By Dan Limmer
A friend who teaches for the Army in Texas called me and began the conversation with, “Our students preparing for the NREMT think ‘How much oxygen should this patient get?’ instead of, ‘Should this patient get oxygen?’”
The Wonder Drug Phenomenon
We batted around how to change that thinking. After a bit of discussion, I realized that the American Heart Association changed the oxygen guidelines in 2010, and we still have educators and providers advocating oxygen for every patient. I call this the “wonder drug” phenomenon.
When I speak at conferences and teach my students, I give this example: The next time I treat a patient with anaphylaxis, can I give them 3 or 4 doses of epinephrine with an epinephrine auto-injector? The class is pretty quick to say no. So why do we administer oxygen, a drug capable of doing harm, ignoring any sense of indication or contraindication?
Why? Because we are trying to change an attitude, not a habit. Students don’t come into class thinking oxygen is the wonder drug. The textbooks don’t say it. The NREMT skill sheets say “high concentration oxygen,” but that is because the patients in the medical and trauma assessment scenarios need it based on indications.
How to Think About Oxygen Administration
The fact is, even experienced providers sometimes have trouble figuring out when patient should and shouldn’t get oxygen. It’s not an easy thing to understand, and it’s not an easy thing to teach.
I created this flowchart to help put some reason and definition to the issue of who gets oxygen, and how much. The flowchart isn’t a recipe or strict guideline. There will always be a need for clinical judgment.
Let’s walk through it:
Does the patient’s SPO2 indicate hypoxia? Oxygenation decisions are made during the primary assessment. <94% is the clinical guideline put out by the AHA. You should always verify the reading on the pulse oximeter, but it makes a good starting point.
If hypoxia is present, the patient is going to get oxygen either through nasal cannula (if they need a little oxygen) or a non-rebreather (if they need a lot).
What if the pulse oximeter doesn’t indicate hypoxia? Look for other signs that could indicate the patient is hypoxic – e.g., abnormal breathing signs or cyanosis. Also look for evidence of instability or shock. If those signs are present, administer oxygen at the lowest level to adequately address it.
And if the pulse oximeter doesn’t indicate hypoxia, there are no signs of hypoxia and no signs of shock, then the patient does not need oxygen.