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

StCEMT

Forum Deputy Chief
2,526
1,374
113
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.
 

Peak

ED/Prehospital Registered Nurse
433
242
43
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.
 

medic2EMSdoc

Forum Probie
20
2
3
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.
 

DesertMedic66

Forum Troll
10,323
2,650
113
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).
 

medic2EMSdoc

Forum Probie
20
2
3
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.
 

DesertMedic66

Forum Troll
10,323
2,650
113
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.
 

Peak

ED/Prehospital Registered Nurse
433
242
43
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.
 

medic2EMSdoc

Forum Probie
20
2
3
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.
 

Akulahawk

EMT-P/ED RN
Community Leader
4,353
822
113
I personally think that all transports show be with lights and sirens.
This looks a LOT like a blanket statement.
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.
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.
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."
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."
 

medic2EMSdoc

Forum Probie
20
2
3
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.
 

Akulahawk

EMT-P/ED RN
Community Leader
4,353
822
113
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.
 

johnrsemt

Forum Deputy Chief
1,311
155
63
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
 

Remi

Forum Deputy Chief
Premium Member
3,856
2,477
113
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.
 
Last edited:

johnrsemt

Forum Deputy Chief
1,311
155
63
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.
 

SandpitMedic

Shock&Awe
1,809
850
113
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.
 

medic2EMSdoc

Forum Probie
20
2
3
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)
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.
 

truetiger

Forum Asst. Chief
520
14
18
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.
 

Bishop2047

Forum Probie
22
9
3
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.
 
Top