# 2nd degree heart block - does it warrant code 3 return to the hospital?



## ParamedicStudent (May 9, 2019)

Question above. Obviously, treat the pt, not the monitor. But there are also times in which I've had asymptomatic patients, or "little" sick ones, with a cardiac complaint - SVT, Vtach, LVAD problem, which all warranted code 3 returns.
I've never seen a 2nd degree before out in the field. Would a 2nd degree (I/II) warrant a code 3 trip?


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## DesertMedic66 (May 9, 2019)

If their vitals are stable then personally no however I rarely transport code 3 (lights and sirens).


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## Akulahawk (May 9, 2019)

If the problem is going to be immediately lethal, by all means, bring 'em in Code 3. If it's not going to be immediately lethal, Code 2 and just prepare for (anticipate) the need to perform immediately lifesaving procedures.

I had patients come into my ED within the past week that were brought in Code 3. More than one of them probably didn't need the Code 3 run, especially if the crew had been more aggressive with the treatment given.


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## StCEMT (May 9, 2019)

No.


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## Gurby (May 9, 2019)

StatPearls said:
			
		

> *Mobitz type I (Wenckebach) is often a normal variant* and seen in individuals with a high vagal tone without evidence of structural heart disease. However, this rhythm can result from inferior myocardial ischemia, medication toxicity (AV nodal blocking agents), hyperkalemia, cardiomyopathy (Lyme disease), or following cardiac surgery.
> 
> *Mobitz type II is rarely seen in patients without structural heart disease*. It is often associated with myocardial ischemia and fibrosis or sclerosis of the myocardium. This rhythm often progresses to third-degree atrioventricular block.


https://www.ncbi.nlm.nih.gov/books/NBK482359/

If I incidentally found a 2nd degree type 1, I'd probably ask a little bit about cardiac history and things that could cause it, but not worry too much.

If you found a 2nd degree type 2, you probably want to have a high index of suspicion.  If you're doing a 12 lead on them they probably have some complaint and aren't completely asymptomatic... If it could be related to a heart issue in any way shape or form, I probably take them lights + sirens, unless when asking about their history it turns out that they've had this rhythm for a while.


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## mgr22 (May 9, 2019)

Sometimes we over-do treatment by mechanically following algorithms or policy -- e.g., atropine for bradycardia, code 3 for potentially unstable patients. If someone's in a stable arrhythmia, I think the first priority should be to not make it worse. I'd be happy to get any comfortable, asymptomatic pt to the ED just as healthy as I found him/her. Transporting with lights and sirens adds risk -- not only for the pt, but for the crew.


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## Akulahawk (May 9, 2019)

Gurby said:


> https://www.ncbi.nlm.nih.gov/books/NBK482359/
> 
> If I incidentally found a 2nd degree type 1, I'd probably ask a little bit about cardiac history and things that could cause it, but not worry too much.
> 
> *If you found a 2nd degree type 2, you probably want to have a high index of suspicion.*  If you're doing a 12 lead on them they probably have some complaint and aren't completely asymptomatic... If it could be related to a heart issue in any way shape or form, I probably take them lights + sirens, unless when asking about their history it turns out that they've had this rhythm for a while.


You don't run someone in Code 3 based solely on having a "high index of suspicion." If a patient has otherwise stable vitals and otherwise appears OK, bring 'em in Code 2 and be ready to implement an appropriate treatment should the patient's rhythm changes to CHB _and_ the patient becomes actually unstable.


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## Gurby (May 9, 2019)

Akulahawk said:


> You don't run someone in Code 3 based solely on having a "high index of suspicion." If a patient has otherwise stable vitals and otherwise appears OK, bring 'em in Code 2 and be ready to implement an appropriate treatment should the patient's rhythm changes to CHB _and_ the patient becomes actually unstable.



Maybe this scenario is too abstract -- there are so many variables to consider.  The likelihood that we find a Mobitz 2 in an asymptomatic patient is basically 0%.  Somehow somebody called 911 and we were suspicious enough to put patient on the monitor...

I guess it comes down to are we absolutely, positively, bet-your-license-on-it sure that the patient is not having an MI?  I don't want to sit in traffic for an hour with this patient hoping I didn't miss something subtle on the 12-lead.


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## gotbeerz001 (May 9, 2019)

I’m not sure I would categorize SVT or Vtach as “little sick”... especially as a student.  Stable or unstable, these are not sustainable rhythms and require intervention.

Or maybe you are generalizing “little sick” off of your initial impression? In that case, I would encourage you to refrain from making that decision until you have finished your assessment.


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## rescue1 (May 9, 2019)

With the exception perhaps of vtach, I don't think there's a single cardiac rhythm that means, by itself, that you must transport lights and sirens. Even vtach doesn't mean that, but I think most people would be forgiven for transporting emergently with that patient.

Mobitz type 1 is almost always benign and does not warrant you going L&S. Yes, technically it can cause a symptomatic bradycardia. But do you go L&S for every old person in a-fib because they could throw a clot and stroke out at any minute? Do you transport every young person with early repolarization hot because it could be a STEMI? Of course not.

Mobtiz 2 and SVT will likely not require L&S either. If these patients are very symptomatic (hypotensive, altered mental status, etc)--treat them. If you've broken SVT with atropine/CCBs/BBs or cardioversion there is no longer an emergency. If a Mobitz (or any bradycardic rhythm, it doesn't matter) patient is symptomatic enough to be unstable/hypotensive then yes, they may warrant lights and sirens, but if you can bring them back to a decent pressure with atropine or pacing you should consider how much difference the time saved is going to make.


As a general rule of thumb, if the doctor isn't getting up and coming into the ED room quickly to see the patient or a specialty team isn't waiting for you at the doorway, you probably didn't need to go lights and sirens. Unfortunately given the limited time window that we see patients, we have a very poor idea of what makes a stable or unstable patient outside the extremes (trauma alerts and codes vs toe pain and upper respiratory infections). Most (90% or more) ALS patients will not be impacted by waiting an hour for definitive care--even STEMI patients have 90 minutes to go to the cath lab from when they hit the ER. If you're in an area where mechanical thrombectomy is done, stroke patients may have up to 24 hours to have clot retrieval depending on the hospital. The ten minutes you save in the field isn't going to change anything in that patient's outcome. It's safer for you and your patients to take your time and drive normally unless the patient truly needs it.

Remember there has never been a study that showed that lights and sirens improved patient outcomes--all of them show it makes no difference, and you likely save much more time getting to the ED by limiting your on scene time as opposed to trying to beat traffic.


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## Gurby (May 9, 2019)

rescue1 said:


> even STEMI patients have 90 minutes to go to the cath lab from when they hit the ER. If you're in an area where mechanical thrombectomy is done, stroke patients may have up to 24 hours to have clot retrieval depending on the hospital. The ten minutes you save in the field isn't going to change anything in that patient's outcome.



At a quick glance, there appears to be a mountain of evidence suggesting that shorter door-to-balloon times are associated with better outcomes.  10 minutes can make a difference.  Just because you have 90 minutes until Medicare dings you or whatever doesn't mean faster isn't better for those patients.

https://www.ncbi.nlm.nih.gov/pubmed/29437704


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## rescue1 (May 9, 2019)

Gurby said:


> At a quick glance, there appears to be a mountain of evidence suggesting that shorter door-to-balloon times are associated with better outcomes.  10 minutes can make a difference.  Just because you have 90 minutes until Medicare dings you or whatever doesn't mean faster isn't better for those patients.
> 
> https://www.ncbi.nlm.nih.gov/pubmed/29437704


I'll have to read the full study when I get a chance, but the abstract specifically only mentions less than 90 minutes and greater than 90 minutes.

Regardless (and you're probably right--and faster is probably better in clot retrieval too), I would argue that you'd save considerably more time by streamlining on scene time prehospitally than by running lights and sirens in all but the most congested areas, since most of the data suggests you only save 3-5 minutes in urban areas.


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## Peak (May 9, 2019)

I think that in a lot of cases like this experience will change your opinion. What I would consider stable when I was a new medic is very different than now. 

In my opinion patients very rarely deconpensate in an unpredictable manner, but rather in ways that are more subtle and we get better at assessing over time. I also think that with experience we become more comfortable with high risk presentations.

For example I don't think I would consider emergent transport for the majority of SVT cases. Only if they were hemodynamicly unstable and cannot be converted with adenosine or electricity would I consider emergent transport. My main job is in a referral center with one of our large programs being congenital heart disease. If a crew transported a somewhat unstable neonate in SVT I wouldn't hold it against them though.

Similarly I wouldn't automatically assume that an LVAD patient requires emergent transport every time, I'm not going to emergency transport a patient who injured their wrist but is otherwise stable just because they have an LVAD for example.

I have seen patients sit in a mobitz or wenckebach for days before converting back into a 1st degree or NSR. I've also seen pretty quick deterioration into 3rd degrees with very poor perfusion and end up real sick real quick. 

I always think that you need to look at what benefit emergent transport actually brings as well. In the majority of cases emergent transport cuts off seconds at most, while increasing the risk of accidents and increasing the stress to crew and possibly the patient. Back when I was on fire we often transported traumas, patients in extremis, and codes without lights or sirens barring the last few turns right before the hospital (which was typically the only area of real traffic congestion).


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## Akulahawk (May 9, 2019)

Gurby said:


> Maybe this scenario is too abstract -- there are so many variables to consider.  The likelihood that we find a Mobitz 2 in an asymptomatic patient is basically 0%.  Somehow somebody called 911 and we were suspicious enough to put patient on the monitor...
> 
> I guess it comes down to are we absolutely, positively, bet-your-license-on-it sure that the patient is not having an MI?  I don't want to sit in traffic for an hour with this patient hoping I didn't miss something subtle on the 12-lead.


If you have a symptomatic Mobitz II patient _and_ the patient has become unstable, then by all means run 'em in Code 3. Just be safe doing so and know that you'll only be "saving" a couple minutes or a few seconds over a Code 2 return most of the time. If the patient converts into a CHB _and_ is unstable, that _may_ warrant a Code 3 return but remember that ALS crews also are going to have the ability to do TCP. Sedate and pace, bring in Code 2 if stable, unless your protocols require a Code 3 return for that. 

For me, I rarely consider Code 3 returns. Why do I NOT run most patients in Code 3? Because I have the tools at hand to continue working on stabilization and I'm not saving much time otherwise. This is a clinical decision that I make that is individual to each patient.


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## medichopeful (May 11, 2019)

ParamedicStudent said:


> Obviously, treat the pt, not the monitor.



I'm guessing you're a medic student by your name, so I don't fault you for using this, but try to get this saying out of your vocabulary.  It's not a good mindset to have.



ParamedicStudent said:


> I've never seen a 2nd degree before out in the field. Would a 2nd degree (I/II) warrant a code 3 trip?



Very, very few things actually need lights and sirens, especially at the ALS level.   If you're not treating it in the field as a medic, a 2nd degree heart block absolutely doesn't need L&S.  If you are treating it, it still probably doesn't need them.

Lights and sirens saves very little time in the majority of the cases, and should be considered a medical treatment.


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## StCEMT (May 12, 2019)

medichopeful said:


> I'm guessing you're a medic student by your name, so I don't fault you for using this, but try to get this saying out of your vocabulary.  It's not a good mindset to have.


This I'll second. The longer I've been out of medic school, the more I dislike that statement.


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## E tank (May 12, 2019)

StCEMT said:


> This I'll second. The longer I've been out of medic school, the more I dislike that statement.



Then we need a new phrase to get that valid point across to the under-experienced. Treating numbers is pandemic in nearly all phases of care and it's most usually, tho not always, the new guys....


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## StCEMT (May 12, 2019)

E tank said:


> Then we need a new phrase to get that valid point across to the under-experienced. Treating numbers is pandemic in nearly all phases of care and it's most usually, tho not always, the new guys....


I don't think they need a new phrase as much as just understanding how to apply the information it gives. I could give them a reason to treat purely based on numbers and nothing hands on, but that falls back to putting pieces together into the big picture.


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## Bullets (May 12, 2019)

StCEMT said:


> This I'll second. The longer I've been out of medic school, the more I dislike that statement.


Funny because i feel the exact opposite. I find that ive been getting more requests by BLS to treat based on one aberrant number than ever before.  I think its a good phrase to help newer providers actually look at the patient and emphasis the importance of laying hands on the patient rather than looking at a computer screen


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## GMCmedic (May 12, 2019)

StCEMT said:


> I don't think they need a new phrase as much as just understanding how to apply the information it gives. I could give them a reason to treat purely based on numbers and nothing hands on, but that falls back to putting pieces together into the big picture.


New phrase: "treat the big picture"


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## medichopeful (May 12, 2019)

GMCmedic said:


> New phrase: "treat the big picture"



"Be a clinician?"


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## DesertMedic66 (May 12, 2019)

medichopeful said:


> "Be a clinician?"


EMTs save paramedics


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## StCEMT (May 13, 2019)

Bullets said:


> Funny because i feel the exact opposite. I find that ive been getting more requests by BLS to treat based on one aberrant number than ever before.  I think its a good phrase to help newer providers actually look at the patient and emphasis the importance of laying hands on the patient rather than looking at a computer screen


Yeah, but on the flip side I had a guy walk to me while he was in VTach and he looked really good as far as my first look impression went. I just dislike how it comes off as brushing off an important part of your assessment.


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## Peak (May 13, 2019)

StCEMT said:


> Yeah, but on the flip side I had a guy walk to me while he was in VTach and he looked really good as far as my first look impression went. I just dislike how it comes off as brushing off an important part of your assessment.



I had the same thing from a guy who did Ultramans, he complained that he was relaxing at home and his heart rate was too fast and wouldn't come down. He didn't love the idea of cardioversion.


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## medic2EMSdoc (May 22, 2019)

From the receiving physician side: Most medic's are amazing but some times ....well.... you know not so great. I personally think that all transports show be with lights and sirens. Someone called 911 because they thought that they were having an emergency they should be treated like they are having one until we prove they are not.  I don't think an ambulance should have to be waiting in traffic or at every light in the city transporting a patient to the emergency department. Hopefully when the new triage, treat, and transport model get into full swing - the only patient's you will be taking to the emergency department will be the potentially emergent one's. Now with that being said there is a difference between driving code 3 to driving reckless.  A patient is never so sick to do the later - it just put you, your crew, your patient, and others at risk of injury.


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## DesertMedic66 (May 22, 2019)

TernionEMSdoc said:


> From the receiving physician side: Most medic's are amazing but some times ....well.... you know not so great. I personally think that all transports show be with lights and sirens. Someone called 911 because they thought that they were having an emergency they should be treated like they are having one until we prove they are not.  I don't think an ambulance should have to be waiting in traffic or at every light in the city transporting a patient to the emergency department. Hopefully when the new triage, treat, and transport model get into full swing - the only patient's you will be taking to the emergency department will be the potentially emergent one's. Now with that being said there is a difference between driving code 3 to driving reckless.  A patient is never so sick to do the later - it just put you, your crew, your patient, and others at risk of injury.


Driving code 3 period increases the risk of being involved in a TC substantially. We may drive safe while going code 3 but the general public does not. 

So by your logic everyone should be transported code 3 because they called 911 and it could be an emergency however when I show up to the ED with 90% of my patients I am told to bring them to the lobby without them being assessed by the MD/DO or even nurses. Shouldn’t you be treating everyone as if it’s a life threatening emergency just because they show up to the ED? 

I encourage you to do some shifts on the ambulance in the front seat to see how stupid people are when we are driving code 3. Your mindset on everyone gets code 3 will change when we are risking our safety and the public’s safety for a patient who stubbed their toe (yes these are 911 calls).


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## medic2EMSdoc (May 22, 2019)

DesertMedic66 said:


> Driving code 3 period increases the risk of being involved in a TC substantially. We may drive safe while going code 3 but the general public does not.
> 
> So by your logic everyone should be transported code 3 because they called 911 and it could be an emergency however when I show up to the ED with 90% of my patients I am told to bring them to the lobby without them being assessed by the MD/DO or even nurses. Shouldn’t you be treating everyone as if it’s a life threatening emergency just because they show up to the ED?
> 
> I encourage you to do some shifts on the ambulance in the front seat to see how stupid people are when we are driving code 3. Your mindset on everyone gets code 3 will change when we are risking our safety and the public’s safety for a patient who stubbed their toe (yes these are 911 calls).



Actually, I was a paramedic for many years before medical school and even sat up front sometimes (two medic trucks); I get it. No, I don't think that you should risk your safety or the public's safety for the stubbed toe but this thread started on a patient in 2nd degree heart block. I am assuming they had some sort of cardiac complaint. 

There are other logistics that I think influence a decision to use lights and sirens. I understand that there are reasons that the risk does not out weight the benefits....which I don't think has a blanket answer.


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## DesertMedic66 (May 22, 2019)

TernionEMSdoc said:


> Actually, I was a paramedic for many years before medical school and even sat up front sometimes (two medic trucks); I get it. No, I don't think that you should risk your safety or the public's safety for the stubbed toe but this thread started on a patient in 2nd degree heart block. I am assuming they had some sort of cardiac complaint.
> 
> There are other logistics that I think influence a decision to use lights and sirens. I understand that there are reasons that the risk does not out weight the benefits....which I don't think has a blanket answer.


The statement of “I personally think that all transports should be with lights and sirens” seemed very much like a blanket statement regarding all ambulance transports regardless of the patient presentation.


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## Peak (May 22, 2019)

TernionEMSdoc said:


> From the receiving physician side: Most medic's are amazing but some times ....well.... you know not so great. I personally think that all transports show be with lights and sirens. Someone called 911 because they thought that they were having an emergency they should be treated like they are having one until we prove they are not.  I don't think an ambulance should have to be waiting in traffic or at every light in the city transporting a patient to the emergency department. Hopefully when the new triage, treat, and transport model get into full swing - the only patient's you will be taking to the emergency department will be the potentially emergent one's. Now with that being said there is a difference between driving code 3 to driving reckless.  A patient is never so sick to do the later - it just put you, your crew, your patient, and others at risk of injury.



I can't believe that a board certified emergency physician would actually say this, maybe a intern or pgy 1.

Anyone who has spent any time in the ED from the unit secretary to the medical director knows that a lot of complete BS comes into the ED, and no shortage of it from the public who calls 911.


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## medic2EMSdoc (May 23, 2019)

Peak said:


> I can't believe that a board certified emergency physician would actually say this, maybe a intern or pgy 1.
> 
> Anyone who has spent any time in the ED from the unit secretary to the medical director knows that a lot of complete BS comes into the ED, and no shortage of it from the public who calls 911.



Please share your opinion as to when an ambulance should travel lights and sirens? When the patient is going to potentially decompensate in 5 minutes, 10 minutes, 1 hr, 8 hrs or Should they only go lights and sirens when the patient is in full arrest?

Additionally, some systems have logistical reason for code 3. A friend of mine covered a small town in Texas that was 30 min going code 3 to the nearest hospital and whenever they left there city there was absolutely NO COVERAGE for emergent calls. So yes, they would go code 3 even with the ankle sprain to get back in their city a little bit sooner to be there for the next stroke, heart attack, and/or overdose etc. 

I don't think the answer is not to travel code 3 to the emergency department but rather not transport patient's that don't need code 3 to the emergency department (which is coming soon  and super exciting.


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## Akulahawk (May 23, 2019)

TernionEMSdoc said:


> I personally think that all transports show be with lights and sirens.


This looks a LOT like a blanket statement.


TernionEMSdoc said:


> Hopefully when the new triage, treat, and transport model get into full swing - the only patient's you will be taking to the emergency department will be the potentially emergent one's.





TernionEMSdoc said:


> Someone called 911 because they thought that they were having an emergency they should be treated like they are having one until we prove they are not.


By your own statements, since someone called 911, they must be having an emergency so we must treat them like they're having one until proven otherwise. This would, therefore, mean all 911 calls would terminate at the ED, not an "alternate" destination. 


TernionEMSdoc said:


> Actually, I was a paramedic for many years before medical school and even sat up front sometimes (two medic trucks); I get it.


I actually was (and am) a paramedic for many years. I'm also an ED RN of many years. You don't treat patients by sitting up front "sometimes." 


TernionEMSdoc said:


> Please share your opinion as to when an ambulance should travel lights and sirens? When the patient is going to potentially decompensate in 5 minutes, 10 minutes, 1 hr, 8 hrs or Should they only go lights and sirens when the patient is in full arrest?


Those of us who actually _are_ or _have been_ paramedics know this, and know this well. As a receiving physician, you should also know that we don't treat "potential decompensation" because _everyone_ could potentially do so. If we know that our patient is about to decompensate in 10 minutes, or 8 hours, that'd be great! "Hey Doc, this patient looks great now but in about 8 hours, you're gonna have to code 'em."


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## medic2EMSdoc (May 23, 2019)

Seems we have gotten way off topic from the origins from this post.....back to the original topic 

2nd degree heart block type I tends to be fairly stable but can progress. So in and of itself, not so concerning 
2nd degree heart block type II can be a little more unstable and can progress to complete  3rd degree heart block which would potentially require emergent pacing. A patient in 3rd degree heart block usually can be successfully transcutaneous paced but sometimes needs transvenous pacing prior to getting mechanical capture.  

A patient with cardiac symptoms and a new onset heart block would be concerning for a myocardial infarction (right sided MI's can knock out your AV node) and that is where time is muscle. I think it you can get a patient having a heart attack to the hospital is a fair amount of time going code 2 and you feel that is the safest thing then of course you guys should stay safe and travel code 2. 15-20 min transport vs an hour transport can make a world of difference when heart muscle is actively dying.


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## Akulahawk (May 23, 2019)

TernionEMSdoc said:


> 15-20 min transport vs an hour transport can make a world of difference when heart muscle is actively dying.


Given that Code 3 travel doesn't actually save as much time as you might think vs Code 2, you're not going to make an hour ride Code 2 magically become a 15-20 minute ride Code 3. What's going to make a world of difference is knowing that there's an evolving cardiac problem and choosing the correct destination. The time savings by choosing the right destination can be, quite literally, a matter of hours.

If you start thinking of Code 3 as a treatment modality instead of a travel mode, then you start thinking about whether or not Code 3 travel is clinically indicated.


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## johnrsemt (May 23, 2019)

Instead of one specific case; why not talk about patients in general?

Where I work PT is a good example:  We only run L & S to MVC's, Chest pain, and Resp distress calls:  and some of our runs can be up to 2 hours to the scene.  then 2 hours back to town, then 110 -130 miles to the hospitals.
  We transport nothing L & S unless we are running to the Freeway to meet a helicopter, but as soon as we get to the highways or freeway we shut them off because we are now slower than almost everything else on the roads.  We usually run 40 + miles to meet a helicopter from our town, if we call when we get to the scene.  
   Probably 25-35% of the time I call for a helicopter we can't get one, either due to weather where we are or where they are.  so you get used to long transports with critical patients.   
    Couple of years ago, crew took an Acute MI 130 miles to a Level I by ground;  only took them 5.5 hours due to Ice, Snow and wind.  Almost 2 feet of new snow on the freeway during the transport;  They called dispatch and got a snowplow to lead them;  but that was still their best transport.  They got a helicopter crew to meet them, via State Trooper pickup;  about 3 hours into the transport.  Time is muscle sucked during that run


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## Carlos Danger (May 23, 2019)

Peak said:


> I can't believe that a board certified emergency physician would actually say this, maybe a intern or pgy 1.



I was thinking the same thing. 

I also call BS that anyone who actually spent a significant amount of time working in EMS could actually think that all transports should be L&S.


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## johnrsemt (May 23, 2019)

Sorry;  I am subbing at the local High School today, and I had a student ask me a question and another student hit Post Reply for me.  Why I thought the last day of school would be an easy day to sub I don't know.  LOL

  Transport patients due to how they present:  If they are stable or not.  Which doesn't always mean just vital signs.
  Going just by VS, I am always unstable:  I walk around with a BP of 90/50 on a good day.  I went to donate blood a couple of weeks ago and freaked them out because I was 72/34.  I was fine, not weak, not dizzy, etc.  I also have a SPO2 of 90% normally.
  If you patient is conscious ask the patient if that is normal VS for them.


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## SandpitMedic (May 26, 2019)

1. When did “treat the patient, not the monitor” become bad/taboo/obsolete? With the exception of obvious ACLS interventions on a textbook lethal rhythm, I’m a firm believer in using clinical judgement and all the tools at your disposal during every patient encounter. Sometimes the best tool is a calming and reassuring demeanor with a plan to stay ahead of the curve, and a plan in case they take the curve.

2. Has anyone verified that former medic/ER doc is an ER doc?! Pretty wild and out ideas for someone with that much experience. Also, not to be _that_ guy, but grammar and punctuation are important at such a professional level if you want people to take you seriously. My BS radar is pinging.


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## medic2EMSdoc (May 26, 2019)

1) After some additonal review of more current research and information, I feel that my opinion has changed on the matter of L&S use in EMS. I feel that it is a very complex issue that will not have a black and white answer that will fit for all ems systems. Instead of trying to reinvent the wheel, so to speak, I looked for a position statement that most aligned with my own opinions on the matter. NAEMSP's position statement considers all the complexity of this issue and I would agree with their collaborative position.

2) 





SandpitMedic said:


> I’m a firm believer in using clinical judgement and all the tools at your disposal during every patient encounter.



I agree, this is an excellent approach to patient care.


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## truetiger (Jun 21, 2019)

TernionEMSdoc said:


> From the receiving physician side: Most medic's are amazing but some times ....well.... you know not so great. I personally think that all transports show be with lights and sirens. Someone called 911 because they thought that they were having an emergency they should be treated like they are having one until we prove they are not.  I don't think an ambulance should have to be waiting in traffic or at every light in the city transporting a patient to the emergency department. Hopefully when the new triage, treat, and transport model get into full swing - the only patient's you will be taking to the emergency department will be the potentially emergent one's. Now with that being said there is a difference between driving code 3 to driving reckless.  A patient is never so sick to do the later - it just put you, your crew, your patient, and others at risk of injury.



Ya...you're an idiot.


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## Bishop2047 (Jun 21, 2019)

ParamedicStudent said:


> Question above. Obviously, treat the pt, not the monitor. But there are also times in which I've had asymptomatic patients, or "little" sick ones, with a cardiac complaint - SVT, Vtach, LVAD problem, which all warranted code 3 returns.
> I've never seen a 2nd degree before out in the field. Would a 2nd degree (I/II) warrant a code 3 trip?



Back to this. 

2nd degree type I - A rhythm that rarely transitions into a worse rhythm and is generally well tolerated. Its actually pretty common in young people while they sleep and in athletes with high vagal tone.

2nd degree type II - Can progress to a complete block.  If they are asymptomatic I would not go lights and sirens, but keep an eye on them. As others (and you have said) Treat the patient.


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## hometownmedic5 (Jun 22, 2019)

If there’s enough of a difference in how you drive when you have the lights on vs when you don’t, you’re doing it wrong.


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## nfsu1290 (Dec 3, 2019)

I agree with what a lot of others have said. It really depends on your pt presentation. If they look like crap, and you genuinely feel that there is a problem, then sure. Though I have ran across PTs that know that they go in and out of 2nd degree type 1 rhythms and that is normal for them.


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## bizzy522 (Dec 10, 2019)

If they are hemodynamically stable then by all means dont put you, the patient, or the public at risk by going code 3. I dont care if they are in a complete block, If they are stable just let it ride man.


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