By Dan Limmer
I love formative discussions with other educators—the kind that I can’t stop thinking about even after I hang up the phone. I had one of those conversations today.
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?’”
I agreed. We can’t seem to get the oxygen monkey off our backs.
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. We somehow model that for them. Their books 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.
So how do we change this attitude?
Changing How We Think About Oxygen Administration
My answer was that small changes haven’t worked. We need to look at the system that got us to this point and change it. Some ideas include:
- Teaching pharmacology before the airway module in an EMT class. Present oxygen as a drug with indications and contraindications—just like the other drugs they learn.
- Move the pulse oximetry part of the NREMT patient assessment skill sheets up into the primary assessment part of the sheet. If pulse oximetry is part of the decision-making process for oxygen administration, move it to where the student is required to make that decision. Some educators and most students follow those sheets verbatim. At some point, I hope we get away from these practical exams, but that is another topic.
- Make the criteria for oxygen administration clearer to students. There is near universal agreement on the chest pain patient without respiratory distress using the pulse oximeter reading. But what happens if there is also respiratory distress and a saturation of 95%? What if the patient’s skin is moist and their color is poor with a reading of 95%? Let’s not even get into oxygen administration in trauma. That one is all over the board.
As I typed that last point, the real reason hit me. We might be teaching students, intentionally or inadvertently, to administer oxygen because we ourselves have trouble figuring out when they should and shouldn’t.
Once I realized the issue, I wanted to come up with a solution. I created a flowchart to help put some reason and definition to something we have been struggling with for almost ten years. You can download it here. I’d love to know what you think of it.
There will always be a need for clinical judgment. The flowchart isn’t a recipe or strict guideline. But right now, the target is moving so much it is challenging to teach oxygen delivery. It is challenging for students to learn and apply oxygen concepts to practice (and especially the NREMT). Hopefully, we can change that.
It is time to put this issue to rest. Still.
Please feel free to share this with your classes and agencies. We also created a video overview of the oxygen administration flowchart, which you can watch below. We’d love your feedback.