

How many places QA for good pain management?

Are you more likely to get a spanking from QA for not enough pain
medicine or for too much - even though the patient is still in moderate
to severe pain with a good BP and more than adequate respiratory drive?

I see too many medics who have no idea what is going on with the patient
they are treating.

This should not happen.

In the airline industry they had problems with quality.

Those darned planes kept falling out of the sky.

They want ALL errors, no matter how minor, to be reported.

Here's the scary part - they are not looking for reasons to punnish
people.

They are looking for ways to constantly improve systems, to avoid
errors.

What happens in medicine?

The QA/risk management people do not want errors reported - then there
would be a record of a problem if someone were to sue.

Medicine creates an expectation that nothing less than perfection is
acceptable, but this can never be attained, so we deceive ourselves.

Does this do anything to improve patient care?

Well there are fewer mistakes documented, but that does not mean that
fewer occur.

A long winded response, but the way to fix it is to overhaul the
education of medicine at all levels.

We need to focus more on understanding and less on memorization.


> Is pulse oximetry a useful technology that's being used badly, or is
> it a bad idea, period?

It is a technology that is too often used as a substitute for a good
assessment.

It is not a bad technology, but it could be better (I doubt there is any
technology that couldn't be better).

The technology that we ignore too much is waveform capnography, but that
is a different post.

I'm interested in your thoughts as well.

Tim Noonan.


> I'd be interested to hear your thoughts on this.
> 
> Thanks,
> 
> Ashton
> 
> On 12/22/05, htaed_rd at 123mail.org <htaed_rd at 123mail.org> wrote:
> > "We are expected to evaluate the patient to the best of our ability (in
> > the prehospital environment, this tends to mean pulse oximetry, the
> > accuracy of which is notoriously variable, and patient assessment for
> > improvement) to determine whether intubation will improve the
> > patient's saturation over a BVM-plus-oxygen-plus-adjunct."
> >
> > I guess I was reading a little into this.
> >
> > Since you placed pulse oximetry first, I interpreted it as the priority.
> >
> > My mistake.
> >
> > My apologies to your instructors.
> >
> > So, rather than maintain that what you are being taught is wrong, let me
> > say that focusing on oximetry is wrong, and I am glad that they are not
> > misleading you in that way.
> >
> > And I apologize to you for the misinterpretation and for bringing so
> > much frustration your way.
> >
> > Tim Noonan.
> 
> [snipped]
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