# Code 3



## Angel (Mar 27, 2015)

or lights and sirens...for clarification

Im going to try and make this as short winded as possible. But I am curious about medicals, and when people decide to go code 3.

my situation was a 35 YOF hx asthma, basically having an asthma attack all day refractory to home meds and was continuing to get worse. Vitals were ok, 130/70's, Sinus Tach 123, 26-30
very little lung sounds, (wheezes up top) and none below, SpO2 stayed in the high 90s, 5-6 word sentences, had a dry cough, no cyanosis and no accessory muscles, but she was clearly working to breathe. initially she was put on an albuterol and atrovent via HHN but kept complaining it was getting worse and not helping, so she got put on CPAP with those 2, no epi was given but the CPAP did help

she was transported code 3 to the ER, and was put on bipap, given solumedrol and a mag drip

later on I was told I should not have taken her code 3 and given a list of reasons why (not worth the potential car accident, misuse of code 3 ect ect)
while I disagree, im kind of curious what others would have done.


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## wtferick (Mar 27, 2015)

Had one similar to that type of call aswell. Took it code 3, ended up surpassing  a chest pain pt aswell brought by another crew.


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## Brandon O (Mar 27, 2015)

Just as a passing point: it's only called "code 3" in California and maybe some similar haunts.

Terminology in this business is never as universal as it seems. Although I admit the "code 3 club" seems to have nationwide acceptance...


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## Angel (Mar 27, 2015)

noted, i cant change the title so I just put it in the post. Again, Im a self centered californian and forget not everything is the same


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## Gurby (Mar 27, 2015)

I feel like it's hard to say without seeing the patient... Respiratory patients can crash hard and fast, so I think erring on the side of caution and going lights + sirens is fine here.  During my ride time we had a patient who I thought wasn't _that_ sick, and 30 seconds later we're bagging and pt is tubed on arrival.  Then again, that was a 75 year old COPD'er - I guess a 35yo has less risk of crashing all at once like that?


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## OnceAnEMT (Mar 27, 2015)

I think it definitely depends on the holistic patient presentation, and its something that we can't really quarterback from here. That said, I've had patients come in to the ED from a code 3 trip that was escalated because of respiratory deterioration. The way I see it, if you aren't the fix and that patient needs a fix yesterday, then its worth code 3. That includes your gut feeling that you are missing something or you don't feel comfortable with this crashing patient. Now, this should follow up with education on how to better handle the situation (which you've done), so "I wasn't feeling it" isn't an infinite excuse, but I don't think it is "wrong". All of that said, other factors still play a role in the decision to escalate. Was going code 3 worth the time saved, if any time saved?


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## teedubbyaw (Mar 27, 2015)

And it's universally known as code 3 almost everywhere...

Our transport times in the city are generally short (<10min) unless it's trauma, then we're looking at a 45 minute transport w/o lights. I tend to only use code 3 if we're going to our trauma center and it is a busy time during the day and the pt's condition necessitates it.

Any decreased LOC/GCS due to an acute life threatening medical issue will get code 3. I try not to use it otherwise, especially in airway pt's. Lights and sirens only makes patients freak out more.


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## Brandon O (Mar 27, 2015)

teedubbyaw said:


> And it's universally known as code 3 almost everywhere...



You're quite a traveler!


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## RefriedEMT (Mar 27, 2015)

heard of code 3 but my area and all the EMT's and medics ive talked to just say going *priority*.


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## OnceAnEMT (Mar 27, 2015)

RefriedEMT said:


> heard of code 3 but my area and all the EMT's and medics ive talked to just say going *priority*.



To which I say "Priority what?" 

"Emergent" and "Non-emergent" are more common here, but code 1/3 still come out as lingo from time to time.


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## PotatoMedic (Mar 27, 2015)

Just in the few places I have worked and heard on the radio I have heard, "Priority" "Red" "Code" "Emergent" "L&S."  Probably a few more that I can't remember.


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## RebelAngel (Mar 27, 2015)

Code 3 in our county means third call for said EMS service. 

Our priorities go from Alpha (asinine) to Delta (don't get in my way), lol. 

I've seen lights and sirens go on at EMT discretion for nothing an times when Paramedics probably should have run lights and siren bit for whatever reason didn't.


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## Ewok Jerky (Mar 27, 2015)

As others have pointed out its a case by case basis. Just about anybody who is unstable, altered, or scares me some other way.

Also as others have stated, scary airways can get very scary very quick (for everyone involved).

Once you have someone on CPAP I wouldn't be surprised if you went in hot.


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## Angel (Mar 27, 2015)

I too have had a pt go from alert and talking to us bagging her within a span of 10 minutes so I know things can go to crap fast and always keep that in the back of my mind. I feel fine going code 3 with cpap even though this pt wasnt on the crap end of the spectrum yet, she had the potential to go there. 
IDK, my partner chalked it up to me being new and not cynical yet. 

I guess the next step is to wait and hear from the bosses (and QA), though, based on past experience, they wont have an issue with it.


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## Handsome Robb (Mar 28, 2015)

Emergent transport is very rarely worth the risk to you, your partner, your patient or others on the road.

I wasn't there so I'm not going to tell you you were wrong but personally I would not have transported this patient emergent from the information provided. Also, I would be dinged and thoroughly questioned by QA as to my reasoning for why I went emergent with the patient you described. 

The only times I really go code with a patient anymore is CVA patients who're tPA candidates or severe traumas that are circling the drain. We get dinged by QA for not taking STEMIs emergent but there was a study done about it actually having a negative effect on outcomes. Increased anxiety = catecholamine release = increased afterload, HR and cardiac workload = increased MVO2 = worsening injury and infarction. I don't have the study handy but I will look for it for you.

If you think about it how often is it that if you take a FF and go emergent that the Engine is rolling into the hospital as you're backing up or unloading the PT and they didn't go emergent following you. It really doesn't save that much time.

Even with your experience of needing to bag the patient what does emergent transport do to help them? You're supporting their airway, oxygenating and ventilating them.

Regarding CPAP patients, personally CPAP =/= emergent transport. The question I will ask is if she's not sick enough to need CPAP/BiPAP why does she need to be transported emergently?

There really are only a handful of things where minutes and seconds actually count.


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## Angel (Mar 28, 2015)

that being said, why go code 3 at all? is a couple of seconds/minutes going to make a difference for said CVA? (unloading the gurney takes "seconds" inputting the ER code takes "seconds") Trauma pt? no, and I know code 3 only saves seconds, but Ive seen the cluster going code 2 for critical pts causes for the ER and the delay in care.  
To me none of these are good excuses NOT to go code 3 vs going but I do appreciate your opinion.


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## RedAirplane (Mar 28, 2015)

Doesn't the latest version of NIMS/ICS discourage any codes, including "Code 3?"

Everyone says it all the time, but isn't the federally correct phrase something like "high priority" or "lights and sirens?"


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## Handsome Robb (Mar 28, 2015)

Alright, the thread is about the patient not the terminology.


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## PotatoMedic (Mar 28, 2015)

Aside from the code 3 part.  I read you posy and skimmed the rest past mine.  Did you try a mag or epi neb?  Or can you not do any of those?


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## captaindepth (Mar 28, 2015)

Has anyone decided to take a pt emergently in order to have the proper reception at the ER when you arrive? meaning that the pt may not truly require emergent transport but in order to get the "big room" at the ED with the appropriate staff/resources waiting for your arrival, then just bring the pt in emergently. 

The pt in the original post was certainly sounds like they were in respiratory distress but maintaining well (overall) with good O2 sats and expected vital signs for a moderate/severe asthma attack. With the improvement following CPAP I think starting off non emergent and being ready to upgrade to emergent at the slightest sign of deterioration is appropriate.


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## Handsome Robb (Mar 28, 2015)

captaindepth said:


> Has anyone decided to take a pt emergently in order to have the proper reception at the ER when you arrive? meaning that the pt may not truly require emergent transport but in order to get the "big room" at the ED with the appropriate staff/resources waiting for your arrival, then just bring the pt in emergently.



Most definitely not...why would you take that risk rather than just give a good radio report? "Medic 341 inbound with a 5 minute ETA. Onboard I have a 35 year old female complaining of SOB secondary to an asthma exacerbation. Moderate to severe respiratory distress. Vitals are xxx, *brief blurb of interventions*, unless you have any questions I'll give you the rest in 5".


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## DesertMedic66 (Mar 28, 2015)

We actually do save time transporting code due to our opticom system and the fact that all of our hospitals are pretty much located in the center of towns. It is very common for the EMTs to be cleaning the gurney by the time the engine shows up if they were driving normally. 

We are also met by a lot of resources if we come in code. It is not uncommon for the Doc to be waiting in the ambulance bay. As soon as we walk in registration gets the paperwork and we give a report to the nurse/doctor as other nurses/techs are helping us move the patient over.


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## Angel (Mar 28, 2015)

@captaindepth, yes and no. In one instance I transported a stable PT who ended up needing a chest tube and even based on my radio report (we went code 2) they were not ready and scrambling to get a doc to put the chest tube and it ended up being an issue, so it can matter and I can see why transport decision matters.

@FireWA, no, we JUST got atrovent I doubt we'll ever get anything else.


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## OnceAnEMT (Mar 28, 2015)

captaindepth said:


> Has anyone decided to take a pt emergently in order to have the proper reception at the ER when you arrive? meaning that the pt may not truly require emergent transport but in order to get the "big room" at the ED with the appropriate staff/resources waiting for your arrival, then just bring the pt in emergently.



If that's not wrongful use then I don't know what it. In the ED we make the decision where you go, bottom line. We've had crews whisper if a Pt needed a room vs. fast track or triage chairs (extra fast track), but I've never seen a crew try to get a crash room. If you think your Pt needs it, prove it in the radio report (briefly please). Otherwise, get in line.


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## Ewok Jerky (Mar 28, 2015)

captaindepth said:


> Has anyone decided to take a pt emergently in order to have the proper reception at the ER when you arrive? meaning that the pt may not truly require emergent transport but in order to get the "big room" at the ED with the appropriate staff/resources waiting for your arrival, then just bring the pt in emergently.


Nope. What would necessitate "the big room" that wouldn't be apparent in the radio report or require a legitimate code 3 transport?

You call in radio reports for a reason, to give the ED a heads up so they can triage appropriately. They are probably better at knowing what rooms are available, what staff is necessary, what is coming in 4 minutes begind you, and where to put your patient.


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## captaindepth (Mar 28, 2015)

Wow im glad my question got such a strong response, I was really just curious what people would have to say. 

Where I started working we have the ability to do "Set ups" where you can transport a SICK but not critical pt non emergently and still have the all the appropriate resources waiting. And of course the hospital determines what resources are needed by the radio report which is why a quick clear and concise radio report is crucial. I guess when I asked the question I was thinking of all those borderline calls where you are on the fence, you know dude is sick and he cant go sit in a back room in the corner and not be addressed for 30 minutes once he is at the hospital.


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## Brandon O (Mar 28, 2015)

Ewok Jerky said:


> Nope. What would necessitate "the big room" that wouldn't be apparent in the radio report or require a legitimate code 3 transport?
> 
> You call in radio reports for a reason, to give the ED a heads up so they can triage appropriately. They are probably better at knowing what rooms are available, what staff is necessary, what is coming in 4 minutes begind you, and where to put your patient.



Yes and no. I never did this with transport priorities, because my receiving hospitals usually didn't know or care how you rolled in (I suppose I told them on the radio, but I doubt they listened). But I would say I've done this by intercepting with ALS. While I generally looked for medics -- or avoided them -- based on the specific diagnostics or interventions they could provide, there are times when I had a patient who was less obviously sick yet whom I thought needed a full-court press (e.g. occult sepsis) where I just felt they were more likely to get the right attention if we walked in with tubes and wires.

One of my central goals, and I think an appropriate central goal for BLS providers, was always to ensure the best transfer of care, which means appropriate triage at the ED -- and getting a worrisome patient thrown into the waiting room or something is a pet peeve of mine.


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## Jim37F (Mar 28, 2015)

Here, with unstable/unsecured ABC's is pretty much automatic code 3, unless the medic specifically requests code 2 (no lights, no sirens for those who use other terminology). We're also a relatively dense urban environment with traffic lights every 50 feet or so it seems. So yeah, sometimes the engine following up code 2 is pulling into the hospital bay while we're still wheeling the patient in, sometimes I'm loading the cleaned and dressed gurney into the rig when they pull in. So yeah if I was in the back of an ambulance struggling to breath (whether due to asthma or any other reason), I  sure as heck don't want to be sitting in traffic at the whims of the red lights


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## Chewy20 (Mar 29, 2015)

We use code 3 as well. Based on her vitals and what I am picturing in my head, we would have taken it code 1 (No lights or sirens) and the paramedic would have been up front driving.

Unless her Spo2 took a turn for the worse somehow, I am not to worried about this pt to be honest. Shes tacky because of her being all worked up, everything looks and sounds good clinically from what you are providing to us. Also, probably wouldn't have gone past a NEB treatmeant with this presentation. Though solumedrol may help the pt later on during the day from it coming back.

I wasn't there though so it doesn't matter much!


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## Handsome Robb (Mar 29, 2015)

Chewy20 said:


> We use code 3 as well. Based on her vitals and what I am picturing in my head, we would have taken it code 1 (No lights or sirens) and the paramedic would have been up front driving.
> 
> Unless her Spo2 took a turn for the worse somehow, I am not to worried about this pt to be honest. Shes tacky because of her being all worked up, everything looks and sounds good clinically from what you are providing to us. Also, probably wouldn't have gone past a NEB treatmeant with this presentation. Though solumedrol may help the pt later on during the day from it coming back.
> 
> I wasn't there though so it doesn't matter much!



Your agency would really BLS/ILS this patient?

I'm sure anxiety has a roll in her tachycardia but I'm also pretty sure that inhaled beta agonists have a solid roll in it as well. While she may not be circling the drain I think mag and solumedrol are very justifiable in this situation. She's in distress and refractory to inhaled beta agonists and anticholinergics.

She also does have the potential to decompensate. Like you said I wasn't there, I also don't work in your system but as a Paramedic I wouldn't give a PT like this to my ILS partner. Definitely not to a BLS partner.

Another question I had for you @Angel is did you CPAP her or no? OP says you did then a later post states "she wasn't on the CPAP end of the spectrum yet".


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## Carlos Danger (Mar 29, 2015)

Chewy20 said:


> We use code 3 as well. Based on her vitals and what I am picturing in my head, we would have taken it code 1 (No lights or sirens) and the paramedic would have been up front driving.
> 
> Unless her Spo2 took a turn for the worse somehow, I am not to worried about this pt to be honest. Shes tacky because of her being all worked up, everything looks and sounds good clinically from what you are providing to us. Also, probably wouldn't have gone past a NEB treatmeant with this presentation. Though solumedrol may help the pt later on during the day from it coming back.



You are described a scenario where a patient is in status asthmaticus for most of a day and continuing to worsen, and you 1) assume the tachycardia is mostly anxiety, 2) would be "not too worried", 3) would BLS the call, and 4) even though nebs haven't worked all day, still think that's the only appropriate treatment?

Wow. That is all.


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## TRSpeed (Mar 29, 2015)

Lol, what remi said.


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## gotbeerz001 (Mar 29, 2015)

Remi said:


> You are described a scenario where a patient is in status asthmaticus for most of a day and continuing to worsen, and you 1) assume the tachycardia is mostly anxiety, 2) would be "not too worried", 3) would BLS the call, and 4) even though nebs haven't worked all day, still think that's the only appropriate treatment?
> 
> Wow. That is all.


Amen.


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## cruiseforever (Mar 29, 2015)

Angel said:


> very little lung sounds, (wheezes up top) and none below,.



Does not sound like a stable pt.


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## Angel (Mar 29, 2015)

@Handsome Robb I did cpap her. She actually asked for it. I meant to say epi, (IMO: since she still had decent tidal volume, vitals were decent and cpap was helping) I did not give her epi even though I put her in the moderate category and technically they are supposed to get it.


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## Chewy20 (Mar 30, 2015)

Handsome Robb said:


> Your agency would really BLS/ILS this patient?
> 
> I'm sure anxiety has a roll in her tachycardia but I'm also pretty sure that inhaled beta agonists have a solid roll in it as well. While she may not be circling the drain I think mag and solumedrol are very justifiable in this situation. She's in distress and refractory to inhaled beta agonists and anticholinergics.
> 
> ...


 
Like I said, I am going off of what she wrote and how I am picturing it...I also agree that mag and solumedrol are completly acceptable, and then it would have been the paramedics call. All I am saying is that I would have been comfortable taking this pt if the paramedic decided against further meds. Would he/she have let me? Maybe, maybe not. Again, I wasnt there, it is just what I am picturing.


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## Chewy20 (Mar 30, 2015)

Remi said:


> You are described a scenario where a patient is in status asthmaticus for most of a day and continuing to worsen, and you 1) assume the tachycardia is mostly anxiety, 2) would be "not too worried", 3) would BLS the call, and 4) even though nebs haven't worked all day, still think that's the only appropriate treatment?
> 
> Wow. That is all.


 
1. Ok, should have said could likely be due to anxiety. My fault there.
2. No, I have no reason to be worried with all the vitals she gave, again going off of what she told us. Her presentation in person could have been completly different.
3. Why not? Don't trust your basic to be able to monitor a pt with stable vitals? Any pt can decomp, so I guess ALS is always the answer. If CPAP is working. Pretty confident in my abailities to take a respiratory call, also feel confident to tell my partner I think you should take this, or get on the mic and let them know she is getting progressivly worse.
4. If CPAP was working and bringing her HR down and RR down, then I am fine with that right there if she is getting better.

She has been in this state "all day" but her vitals are still like that? Are you REALLY concerned about them tanking in the next 15 minutes?

If the pt on scene needs the meds, give them the meds. My appologies for ruffling some feathers by the scenario that popped into my head.

@cruiseforever I read those lung sounds as clear besides a little wheezing. Not diminished or absent.

Back to topic, if the call went to ALS side like yours did angel, the call would have still been code 1.


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## Chewy20 (Mar 30, 2015)

Tried to edit last one but wouldnt let me. @Remi I am completely for constructive critisim, if you actually provide some. "Wow, just wow" does not teach me much unless you add onto it. Next time, just say "hey idiot how about all the stuff you dont know that could happen like XYZ." I can learn from that to apply to calls in the future.


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## Tigger (Mar 30, 2015)

I am very happy that my receiving hospitals arrange their resources based around the report or provider report rather then whether or not we are coming in emergently. That's just stupid.


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## Carlos Danger (Mar 30, 2015)

Chewy20 said:


> 1. Ok, should have said could likely be due to anxiety. My fault there.



If they called 911 before even using their inhaler and were in full panic mode when I got there 5 minutes later, despite no objective evidence of a severe attack, then I'd probably agree that anxiety is a component. Anxiety _is_ common in asthmatics, and it can sometimes cloud the picture a little. Turns out it's scary to feel like you are slowly suffocating to death.

But if someone calls after an attack has been going on for a good part of a day and multiple inhaler treatments have failed, then anxiety would be low on my list of differentials. 



Chewy20 said:


> 2. No, I have no reason to be worried with all the vitals she gave, again going off of what she told us.


I wouldn't be worried about the vitals that Angel listed, either. But I would not be dismissive of a day-long asthma attack that was refractory to nebs and slowly worsening. That is actually the classic description of an asthma attack that progresses to life-threatening. 

The whole point is _not _to wait until their RR is 50 and their HR is 160 and their lips are blue. 



Chewy20 said:


> 3. Why not? Don't trust your basic to be able to monitor a pt with stable vitals? Any pt can decomp, so I guess ALS is always the answer. If CPAP is working. Pretty confident in my abailities to take a respiratory call, also feel confident to tell my partner I think you should take this, or get on the mic and let them know she is getting progressivly worse.


Trust has nothing to do with it. 

It's pretty rare that I call something "always right or always wrong", but this is one of them. Status asthmaticus is an ALS call. Turfing it to BLS when ALS is available is lazy and inappropriate, period. 

And "ALS is always the answer" is a straw man. I never said anything even remotely like that. Clearly ALS is more appropriate than BLS in _some_ cases, and this is one of those.



Chewy20 said:


> She has been in this state "all day" but her vitals are still like that?


So she's compensating because she's young and (presumably) healthy, and because the attack has not yet progressed to the point that her compensatory mechanisms fail. That's a good thing. 

That's not an excuse to be complacent thought, because it doesn't mean she isn't really sick. What it means is you have the opportunity to manage aggressively and prevent progression, rather than waiting until she is in extremis when your therapies are less likely to work.



Chewy20 said:


> Are you REALLY concerned about them tanking in the next 15 minutes?



Thinking something is very likely to happen and being concerned about the possibility of it happening are not the same. It's my job to think about - and be concerned about - what might happen.

Status asthmaticus has an overall mortality rate ranging from 4%-9%, and with certain co-morbidities the chance of death is much higher. *85% of asthma-related deaths follow a gradually worsening attack that lasted longer than 12 hours,* rather than an abrupt, severe attack.

Asthma refractory to inhaled b-agonists and combined with a patient description of worsening dyspnea over a period of hours should get your attention like few other things.


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## Ewok Jerky (Mar 30, 2015)

@Remi - Would you transport status asthmaticus Code 3 or Code 2? Or to put it another way, Priority 1 or Priority 2?

**knowing that you aren't there to see the OPs patient yada yada yada**


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## Carlos Danger (Mar 30, 2015)

Ewok Jerky said:


> @Remi - Would you transport status asthmaticus Code 3 or Code 2? Or to put it another way, Priority 1 or Priority 2?
> 
> **knowing that you aren't there to see the OPs patient yada yada yada**



Hey Ewok.

I've always felt that the whole point of L&S was to save a significant amount of time in getting the patient to a therapy that they needed. So with that in mind, _if_ the patient has a time-sensitive problem that the hospital can fix but you can't, and _if_ driving noisy will get you there significantly quicker, then sure. OTOH, sometimes noise just doesn't help....the patient can be sick as hell and if L&S isn't going to save any time, it's probably more risk and trouble than it's worth.

So it really depends on lots of factors. Operational (traffic, road condition), clinical (is the patient getting better or worse with what you are doing?), etc.

There's no question that statistically, L&S increases risk to the patient, to us, and to the public. So it shouldn't be done nonchalantly. But I think it can be done with a minimum of added risk, and there are times that getting to the ED a few minutes quicker could potentially impact outcomes. You just have to be honest about that risk and do your best to weigh it against any expected benefit.

As far as L&S for a status asthma? Of course, if my interventions weren't clearly having a positive impact, and if doing so would save some time. No different than a sick multitrauma or an MI or stroke.


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## Angel (Mar 30, 2015)

I really like the discussion going on and it has given me a lot to think about. Truth be told I sometimes struggle with this. I've gotten in trouble (not big trouble but the ER complained) about me not going code 3 for a STABLE Trauma PT because of "mechanism" (whole other subject) so unfortunately some of the factor in my transport decision is discipline, but it's NOT enough to sway my entire decision if that makes sense. 
Anyway, seeing the varying opinions just illustrates that there is no blanket answer or one size fits all. 
@Remi, that is the perfect explanation, I wish I could've said even half of that when I was questioned but it caught me off guard.


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## Chewy20 (Mar 30, 2015)

Remi said:


> If they called 911 before even using their inhaler and were in full panic mode when I got there 5 minutes later, despite no objective evidence of a severe attack, then I'd probably agree that anxiety is a component. Anxiety _is_ common in asthmatics, and it can sometimes cloud the picture a little. Turns out it's scary to feel like you are slowly suffocating to death.
> 
> But if someone calls after an attack has been going on for a good part of a day and multiple inhaler treatments have failed, then anxiety would be low on my list of differentials.
> 
> ...


 
Thank you for your explanations. I know I am not experienced, thus why I ask for the explanations.


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## Ewok Jerky (Mar 30, 2015)

Angel said:


> I wish I could've said even half of that when I was questioned but it caught me off guard.


"I acted in the best interest of the patient because of XYZ" is my standard reply when questioned.  Maybe things could have been done differently, especially knowing what we know after we get a full assessment in the ED, or after the patient DOESN'T crump out, but in the moment as long as you are acting in the best interest of the patient every one else can f off.  This is not mutually exclusive to learning from mistakes made or having a different perspective. 

@Angel  looking back, would you have still gone in hot?


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## cprted (Mar 30, 2015)

A lot of people have been talking about this patient's sats as a sign that they're doing fine.  Remember this is a young, otherwise healthy patient with no underlying lung pathology.  She doesn't have anything impairing gas exchange.  These patients oxygenate well and can maintain sats >95% even as they spiral into respiratory failure.  She's getting oxygen: that isn't the main problem.  What is impaired is her ability to blow off CO2.

In your history, you should be considering risk for a fatal asthma attack:



			
				UpToDate said:
			
		

> ●Previous severe exacerbation (eg, intubation or intensive care unit admission)
> 
> ●Hospitalization or emergency department visit for asthma in the past year
> 
> ...


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## Angel (Mar 31, 2015)

@Ewok Jerky, I am definitely going to be using that. I would, if for no other reason than her lack of lung sounds and labored breathing. It would've taken us at least 20 mins to get to the ER code 2 so I imagine her getting worse in that amount of time and literally all I could do would be to bag her by myself.

I'm still learning and trying to figure stuff like this out. I'd say this (transport decision) and whether or not to bring a rider are the top things I struggle with. (Besides the obvious cases).


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## zzyzx (Mar 31, 2015)

Angel, I think you did the right thing taking the patient Code 3 if, as you say, you were unsure if the patient was going to continue to be stable. I think it is pointless for someone to question you on this. Really, Code 3 driving is not that dangerous, and we do it all the time going to the call.  

That's not to say that some medics overuse Code 3. For example, LA County transports all their ALS patients Code 3, which is completely stupid.

What you ought to do next time you take a patient like this to the hospital--one that is stable but that you have some amount of concern about--is to simply tell the hospital, "The patient is stable at this time, and we are going Code 3 as a precaution."

You might get some know-it-all medic or EMT giving you a hard time for going Code 3, but if you take someone Code 2 and they crash, it looks a lot worse that you didn't initially go with lights and sirens. If something like this goes to court, you can be that a lawyer is going to be all over you asking why you didn't take the patient to the ER with lights and sirens. The public thinks we go with lights and sirens all the time, so it gives the perception that you were legligent.


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## RocketMedic (Apr 1, 2015)

I'd go emergent if traffic became an issue. Respiratory deterioration actually equals a stop; time to bring your oartner back and secure an airway.


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## Tigger (Apr 1, 2015)

zzyzx said:


> Angel, I think you did the right thing taking the patient Code 3 if, as you say, you were unsure if the patient was going to continue to be stable. I think it is pointless for someone to question you on this. Really, Code 3 driving is not that dangerous, and we do it all the time going to the call.



That is not the most solid reasoning I've ever heard...doing something frequently does not make it right. 

We know driving emergent is dangerous and absolutely makes getting into a collision more likely. Whether or not the risks outweigh the benefits is the question.


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## zzyzx (Apr 2, 2015)

"That is not the most solid reasoning I've ever heard...doing something frequently does not make it right." Tigger, how many times have you driven Code 3 (including to a call)? How many accidents have you had?


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## chaz90 (Apr 2, 2015)

zzyzx said:


> "That is not the most solid reasoning I've ever heard...doing something frequently does not make it right." Tigger, how many times have you driven Code 3 (including to a call)? How many accidents have you had?



Statistically, driving with lights and sirens is correlated with a higher risk of accident and injury. This doesn't mean all emergent driving is equally risky and I imagine we all do what we can to drive as safely as possible even when our lights and sirens are activated. 

Just because someone hasn't experienced something doesn't mean they don't recognize the risks involved. I've never been shot, but I still recognize that could be painful and detrimental to my health so I try to avoid it. I've also never been involved in an accident driving Code 3, but I still try to minimize my usage of lights and sirens.


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## Tigger (Apr 3, 2015)

zzyzx said:


> "That is not the most solid reasoning I've ever heard...doing something frequently does not make it right." Tigger, how many times have you driven Code 3 (including to a call)? How many accidents have you had?


I've never been invovled in a cose three accident, though I've caused several wake collisions. Also, that's not really how this works. Normalizing risk does not make the behavior safe.

Also I have no idea how many times I've driven code three. Who cares?


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## TheLocalMedic (Apr 6, 2015)

Stroke, STEMI, major trauma, or REALLY sick patients are generally the only ones who will get a code 3 ride in my bus.  Rolling with lights and siren really doesn't save a whole lot of time, plus the ride is terrible and it just adds to the patient's anxiety level.  I try to avoid it if possible.  

Here's my rule of thumb:  If you have to think about whether or not you should go code 3, then you don't need to go code 3.  If a patient is sick enough to warrant a fast ride, you will recognize it immediately.


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## Angel (Apr 6, 2015)

And others say trust your gut/do it...


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## Handsome Robb (Apr 6, 2015)

I wouldn't be surprised if eventually it became a standard to not transport patients code three unless there was a lifesaving, time-sensitive intervention the hospital can perform and you couldn't. 

The more time you get under your belt @Angel the fewer patients you will transport emergently.


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## Angel (Apr 6, 2015)

That's what a couple of the "vets" said too. I accept that.


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## Handsome Robb (Apr 6, 2015)

It's not a bad thing that you went emergent with this patient, far from it. The only question I will ask is how much time did you truly save and did that time make a difference in the patient's outcome? If you're fighting heavy traffic and lots of lights then you can save a ton of time, but even with medium traffic and lights over short to medium distances the time saved is measured in seconds, maybe minutes. 

I see medics go emergent with far less sick patients than yours every day.


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## Angel (Apr 6, 2015)

I'd say 5 minutes maybe? I wasn't paying too much attention but we were farther away from the city than we normally are. 

Oddly enough I had almost this exact same call today, and same thing code 3, but I honestly felt like he would go into respiratory failure at any minute. Last I checked he was getting RSId  (about 10 minutes after we got there) and I did have this whole discussion run through my head. I decided on code 3 because he was deteriorating 
If you care to know: RR ~30, accessory muscle use, 1-3 word dyspnea, clammy, NO lung sounds, hypertensive, and he was lethargic compared to the firefighters that knew him. 
Probably would've been a good idea to bring a rider, but I checked our time and we made it code 3 in 5 minutes. So there's that.


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