Maybe not a complete, out of my mind, drooling, almost incomprehensible rant, but a rant none the less.
Pulse Oximetry was hailed as the “Fourth Vital Sign” back in the early 1990s when it started to filter it’s way out of units into Emergency Departments and EMS systems. It really wasn’t but it was a great slogan to sell it to the skeptical.
Pulse Oximeters are indirect measuring devices. That is they don’t directly sample the blood, they do it with LEDs. Which are the first cousins to LASERs. Really, would Britney Spears lie to you? So, a Pulse Oximeter shines a LED light into your finger and measures the amount of light absorbed by the blood and calculates hemoglobin saturation. Just in case you wanted to know.
I’m not sure I’ve ever seen a more misused technology in EMS, one with questionable benefit to the patient. Pulse Oximetry is supposed to be used as a trending tool, not a spot check. Yet invariably I see practitioners place the probe on a finger, get a reading, and then toss the device back into their bag. What, pray tell, does a reading of 100% tell you about a patient? Now, a reading of 84% does tell you something about the patient, but I’m not sure I’d like to work with a medic or EMT that can’t tell a hypoxic patient without using a Pulse Oximeter. I AM sure that I wouldn’t want one treating a loved one.
So, what does a Pulse Oximetry reading of 100% tell you? It tells you that the patient’s blood is well saturated with Oxygen. Great news, but again not all that important, especially as a spot check. My resting Pulse Oximetry reading is 96%, sometimes 97%. I don’t feel hypoxic, I don’t get Dyspnea on Exertion. No, I don’t need home O2 or intubation, I just have a low Pulse Oximetry reading.
Don’t even start me on medics and EMTs that use the thing just to get a pulse. Touching a patient? How radical.
What that number doesn’t tell you is how well the patient is ventilating. The old “in with the good, out with the bad” from the Looney Tunes cartoons. Here are some patient types that might have good readings despite being really, really, sick. CHFers, COPDers, Pulmonary Emboli, Carbon Monoxide Poisoning, Smoke Inhalation and of course Asthmatics.
Any of those patients can, and have, had readings of 100%. I’ve seen it and I’ll bet you have too.
So, how do we really assess a patient’s ventilatory status? It’s really simple, in fact you probably learned it your first week in EMT school.
Look at the patient. How hard are they working to breath? Retractions? Tripoding? Prolonged expirations? Are they working to inhale, exhale, or both? What does their skin color look like? If they have dark skin, look at the oral mucosa, it should be pink. Most importantly, do they have that “I’m gonna die right here in front of you” look?
Listen to the patient. Can they speak? How many words can they speak between breaths. Five or more is good. Listen to lung sounds. That $5000.00 stethoscope is good for more than just looking cool for the cute young nurses and EMTs. Ronchi, rales (crackles is what a particular brand of breakfast cereal does), wheezes, stridor? Good breathing isn’t noisy, you should hear a gentle rush of air moving in and out. If you don’t hear anything, you either spent way to much for that stethoscope, have the bell turned the wrong way, or an about to die patient on your hands.
Feel the patient’s skin. Is it wet and cold? Hot and dry? Wet and hot?
Do that for every patient no matter what the call is dispatched as. Do it on transfers, do it on ankle fractures, do it on idiots that call for a toothache. Do it until it becomes automatic. Do it until you can do everything I wrote in the preceding three paragraphs automatically. Know what is normal and what isn’t. Soon, you’ll be able to walk into a room and in about thirty seconds have a pretty good idea of what the patient’s ventilatory and respiratory status is.
Before you know it, you’ll hardly glance at the little beeping box and will never need it to tell you if a patient is sick.