# CPAP = code 3?



## jwmedic (Dec 13, 2009)

Hey guys,

Just wondering what your opinions are whether or not you should be going code 3 when using cpap? Another way of saying this is if you are using cpap you have a patient that is severe enough that they require a code return.

I'm asking because I've used cpap several times with good results in patients with moderate distress and my QA/QI person has flagged me for it.

The explanation: "you should be needing to go code 3" is not good enough for me. Why?

For me there is a group of patients in moderate distress who can benefit from cpap but don't require a more dangerous rush into the hospital saving 1-2 mins. And in my admittingly small amount if experience (that's why I'm here asking) these patients improve.

Cpap is not a medication in the sense you can turn it off if it causes a 
complication or doesn't work.

So to summarize is cpap a tool only for severe patients or can it be used for a wider range of patients?


----------



## BLSBoy (Dec 13, 2009)

Use your clinical judgement.


----------



## DrankTheKoolaid (Dec 13, 2009)

*re*

Have used it fairly frequently in my practice and i dont believe just because somebody is placed on CPAP that they are a C3 patient. Actually ive yet to bring in a patient on CPAP C3 as each time i have used it it worked as expected and improved the patient.


----------



## VentMedic (Dec 13, 2009)

> "you should be needing to go code 3"


 
Was this just because of the CPAP? 

What else did you document for the working diagnosis, vitals and assessment? 



jwmedic said:


> So to summarize is cpap a tool only for severe patients or can it be used for a wider range of patients?


 
CPAP can be used for a wide range of patients but one must remember it is NOT 2 level ventilation or BiPAP(tradename).


----------



## medicdan (Dec 13, 2009)

If the treatment (CPAP) stabilizes the patient, why risk your own and others on the road's safety by driving Code 3?


----------



## TexasEMS_Paramedic (Dec 13, 2009)

I would see no reason to transport code 3 just because you have a patient on CPAP.  It is a treatment for a condition just like a medication.  If the treatment does not work or your patient is unstable I could see the reason.  I agree with the above and just use your clinical judgment.  I usually go code 3 when I have a patient on CPAP.. only cuz im usually 30-40 minutes from a receiving facility and I only have so much oxygen.


----------



## VentMedic (Dec 13, 2009)

The OP didn't give much information about the patient.  It may have been possible that patient actually required ETI or there might even have been an attempt made.  The patient also could have be intubated immediately upon arrival at the hospital and a QA/QI was done there.

Too little information and there is probably more than just the CPAP issue.


----------



## MrBrown (Dec 13, 2009)

Um, no


----------



## jwmedic (Dec 13, 2009)

Vent I didn't give a specific patient because I was referring to a set of calls I've had.

My company QA person told me I should only use CPAP if the patient is so bad I would also be going code 3 to the hospital which is the argument I'm putting up for debate.

My take is that there are patients who can benefit from CPAP that are somewhere inbetween mild and critical.

I guess one example is a CHF patient with crackles but good air movement. If I recall correctly he was RR 24 sp02 95% RA HR 90 BP 140/90 EKG no stemi or ectopy... new pedal edema present. So not severe but also sympomatic. (Hx of CHF HTN Diabetes.....)

On a NRB he was telling me he still needed more air saying "I want air" (3-4 word sentances with some minor accessory muscle usage).

I put him on CPAP and he immediately improved. I went code 2 with a transport time of 11 mins.

QA guy tells me the BP wasn't high enough for cpap and if I used it I should have been going code 3 because then the patient was severe enough to need rapid transport.

So I could have rode this guy in on a NRB I know that but I felt I could make him more comfortable and potentially avoid him declining. Was this a bad use for cpap?


----------



## jwmedic (Dec 13, 2009)

Thanks for the replies. I'm a newer medic and I've been around about 4 different EMS systems now because of school and my actualy job. I'm learnign there is a culture around treatment in each system so I'm trying to start by making sound decisions on my own but also practicing within a specific system.


----------



## VentMedic (Dec 13, 2009)

jwmedic said:


> Was this a bad use for cpap?


 
No not at all if it gave him relief.    

I don't get the issue with the BP by the QA guy.

If the airway is stable as well as the other vitals, Code 3 should not come into play.  Even if ETI was implemented, the airway should be secure and code 3 would not be necessary.    If BP was too low, hopefully you as a Paramedic could have pharmacologically supported it to where code 3 would not be necessary.   Actually I can think of very few situations as a Paramedic where code 3 is necessary.


----------



## Lifeguards For Life (Dec 13, 2009)

VentMedic said:


> No not at all if it gave him relief.
> .   Actually I can think of very few situations as a Paramedic where code 3 is necessary.



such as? I agree with you, just curious


----------



## zmedic (Dec 13, 2009)

It depends on your services protocols. If CPAP is something that is in you can use like oxygen, for respiratory distress where you think it'll help then no. If your protocols are written such that CPAP should be used as a last ditch effort before intubation then yes, you should be going code three. 

I agree though that very few patients need lights an sirens. In fact I was trained that when driving code three you drive about the same as if you aren't running code (in terms of speed and turning) because you don't want to through your partner around. The proviso is if you are in a heavy traffic area and you need to go L & S to cut through grid lock, yeah, you probably don't want someone on CPAP in the back of your rig for 45 minutes.


----------



## boingo (Dec 13, 2009)

Lifeguards For Life said:


> such as? I agree with you, just curious




Any case that will require urgent surgical intervention.


----------



## BLSBoy (Dec 13, 2009)

boingo said:


> Any case that will require urgent surgical intervention.



+ failed airway, CLINICAL JUDGEMENT, a critical pt. 

Seriously, BRAVO to you for not going Code 3. 
I was hurt in a collision because of RL&S. 
We need more like you in this field.


----------



## MrBrown (Dec 13, 2009)

jwmedic said:


> My company QA person told me I should only use CPAP if the patient is so bad I would also be going code 3 to the hospital which is the argument I'm putting up for debate.
> 
> ...QA guy tells me the BP wasn't high enough for cpap and if I used it I should have been going code 3 because then the patient was severe enough to need rapid transport.
> 
> So I could have rode this guy in on a NRB I know that but I felt I could make him more comfortable and potentially avoid him declining. Was this a bad use for cpap?



Your QA person needs to be shot.


----------



## rmellish (Dec 13, 2009)

sounds like there's a lack of understanding on the QA's park assuming that CPAP is only indicated for hypertensive CHF exacerbated patient.


----------



## carpentw (Dec 15, 2009)

It sucks when people try to micromanage patient care (ie every person on CPAP requires a code-3 response to the hospital.)   Friggin idiot!


----------



## Smash (Dec 15, 2009)

VentMedic said:


> No not at all if it gave him relief.
> 
> I don't get the issue with the BP by the QA guy.
> 
> If the airway is stable as well as the other vitals, Code 3 should not come into play.  Even if ETI was implemented, the airway should be secure and code 3 would not be necessary.    If BP was too low, hopefully you as a Paramedic could have pharmacologically supported it to where code 3 would not be necessary.   Actually I can think of very few situations as a Paramedic where code 3 is necessary.



Agreed; unless there is an immediate life threat that you are unable to manage for some reason, or something like an evolving infarction that needs intervention, then there is little point in driving fast and making noise. Even in some cases where it would seem to be appropriate, one has to weigh up the risks involved with the potential benefits, which can often be negligible to non-existant.  Saying that CPAP = code 3 transport is ridiculous and inappropriate.


----------



## Markhk (Dec 15, 2009)

What type of CPAP system do you use? Are they worried you might vent out all the oxygen and therapy would be discontinued? 

(We use the Boussignac system which is most certainly not an oxygen miser at 25 lpm...really need to rely on the rig's manifold oxygen tank)


----------



## fma08 (Dec 15, 2009)

As previously stated, CPAP does NOT always equal code 3. Clinical judgment on pt. status determines code 3 or not. That and the status of your O2 supply


----------



## Hal9000 (Dec 18, 2009)

I imagine this has already been stated, but code status should be implemented based upon its ability to benefit the patient, regardless of what other tools are being used.


----------



## austinmedic2004 (Dec 23, 2009)

Actually CPAP can take a "crappy" patient and make them "stable". It is at this point that a non-emergent transport is quite appropriate; less anxiety for the patient and safer for all involved.


----------



## emt1972 (Dec 28, 2009)

I hate when management decides what is best for the patient... Especially when they have _*never*_ worked in the field!


----------

