Responding and Transporting Code 3

[Clare]

Just out of curiosity, how many of these patients have you had?

What is a "time critical" patient here has recently been reviewed and now makes much more sense.

Jobs will be dispatched lights and siren only if they are coded as "purple" or "red" - purple is cardiac or respiratory arrest and "red' is immediate threat to life; things like stroke, new cardiac chest pain > 35, seizure and still fitting, large burns, severe difficulty breathing, altered level of consciousness etc.

Patients will be transported urgently (lights and siren) only if they have a problem that is immediately life threatening or time critical for example post-cardiac arrest, cardiogenic shock, GCS < 10, major trauma with multi system abnormality etc.

I have encountered very few (somewhere between 5 and 10) patients I would consider to be "time critical".

 

[Veneficus]

What is a "time critical" patient here has recently been reviewed and now makes much more sense.

Jobs will be dispatched lights and siren only if they are coded as "purple" or "red" - purple is cardiac or respiratory arrest and "red' is immediate threat to life; things like stroke, new cardiac chest pain > 35, seizure and still fitting, large burns, severe difficulty breathing, altered level of consciousness etc.

Patients will be transported urgently (lights and siren) only if they have a problem that is immediately life threatening or time critical for example post-cardiac arrest, cardiogenic shock, GCS < 10, major trauma with multi system abnormality etc.

I have encountered very few (somewhere between 5 and 10) patients I would consider to be "time critical".

I created a new thread and poll. Please select from there.

 

[RocketMedic]

My answer to this is a hearty "I transport emergently when my agency's policies tell me I have no choice." As a relatively new employee still on 'probation', 100% of my charts are reviewed, and they do come down to things like 'return status'. Completely ignoring that my schedule essentially guarantees low-traffic, clear roads, BTW.

At the end of the day, I rarely have a truly valid medical reason for transporting emergently, but the potential personal financial consequences of being unemployed cause me to transport emergently. "When in doubt, think of how it will look on your paperwork and react accordingly." (a quote I hold in very high regard). I have very little desire to be fired due to 'overconfidence' or whatever excuse may be used, so I simply toe the line and don't provide ammunition. That being said, my partner's 'emergent' driving is quite sedate by request. We literally drive 'textbook' emergently.

Keep in mind, I work in 1996 with fancy toys. Up until recently, 'use of CPAP' was an automatic emergent return.

 

[Clare]

Keep in mind, I work in 1996 with fancy toys. Up until recently, 'use of CPAP' was an automatic emergent return.

Um, we do not have CPAP and we only got PEEP in 2009 so um, what year might I be stuck in?

 

[RocketMedic]

???
How is that? Our CPAP (BiPap-capable and generally used as such, Impact 731s) isn't exactly brand-new...

I thought y'all over in Kiwi Land had awesome everything?

 

[Veneficus]

???
How is that? Our CPAP (BiPap-capable and generally used as such, Impact 731s) isn't exactly brand-new...

I thought y'all over in Kiwi Land had awesome everything?

In a fair number of places CPAP is considered a non emergent therapy and not commonly used outside of pulmonary medicine.

Anesthesiologists tend to resist even learning about it because they claim it will lead to the admission of patients who could go to pulmonary and tie up limited ICU resources.

(sometimes we jokingly call these "intensive ventalatory units" because a patient needing intubation is the absolute criteria)

 

[Clare]

I asked Clinical Standards Unit; they said we do not have it because (1) there is no solid evidence it reduces mortality in the pre-hospital environment and (2) we cannot afford it as our new ambulances only carry one tank of bulk oxygen and one portable oxygen.

 

[katgrl2003]

I asked Clinical Standards Unit; they said we do not have it because (1) there is no solid evidence it reduces mortality in the pre-hospital environment and (2) we cannot afford it as our new ambulances only carry one tank of bulk oxygen and one portable oxygen.

Wow. We have a portable on the cot, one in the airway bag, and 3 spares in a side compartment.

We started with CPAP I think about 2 years ago. Ours screws into the portable tanks, and we have seen a significant drop in intubations since we started using it.

 

[VFlutter]

I asked Clinical Standards Unit; they said we do not have it because (1) there is no solid evidence it reduces mortality in the pre-hospital environment and (2) we cannot afford it as our new ambulances only carry one tank of bulk oxygen and one portable oxygen.

I will admit it does not directly reduce mortality in the pre hospital environment but it does however reduce intubations, ICU admissions, length of hospital stay, complications, and cost to the patient. No CPAP may make sense for EMS but is horrible for continuum of care.

So if you had a patient on Bipap at the hospital that needed to be transferred to another facility would you just throw them on a NRB and hope you don't have to intubate them en route?

 

[RocketMedic]

I asked Clinical Standards Unit; they said we do not have it because (1) there is no solid evidence it reduces mortality in the pre-hospital environment and (2) we cannot afford it as our new ambulances only carry one tank of bulk oxygen and one portable oxygen.

That seems like a horrible punt answer. Some you can use on simple room air in a pinch.

 

[RocketMedic]

In a fair number of places CPAP is considered a non emergent therapy and not commonly used outside of pulmonary medicine.

Anesthesiologists tend to resist even learning about it because they claim it will lead to the admission of patients who could go to pulmonary and tie up limited ICU resources.

(sometimes we jokingly call these "intensive ventalatory units" because a patient needing intubation is the absolute criteria)

That seems like poor medicine.

 

[katgrl2003]

So if you had a patient on Bipap at the hospital that needed to be transferred to another facility would you just throw them on a NRB and hope you don't have to intubate them en route?

I've actually had to do that before. Out of town transfer, dingbat dispatcher told the hospital we had CPAP...nope! We get there and the guy is a DNR. We were told the guy was visiting family, and had a syncopal episode. The hospital ends up putting him on a NRB, because no other service had CPAP at the time either. Halfway to his house, about 45 minutes - 1 hour into the trip, the wife riding with us told me that he had actually had a cardiac arrest and was going home to die, and that the hospital had told her they didn't expect him to survive the trip (found out later it was true). Got him home, on his home CPAP, and found out he died a few days later.

 

[VFlutter]

I've actually had to do that before. Out of town transfer, dingbat dispatcher told the hospital we had CPAP...nope! We get there and the guy is a DNR. We were told the guy was visiting family, and had a syncopal episode. The hospital ends up putting him on a NRB, because no other service had CPAP at the time either. Halfway to his house, about 45 minutes - 1 hour into the trip, the wife riding with us told me that he had actually had a cardiac arrest and was going home to die, and that the hospital had told her they didn't expect him to survive the trip (found out later it was true). Got him home, on his home CPAP, and found out he died a few days later.

It is fairly common for our terminal CHF patients to be on CPAP for comfort measures, more so for the family then the patient. It is tough for them to watch their loved one fighting to breath even after maxing out palliative doses of morphine and benzos. It is usually the last treatment to go almost like a terminal wean from a vent.

 

[Clare]

I've actually had to do that before. Out of town transfer, dingbat dispatcher told the hospital we had CPAP...nope! We get there and the guy is a DNR. We were told the guy was visiting family, and had a syncopal episode. The hospital ends up putting him on a NRB, because no other service had CPAP at the time either. Halfway to his house, about 45 minutes - 1 hour into the trip, the wife riding with us told me that he had actually had a cardiac arrest and was going home to die, and that the hospital had told her they didn't expect him to survive the trip (found out later it was true). Got him home, on his home CPAP, and found out he died a few days later.

This guy seems to resemble that pile up on the southern motorway that happened on Friday or something; for real ... I am not sure where you is but here he'd get turfed to a nursing home, or the Patient Transfer Service would take him home with A-Zero who bought along their transport CPAP machine.

I don't think its right for you get patients who you can't look after; i.e. the hospital shouldn't have let you take him if you didn't have CPAP and he needed.

In the acute patient there is always an argument for not waiting round for back up and just transporting however that is because you are moving them to the hospital and I don't think this applies here ...

That seems like poor medicine.

Welcome to the world of having a charity run the Ambulance Service; hmm, I think its donation appeal week in May or July or something .... its embarrassing, frustrating, rewarding and lots of other things all rolled into one!

We only carry one bulk and one portable sized oxygen and they are expensive to refill so if you drain your portable tank on one patient who gets CPAP then have to refill it well, that is going to cost a significant amount more and well, the deficit last year was $14 million so um ... yeah

 

[Rialaigh]

It is fairly common for our terminal CHF patients to be on CPAP for comfort measures, more so for the family then the patient. It is tough for them to watch their loved one fighting to breath even after maxing out palliative doses of morphine and benzos. It is usually the last treatment to go almost like a terminal wean from a vent.

No such thing...

Max dose is when pain is controlled or when they are no longer breathing...in the case of hospice nursing..whichever you reach first....IMO it should be true of comfort measures as well (When the family is ready...)



Would people agree that right now, in the systems we live in, it would reduce risk more if we worked on the dispatch side rather then the transport side (as we already have control of the transport side)...

 

[Veneficus]

That seems like poor medicine.

It is not really poor so much as it is limited resources.

As much as it pains me, truthfully reserving an ICU bed for somebody who is more critical is good medicine.

The other thing to consider is that these patients are pulmonary patients and they are not only more than capable of using CPAP, they are expert at treating the diseases that it is beneficial for.

It is just a different way of doing things.

 

[Veneficus]

It is fairly common for our terminal CHF patients to be on CPAP for comfort measures, more so for the family then the patient. It is tough for them to watch their loved one fighting to breath even after maxing out palliative doses of morphine and benzos. It is usually the last treatment to go almost like a terminal wean from a vent.

???

No such thing...

Max dose is when pain is controlled or when they are no longer breathing...in the case of hospice nursing..whichever you reach first....IMO it should be true of comfort measures as well (When the family is ready...)

What he said.

I would just ask if your facility is billing for all of these "family" comfort measures, because it just sunds to me like a way to pad the bill.

 

[Mariemt]

Just out of curiosity, how many of these patients have you had?

Well being dispatched too... about 10%. If you see my post about our dispatched calls.

Transporting from scene..... is less. But I would say I have had 2 to 3 in the last month or so where we needed to get through 5 pm traffic

 

[VFlutter]

???



What he said.

I would just ask if your facility is billing for all of these "family" comfort measures, because it just sunds to me like a way to pad the bill.

While in the hospital we still have maximum doses for our palliative/hospice patients. Once they are at a hospice facility they can do more.

I could have worded that better. They are usually already on CPAP we do not just put it on while they are dying. But we leave it on after discontinuing treatments until the very end where they will pass within minutes of taking them off. Even though it is technically still "life prolonging treatment" it is more so for comfort until they are ready to go.