Oxygen Therapy

[Guest guest]

>>> Oxygen therapy may become another EMS myth for certain

conditions. <<<

Good for you Dr. Bledsoe. We were having this discussion just the

other day around here. Some of my colleagues were worked up about a

medic who did not immediately place a chest pain patient on oxygen.

My position was: Do we want the medics to give oxygen because it is

good for the patient or because it will make us feel better about

what they are doing.

With respect to oxygen administration in ACS, the AHA says, " EMS

providers may administer oxygen to all patients. " Notice that it

doesn't say that they SHOULD - only that they MAY. The AHA says it

is " reasonable " to give oxygen in the first six hours of the ACS

despite the fact that a human trial of supplementary oxygen versus

room air failed to show a long-term benefit of supplementary oxygen

therapy for patients with MI.(1) Administering oxygen because it is

reasonable is a far cry from doing it because it is evidence-based.

A quasi-randomized trial did not show any clinical benefit from

routine administration of low-flow (3 L/min) oxygen for 24 hours to

all patients with ischemic stroke.(2) The AHA considers oxygen

administration to be a Class 1 procedure if the patient is hypoxic

(SpO2 < 90%) but only Class 2b for routine, uncomplicated stroke.

The Resuscitation Science Symposium reported better outcomes from

cardiac arrest in the passive insufflation group compared to

traditional ventilation with 100% oxygen and a BVM.(3)

I have similar data for asthma patients and neonatal resuscitation,

but I don't want to bore you. We blather on about " necessary "

treatment with little thought as to whether it is really true.

Abraham Lincoln once riddled, " How many legs does a dog have if you

call the tail a leg? "

The answer, " Four; calling a tail a leg doesn't make it a leg. "

References

1. Rawles JM, Kenmure AC. Controlled trial of oxygen in

uncomplicated myocardial infarction. BMJ. 1976;1:1121-1123.

2. Ronning OM, Guldvog B. Should stroke victims routinely receive

supplemental oxygen? A quasi-randomized controlled trial. Stroke.

1999;30:2033-2037.

3. Vadeboncoeur, et al. The survival rate from out-of-hospital

cardiac arrest is superior with passive oxygen insufflation compared

to active assisted ventilation. Oral abstract presentation.

Resuscitation Science Symposium 2007, Orlando, FL.

Kenny Navarro

Dallas

[Guest guest]

Kenny,

Then how come the “Eagles” haven’t changed our protocols to reflect this

stuff?

Lee

From: texasems-l [mailto:texasems-l ] On

Behalf Of Kenny Navarro

Sent: Wednesday, December 12, 2007 9:31 AM

To: texasems-l

Subject: Oxygen Therapy

>>> Oxygen therapy may become another EMS myth for certain

conditions. <<<

Good for you Dr. Bledsoe. We were having this discussion just the

other day around here. Some of my colleagues were worked up about a

medic who did not immediately place a chest pain patient on oxygen.

My position was: Do we want the medics to give oxygen because it is

good for the patient or because it will make us feel better about

what they are doing.

With respect to oxygen administration in ACS, the AHA says, " EMS

providers may administer oxygen to all patients. " Notice that it

doesn't say that they SHOULD - only that they MAY. The AHA says it

is " reasonable " to give oxygen in the first six hours of the ACS

despite the fact that a human trial of supplementary oxygen versus

room air failed to show a long-term benefit of supplementary oxygen

therapy for patients with MI.(1) Administering oxygen because it is

reasonable is a far cry from doing it because it is evidence-based.

A quasi-randomized trial did not show any clinical benefit from

routine administration of low-flow (3 L/min) oxygen for 24 hours to

all patients with ischemic stroke.(2) The AHA considers oxygen

administration to be a Class 1 procedure if the patient is hypoxic

(SpO2 < 90%) but only Class 2b for routine, uncomplicated stroke.

The Resuscitation Science Symposium reported better outcomes from

cardiac arrest in the passive insufflation group compared to

traditional ventilation with 100% oxygen and a BVM.(3)

I have similar data for asthma patients and neonatal resuscitation,

but I don't want to bore you. We blather on about " necessary "

treatment with little thought as to whether it is really true.

Abraham Lincoln once riddled, " How many legs does a dog have if you

call the tail a leg? "

The answer, " Four; calling a tail a leg doesn't make it a leg. "

References

1. Rawles JM, Kenmure AC. Controlled trial of oxygen in

uncomplicated myocardial infarction. BMJ. 1976;1:1121-1123.

2. Ronning OM, Guldvog B. Should stroke victims routinely receive

supplemental oxygen? A quasi-randomized controlled trial. Stroke.

1999;30:2033-2037.

3. Vadeboncoeur, et al. The survival rate from out-of-hospital

cardiac arrest is superior with passive oxygen insufflation compared

to active assisted ventilation. Oral abstract presentation.

Resuscitation Science Symposium 2007, Orlando, FL.

Kenny Navarro

Dallas

[Guest guest]

Not that it is right, but you have to look at it from a billing stand

point as well. Medicare is known to deny reimbursement for transport of

patients without O2, regardless of the complaint. There stand (or at

least it used to be) is no oxygen, no emergency, alternate

transportation could have been arranged.

Rick

________________________________

From: texasems-l [mailto:texasems-l ] On

Behalf Of Lee

Sent: Wednesday, December 12, 2007 9:34 AM

To: texasems-l

Subject: RE: Oxygen Therapy

Kenny,

Then how come the " Eagles " haven't changed our protocols to reflect this

stuff?

Lee

From: texasems-l <mailto:texasems-l%40yahoogroups.com>

[mailto:texasems-l <mailto:texasems-l%40yahoogroups.com>

] On

Behalf Of Kenny Navarro

Sent: Wednesday, December 12, 2007 9:31 AM

To: texasems-l <mailto:texasems-l%40yahoogroups.com>

Subject: Oxygen Therapy

>>> Oxygen therapy may become another EMS myth for certain

conditions. <<<

Good for you Dr. Bledsoe. We were having this discussion just the

other day around here. Some of my colleagues were worked up about a

medic who did not immediately place a chest pain patient on oxygen.

My position was: Do we want the medics to give oxygen because it is

good for the patient or because it will make us feel better about

what they are doing.

With respect to oxygen administration in ACS, the AHA says, " EMS

providers may administer oxygen to all patients. " Notice that it

doesn't say that they SHOULD - only that they MAY. The AHA says it

is " reasonable " to give oxygen in the first six hours of the ACS

despite the fact that a human trial of supplementary oxygen versus

room air failed to show a long-term benefit of supplementary oxygen

therapy for patients with MI.(1) Administering oxygen because it is

reasonable is a far cry from doing it because it is evidence-based.

A quasi-randomized trial did not show any clinical benefit from

routine administration of low-flow (3 L/min) oxygen for 24 hours to

all patients with ischemic stroke.(2) The AHA considers oxygen

administration to be a Class 1 procedure if the patient is hypoxic

(SpO2 < 90%) but only Class 2b for routine, uncomplicated stroke.

The Resuscitation Science Symposium reported better outcomes from

cardiac arrest in the passive insufflation group compared to

traditional ventilation with 100% oxygen and a BVM.(3)

I have similar data for asthma patients and neonatal resuscitation,

but I don't want to bore you. We blather on about " necessary "

treatment with little thought as to whether it is really true.

Abraham Lincoln once riddled, " How many legs does a dog have if you

call the tail a leg? "

The answer, " Four; calling a tail a leg doesn't make it a leg. "

References

1. Rawles JM, Kenmure AC. Controlled trial of oxygen in

uncomplicated myocardial infarction. BMJ. 1976;1:1121-1123.

2. Ronning OM, Guldvog B. Should stroke victims routinely receive

supplemental oxygen? A quasi-randomized controlled trial. Stroke.

1999;30:2033-2037.

3. Vadeboncoeur, et al. The survival rate from out-of-hospital

cardiac arrest is superior with passive oxygen insufflation compared

to active assisted ventilation. Oral abstract presentation.

Resuscitation Science Symposium 2007, Orlando, FL.

Kenny Navarro

Dallas

[Guest guest]

Time out Rick, are we treating patients for the good of the patients or are we

treating patients for Medicare.

I realize we all must get paid to survive but my opinion is we must look at what

is in the best interest of the patient not what is going pay the EMS service the

most money,

This oxygen therapy thread will be discussed to all ends of the earth really not

commenting against the oxygen therapy just the reason for treatment.

Eddie

Oxygen Therapy

>>> Oxygen therapy may become another EMS myth for certain

conditions. <<<

Good for you Dr. Bledsoe. We were having this discussion just the

other day around here. Some of my colleagues were worked up about a

medic who did not immediately place a chest pain patient on oxygen.

My position was: Do we want the medics to give oxygen because it is

good for the patient or because it will make us feel better about

what they are doing.

With respect to oxygen administration in ACS, the AHA says, " EMS

providers may administer oxygen to all patients. " Notice that it

doesn't say that they SHOULD - only that they MAY. The AHA says it

is " reasonable " to give oxygen in the first six hours of the ACS

despite the fact that a human trial of supplementary oxygen versus

room air failed to show a long-term benefit of supplementary oxygen

therapy for patients with MI.(1) Administering oxygen because it is

reasonable is a far cry from doing it because it is evidence-based.

A quasi-randomized trial did not show any clinical benefit from

routine administration of low-flow (3 L/min) oxygen for 24 hours to

all patients with ischemic stroke.(2) The AHA considers oxygen

administration to be a Class 1 procedure if the patient is hypoxic

(SpO2 < 90%) but only Class 2b for routine, uncomplicated stroke.

The Resuscitation Science Symposium reported better outcomes from

cardiac arrest in the passive insufflation group compared to

traditional ventilation with 100% oxygen and a BVM.(3)

I have similar data for asthma patients and neonatal resuscitation,

but I don't want to bore you. We blather on about " necessary "

treatment with little thought as to whether it is really true.

Abraham Lincoln once riddled, " How many legs does a dog have if you

call the tail a leg? "

The answer, " Four; calling a tail a leg doesn't make it a leg. "

References

1. Rawles JM, Kenmure AC. Controlled trial of oxygen in

uncomplicated myocardial infarction. BMJ. 1976;1:1121- 1123.

2. Ronning OM, Guldvog B. Should stroke victims routinely receive

supplemental oxygen? A quasi-randomized controlled trial. Stroke.

1999;30:2033- 2037.

3. Vadeboncoeur, et al. The survival rate from out-of-hospital

cardiac arrest is superior with passive oxygen insufflation compared

to active assisted ventilation. Oral abstract presentation.

Resuscitation Science Symposium 2007, Orlando, FL.

Kenny Navarro

Dallas

[Guest guest]

>>> Then how come the " Eagles " haven't changed our protocols to

reflect this stuff? <<<

I can't speak for why the Eagles do anything, but our local (BioTel)

protocols have been changed in many ways.

First, they are no longer called protocols (implying a cookbook

approach). They are now considered treatment guidelines which makes

them subject to variation depending on the circumstances encountered

on the scene.

Next, the oxygen administration guidelines (for most guidelines)

suggest . . . " Administer oxygen as needed to maintain an SpO2 of at

least 96%. "

Just because the Eagles gather together once a year and present a

united symposium doesn't mean they have identical positions on many

issues. Some have removed adenosine from their arsenal (for example)

while some have not. Some will not use diazepam for seizures while

others remain loyal to Valium. Some have stopped intubating kids -

others have not.

You know (in our system) that some medics and instructors have been

doing it the same way for a very long time. Change is difficult and

requires an effort.

Kenny Navarro

Dallas

[Guest guest]

Sounds like BioTel is making significant efforts to give paramedics in their

system the tools to practice the art and science of emergency medicine.  

Kudos to them!

It's my sincerest hope that the organizational culture of the respective fire

services involved do not stifle this attempt at progress. It's going to take a

lot of organizational " buy-in " to accomplish this huge shift in mindset.  The

doctors are trying to trust the EMTs and paramedics. Now it's time for us (the

field providers) to show that trust is not misplaced.

See, y'all didn't think I could say anything nice about the BioTel system! 

<GRIN>

-Wes Ogilvie, MPA, JD, LP

-Attorney/Licensed Paramedic

Re: Oxygen Therapy

>>> Then how come the " Eagles " haven't changed our protocols to

reflect this stuff? <<<

I can't speak for why the Eagles do anything, but our local (BioTel)

protocols have been changed in many ways.

First, they are no longer called protocols (implying a cookbook

approach). They are now considered treatment guidelines which makes

them subject to variation depending on the circumstances encountered

on the scene.

Next, the oxygen administration guidelines (for most guidelines)

suggest . . . " Administer oxygen as needed to maintain an SpO2 of at

least 96%. "

Just because the Eagles gather together once a year and present a

united symposium doesn't mean they have identical positions on many

issues. Some have removed adenosine from their arsenal (for example)

while some have not. Some will not use diazepam for seizures while

others remain loyal to Valium. Some have stopped intubating kids -

others have not.

You know (in our system) that some medics and instructors have been

doing it the same way for a very long time. Change is difficult and

requires an effort.

Kenny Navarro

Dallas

________________________________________________________________________

More new features than ever. Check out the new AOL Mail ! -

http://webmail.aol.com

[Guest guest]

If you notice the first 5 words of my post are " not that it is right " . I

agree 100% with you, however I have also felt the pressure from the

service bean counter who was looking at all the denials and pressuring

us to conform. Physicians are faced with performing certain unnecessary

assessments, nurses have to include certain buzz words in the chart, the

stool guiac has to be developed in the lab instead of the bedside, etc.

All things done to maximize reimbursement which in turn reflects on our

own personal economy. I am in no way defending the process, but if

putting O2 on the patient is going to get my employer paid and is not

going to hurt the patient I am putting O2 on, at least until we do

something to fix the badly broken reimbursement system that we all work

under.

In short I am not defending the practice or agreeing with it, just

trying to provide an alternative opinion on why we do some of the the

things we do.

Rick

________________________________

From: texasems-l [mailto:texasems-l ] On

Behalf Of Eddie

Sent: Wednesday, December 12, 2007 10:31 AM

To: texasems-l

Subject: Re: Oxygen Therapy

Time out Rick, are we treating patients for the good of the patients or

are we treating patients for Medicare.

I realize we all must get paid to survive but my opinion is we must look

at what is in the best interest of the patient not what is going pay the

EMS service the most money,

This oxygen therapy thread will be discussed to all ends of the earth

really not commenting against the oxygen therapy just the reason for

treatment.

Eddie

Oxygen Therapy

>>> Oxygen therapy may become another EMS myth for certain

conditions. <<<

Good for you Dr. Bledsoe. We were having this discussion just the

other day around here. Some of my colleagues were worked up about a

medic who did not immediately place a chest pain patient on oxygen.

My position was: Do we want the medics to give oxygen because it is

good for the patient or because it will make us feel better about

what they are doing.

With respect to oxygen administration in ACS, the AHA says, " EMS

providers may administer oxygen to all patients. " Notice that it

doesn't say that they SHOULD - only that they MAY. The AHA says it

is " reasonable " to give oxygen in the first six hours of the ACS

despite the fact that a human trial of supplementary oxygen versus

room air failed to show a long-term benefit of supplementary oxygen

therapy for patients with MI.(1) Administering oxygen because it is

reasonable is a far cry from doing it because it is evidence-based.

A quasi-randomized trial did not show any clinical benefit from

routine administration of low-flow (3 L/min) oxygen for 24 hours to

all patients with ischemic stroke.(2) The AHA considers oxygen

administration to be a Class 1 procedure if the patient is hypoxic

(SpO2 < 90%) but only Class 2b for routine, uncomplicated stroke.

The Resuscitation Science Symposium reported better outcomes from

cardiac arrest in the passive insufflation group compared to

traditional ventilation with 100% oxygen and a BVM.(3)

I have similar data for asthma patients and neonatal resuscitation,

but I don't want to bore you. We blather on about " necessary "

treatment with little thought as to whether it is really true.

Abraham Lincoln once riddled, " How many legs does a dog have if you

call the tail a leg? "

The answer, " Four; calling a tail a leg doesn't make it a leg. "

References

1. Rawles JM, Kenmure AC. Controlled trial of oxygen in

uncomplicated myocardial infarction. BMJ. 1976;1:1121- 1123.

2. Ronning OM, Guldvog B. Should stroke victims routinely receive

supplemental oxygen? A quasi-randomized controlled trial. Stroke.

1999;30:2033- 2037.

3. Vadeboncoeur, et al. The survival rate from out-of-hospital

cardiac arrest is superior with passive oxygen insufflation compared

to active assisted ventilation. Oral abstract presentation.

Resuscitation Science Symposium 2007, Orlando, FL.

Kenny Navarro

Dallas

[Guest guest]

So we are going to “treat the machine and not the patient”? Everybody knows

that Pulse Ox are mostly inaccurate in really low down sick patients and

doesn’t give you enough information to allow good decision making.

Lee

From: texasems-l [mailto:texasems-l ] On

Behalf Of Kenny Navarro

Sent: Wednesday, December 12, 2007 10:48 AM

To: texasems-l

Subject: Re: Oxygen Therapy

>>> Then how come the " Eagles " haven't changed our protocols to

reflect this stuff? <<<

I can't speak for why the Eagles do anything, but our local (BioTel)

protocols have been changed in many ways.

First, they are no longer called protocols (implying a cookbook

approach). They are now considered treatment guidelines which makes

them subject to variation depending on the circumstances encountered

on the scene.

Next, the oxygen administration guidelines (for most guidelines)

suggest . . . " Administer oxygen as needed to maintain an SpO2 of at

least 96%. "

Just because the Eagles gather together once a year and present a

united symposium doesn't mean they have identical positions on many

issues. Some have removed adenosine from their arsenal (for example)

while some have not. Some will not use diazepam for seizures while

others remain loyal to Valium. Some have stopped intubating kids -

others have not.

You know (in our system) that some medics and instructors have been

doing it the same way for a very long time. Change is difficult and

requires an effort.

Kenny Navarro

Dallas

[Guest guest]

>>> So we are going to " treat the machine and not the patient " ? <<<

WOW. How did you come to that conclusion based on the information I

provided?

Did you read the parts about " treatment guidelines " and " variation

depending on the circumstances encountered. "

What our guidelines encourage is treatment decisions based on

physical exams and the machines. Certainly you are not suggesting

that we rid ourselves of glucometers and sphygmomanometers and ECG

monitors and waveform capnographers.

>>> Everybody knows that Pulse Ox are mostly inaccurate in really

low down sick patients and doesn't give you enough information to

allow good decision making.<<<

Most manufacturers claim accuracy to be between within 2% and 4% of

actual values for readings above 70%.(1,2) During periods of

desaturation below 70%, the accuracy is substantially reduced.(3,4)

This seems to me an unimportant limitation, since most patients who

desaturate to such a low level are treated as aggressively as

possible, regardless of whether the true saturation is 40% or 60%.

I have never seen a hypoxic patient with a normal pulse oximetry

reading. The above-mentioned studies (and others) seem to support my

experiences.

Interestingly, one researcher has successfully demonstrated that the

differences in pulse oximeter readings between the right hand and one

foot could be used as a screening tool to aid in the diagnosis of

critical congenital heart disease.(5) Now, that is impressive

accuracy!

With Love,

Kenny Navarro

Dallas

References

1. Tobin MJ. Respiratory monitoring. JAMA 1990;264(2):244–251.

2. Severinghaus JW. History and recent developments in pulse

oximetry. Scand J Clin Invest Suppl 1993;214:105–111.

3. Faconi S. Reliability of pulse oximetry in hypoxic infants. J

Pediatr 1988;112(3):424–427.

4. Severinghaus JW, Naifeh KH, Koh SO. Errors in 14 pulse oximeters

during profound hypoxemia. J Clin Monit 1989;5(2):72–81.

5. de Wahl Granelli A, Mellander M, Sunnegårdh J, Sandberg K, Ostman-

I. Screening for duct-dependant congenital heart disease with

pulse oximetry: a critical evaluation of strategies to maximize

sensitivity. Acta Paediatr. 2005 Nov;94(11):1590-1596.

[Guest guest]

Rick if your putting O2 on just to get paid, you are doing it for the wrong

reason.

Henry

Oxygen Therapy

>>> Oxygen therapy may become another EMS myth for certain

conditions. <<<

Good for you Dr. Bledsoe. We were having this discussion just the

other day around here. Some of my colleagues were worked up about a

medic who did not immediately place a chest pain patient on oxygen.

My position was: Do we want the medics to give oxygen because it is

good for the patient or because it will make us feel better about

what they are doing.

With respect to oxygen administration in ACS, the AHA says, " EMS

providers may administer oxygen to all patients. " Notice that it

doesn't say that they SHOULD - only that they MAY. The AHA says it

is " reasonable " to give oxygen in the first six hours of the ACS

despite the fact that a human trial of supplementary oxygen versus

room air failed to show a long-term benefit of supplementary oxygen

therapy for patients with MI.(1) Administering oxygen because it is

reasonable is a far cry from doing it because it is evidence-based.

A quasi-randomized trial did not show any clinical benefit from

routine administration of low-flow (3 L/min) oxygen for 24 hours to

all patients with ischemic stroke.(2) The AHA considers oxygen

administration to be a Class 1 procedure if the patient is hypoxic

(SpO2 < 90%) but only Class 2b for routine, uncomplicated stroke.

The Resuscitation Science Symposium reported better outcomes from

cardiac arrest in the passive insufflation group compared to

traditional ventilation with 100% oxygen and a BVM.(3)

I have similar data for asthma patients and neonatal resuscitation,

but I don't want to bore you. We blather on about " necessary "

treatment with little thought as to whether it is really true.

Abraham Lincoln once riddled, " How many legs does a dog have if you

call the tail a leg? "

The answer, " Four; calling a tail a leg doesn't make it a leg. "

References

1. Rawles JM, Kenmure AC. Controlled trial of oxygen in

uncomplicated myocardial infarction. BMJ. 1976;1:1121- 1123.

2. Ronning OM, Guldvog B. Should stroke victims routinely receive

supplemental oxygen? A quasi-randomized controlled trial. Stroke.

1999;30:2033- 2037.

3. Vadeboncoeur, et al. The survival rate from out-of-hospital

cardiac arrest is superior with passive oxygen insufflation compared

to active assisted ventilation. Oral abstract presentation.

Resuscitation Science Symposium 2007, Orlando, FL.

Kenny Navarro

Dallas

[Guest guest]

I don't disagree.

________________________________

From: texasems-l [mailto:texasems-l ] On

Behalf Of Henry Barber

Sent: Thursday, December 13, 2007 8:08 AM

To: texasems-l

Subject: Re: Oxygen Therapy

Rick if your putting O2 on just to get paid, you are doing it for the

wrong reason.

Henry

Oxygen Therapy

>>> Oxygen therapy may become another EMS myth for certain

conditions. <<<

Good for you Dr. Bledsoe. We were having this discussion just the

other day around here. Some of my colleagues were worked up about a

medic who did not immediately place a chest pain patient on oxygen.

My position was: Do we want the medics to give oxygen because it is

good for the patient or because it will make us feel better about

what they are doing.

With respect to oxygen administration in ACS, the AHA says, " EMS

providers may administer oxygen to all patients. " Notice that it

doesn't say that they SHOULD - only that they MAY. The AHA says it

is " reasonable " to give oxygen in the first six hours of the ACS

despite the fact that a human trial of supplementary oxygen versus

room air failed to show a long-term benefit of supplementary oxygen

therapy for patients with MI.(1) Administering oxygen because it is

reasonable is a far cry from doing it because it is evidence-based.

A quasi-randomized trial did not show any clinical benefit from

routine administration of low-flow (3 L/min) oxygen for 24 hours to

all patients with ischemic stroke.(2) The AHA considers oxygen

administration to be a Class 1 procedure if the patient is hypoxic

(SpO2 < 90%) but only Class 2b for routine, uncomplicated stroke.

The Resuscitation Science Symposium reported better outcomes from

cardiac arrest in the passive insufflation group compared to

traditional ventilation with 100% oxygen and a BVM.(3)

I have similar data for asthma patients and neonatal resuscitation,

but I don't want to bore you. We blather on about " necessary "

treatment with little thought as to whether it is really true.

Abraham Lincoln once riddled, " How many legs does a dog have if you

call the tail a leg? "

The answer, " Four; calling a tail a leg doesn't make it a leg. "

References

1. Rawles JM, Kenmure AC. Controlled trial of oxygen in

uncomplicated myocardial infarction. BMJ. 1976;1:1121- 1123.

2. Ronning OM, Guldvog B. Should stroke victims routinely receive

supplemental oxygen? A quasi-randomized controlled trial. Stroke.

1999;30:2033- 2037.

3. Vadeboncoeur, et al. The survival rate from out-of-hospital

cardiac arrest is superior with passive oxygen insufflation compared

to active assisted ventilation. Oral abstract presentation.

Resuscitation Science Symposium 2007, Orlando, FL.

Kenny Navarro

Dallas