Code 3

[Handsome Robb]

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".

 

[DesertMedic66]

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.

 

[Angel]

@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.

 

[OnceAnEMT]

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.

 

[Ewok Jerky]

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.

 

[captaindepth]

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.

 

[Brandon O]

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.

 

[Jim37F]

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

 

[Chewy20]

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!

 

[Handsome Robb]

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".

 

[Carlos Danger]

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.

 

[TRSpeed]

Lol, what remi said.

 

[gotbeerz001]

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.

 

[cruiseforever]

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

Does not sound like a stable pt.

 

[Angel]

@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.

 

[Chewy20]

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".

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.

 

[Chewy20]

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.

 

[Chewy20]

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.

 

[Tigger]

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.

 

[Carlos Danger]

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.

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.

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.

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.

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.