Oximeters

Robert Bell rmsbell200 at YAHOO.COM
Wed Jan 31 15:58:40 UTC 2018


Dear Tom,

Thanks - appreciate your illuminating comments/thoughts. If all errors, including diagnostic, are at times inter-related how does the diagnostic error movement move forward? Focus on the commonest problems/combinations or focus on those that produce the greatest damage? Or all. A massive big challenge.

Rob


Sent from my iPad

> On Jan 31, 2018, at 8:04 AM, Tom Benzoni <benzonit at gmail.com> wrote:
> 
> Dr. Bell:
> It's not well known, and is a double tragedy.
> Clinicians get beat up over endangering a patient when there was no expectant danger.
> This has the odd effect of causing interventions when none is warranted and making people less cognitive/aware.
> The way I know it is not well known: Hospitals have pages long protocols for procedural sedation, many written, in my not-very-humble opinion, to protect margins, and i've never seen this error discussed. (Don't make them aware; it's a marker I use for situational awareness.)
> 
> You've only scratched the surface of errors in BP readings. JAMA had a recent paper discussing med student errors in measurement.
> Fortunately, they didn't study attendings or nurses in practice; it would have been worse.
> And nowhere so I see awareness that automated cuffs do not measure BP; they find first turbulent flow (approximately MAP) then, using proprietary algorithms, calculate a systolic and diastolic. Find that method in AHA guidelines?
> I helped write, many years ago, the original ACEP guidelines to NOT normalize/treat asymptomatic BP elevations found in the ER. (Full-on discussion behind that one separately.)
> 
> If we tolerate this low level error systematically, how can we expect to address the large/few errors?
> High frequency-low consequence errors are arguably of greater import than low frequency-high consequence ones; driving to the airport caries greater risk of death than the flight itself.
> 
> tom
>  
> 
>> On Tue, Jan 30, 2018 at 10:21 PM, Robert Bell <0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>> Thanks Tom,
>> 
>> That is something to consider. How many HCPs know about that? 
>> 
>> What about, Ipsilateral sphygmomanometer cuff - oximeter reading error!!
>> 
>> And do not get me started on the frequency with which blood pressures are taken with the wrong sphygmomanometer cuff size, and through clothing (some times thick). 
>> 
>> I have in my postings to the list here always been interested in the level of error in the things we do to help us with diagnoses. I strongly believe that we need, to not only be improving our diagnostic abilities, but also work to improve the errors of support tools at the same time. Both need to be worked upon to get to our goal of significant reductions in diagnostic error. That could be done with partnering with another society or societies, more dedicated to standard errors, with time related goals to help get there soon.
>> 
>> Robert Bell
>> 
>> On Tuesday, January 30, 2018, 2:57:56 PM MST, Tom Benzoni <benzonit at GMAIL.COM> wrote:
>> 
>> 
>> Orthopedic changes do not effect them.
>> Skin thickness does not but we don't use these over callused areas.
>> They can read black skin. Melanin has a different spectral absorption.
>> Very cold extremities where the capillary beds are clamped down can cause erroneous readings as can patients in extremis from end-stage myocardial disease...but don't need a pulse ox there.
>> An interesting error source comes from blood pressure cuffs. Because the cuffs are usually set to automatic, intermittent low readings occur not from the patient but from temporary occlusion of the artery by the cuff if on the ipsilateral arm. If you're not aware of this error source, you can think the patient on whom you're doing a procedure is in trouble when they're fine. And you might terminate the procedure or make an unnecessary intervention on a well person.
>> What is that type of error?
>> 
>> tom
>> 
>> On Mon, Jan 29, 2018 at 11:49 PM, robert bell <0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>> I was thinking also of the accuracy in elderly patients with osteoarthritis, bent fingers, and soft skin versus hard thickened skin and also the differences with different fingers.
>> 
>> Yes, alarms are a problem.
>> 
>> Rob Bell, M.D.
>> > On Jan 29, 2018, at 3:11 PM, Rory Jaffe <rjaffe at CHPSO.ORG> wrote:
>> >
>> > Interpretation is a big issue. Pulse oximetry is very insensitive to hypoventilation when a patient is on supplemental O2. Also tends to have lots of false alarms--the default limits are not very usable and ideally, people would use patient-specific alarm limits.
>> >
>> > -----Original Message-----
>> > From: Grubenhoff, Joe [mailto:Joe.Grubenhoff@ CHILDRENSCOLORADO.ORG]
>> > Sent: Monday, January 29, 2018 8:55 AM
>> > To: IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG
>> > Subject: [No SPF Record] Re: [IMPROVEDX] Oximeters
>> >
>> > Pretty accurate in my experience - the problem may be in how this single value is interpreted in the context of the whole clinical picture:
>> >
>> >
>> >
>> > Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis.
>> >
>> > Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S.
>> >
>> > JAMA Pediatr. 2016 Jun 1;170(6):602-8. doi: 10.1001/jamapediatrics.2016. 0114.
>> >
>> >
>> >
>> > Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial.
>> >
>> > Schuh S, Freedman S, Coates A, Allen U, Parkin PC, Stephens D, Ungar W, DaSilva Z, Willan AR.
>> >
>> > JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637.
>> >
>> >
>> >
>> >
>> >
>> > ´╗┐On 1/29/18, 09:49, "Robert Bell" <0000000296e45ec4-dmarc- request at LIST.IMPROVEDIAGNOSIS. ORG> wrote:
>> >
>> >
>> >
>> >    How accurate are oximeters? Are the errors big enough to make wrong decisions?
>> >
>> >
>> >
>> >    Rob Bell, M. D.
>> >
>> >
>> >
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