Code 3

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**

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.

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.

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.

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.

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.

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.

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.

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

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?

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

●Three or more emergency department visits for asthma in the past year

●Not currently using inhaled glucocorticoids

●Recent or current course of oral glucocorticoids

●Use of more than one canister of short-acting beta agonist per month

●Difficulty perceiving asthma symptoms or severity of exacerbations

●History of poor adherence with asthma medications and/or written asthma action plan

●Illicit drug use and major psychosocial problems, including depression

●Comorbidities, such as cardiovascular or chronic lung disease

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).

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.

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.

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.

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?

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.

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?

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.

Angel · Apr 6, 2015

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

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.

Angel · Apr 6, 2015

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

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.

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.

Code 3

Ewok Jerky

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Carlos Danger

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Angel

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Chewy20

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Ewok Jerky

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cprted

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Angel

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zzyzx

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RocketMedic

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Tigger

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zzyzx

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chaz90

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Tigger

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TheLocalMedic

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Angel

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Handsome Robb

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Angel

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Angel

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