upgrade to code 3 or not?

[PCP]

Okay, yesterday I was working on the transfer car and we were transporting a patient from the CCU down to the CCU in Victoria which is about an hour and half away from Nanaimo. I had a nurse on board with me in the back, the lady was hooked up to a 12 lead monitor, along with two 18g IVs one in the ACF and the other one in the right hand. No IV solution running at this time. The lady was diagnosed with a 1degree heart blockage.

I am the first one to admit that I do not understand the difference between a 1 degree and a 3rd degree heart blockage. But I can learn about that over time. Any how, when we were about 40 minutes from the hospital my patient started to experience chest pain again, the nurse gave the patient some nitro and asked me to put her on 3 lpm of O2 by nasal cann.

Also the monitor's battery was running on a low battery, when it died the nurse switched over to the back up battery which was reading low battery as well.

My question is would you have upgraded to Code 3 due to being about 40 minutes from the hospital due to the patient experiencing chest pain?

The nurse in this scenario did not, so I was just curious to know if we should have possibly upgraded to code 3?

Thanks,

Brian

[HERBIE1]

Definitely upgrade. Clearly this person was decompensating and/or having a cardiac event, so if the person needed to be defibrillated or paced, you need that battery juice.

[akflightmedic]

Not enough information to say but I probably would NOT have upgraded.

What is the past medical hx? What were the vitals?

Does the pt have hx of CP? If so, the nurse was managing it appropriately.

Would turning on the lights and sirens actually benefit the patient's situation? No.

Would the time saved be of benefit? No.

Would the risk for all involved be increased significantly for no major benefit? Yes.

[WolfmanHarris]

Ya I feel like I don't have enough info here. Were it a basic 911 call and I was starting my ACS protocol then ya, I'd upgrade to L&S (called code 4 here). Were my 12 lead to show a STEMI we'd bypass, otherwise L&S into the hospital since that Pt. will be getting stat bloodwork as well as follow-up 12 leads and in the event a non-STEMI is found may still end up heading to the cath lab or being thrombolyzed.

However, as a CCU to CCU transport, what's the Pt.'s Hx? Course of tx in the sending facility?

Mainly my question when deciding to go L&S is, is there a time sensitive treatment that will be done for my Pt. immediately upon arriving? Is my Pt. decompensating or critical and in need of resourced beyond what I can provide immediately? Generally I am very reluctant to proceed L&S to the hospital without compelling reason. The increased risk is not worth the time saved.

[rock_shoes]

I am the first one to admit that I do not understand the difference between a 1 degree and a 3rd degree heart blockage. But I can learn about that over time. Any how, when we were about 40 minutes from the hospital my patient started to experience chest pain again, the nurse gave the patient some nitro and asked me to put her on 3 lpm of O2 by nasal cann.

Sorry but I have to ask about this. Where you not instructed in how to acquire and interpret 3-leads as part of your PCP program? It is part of the Canadian NOCP for PCPs and should have been taught within any CMA accredited program regardless of provincial licensing practices. If you’ve simply forgotten because it isn’t standard practice in BC that’s one thing, if you were never taught that’s a much bigger issue.

I agree with the others in wanting more information prior to deciding whether or not upgrading to L/S would have been appropriate. Was the patient’s pain relieved by the nitro for starters?

[WolfmanHarris]

And since we're on the topic of AV blocks. I vote tell you the answer, (far better to look it up yourself; which is why my gear bag is stuffed with printouts from journal club and textbooks) but to point you in the right direction, look to the relationship between the P-wave and the QRS. Also, once you've gotten a good handle on it, youtube "Diagnosis Wenkebach."

Edit: And sorry, no 3 lead on PCP trucks in BC? No PCP 12-lead I'm used to, don't like it, but I'm used to seeing it. But no 3 lead at all?

Edited December 29, 2010 by docharris

[fiznat]

There is *much* more to know about this patient's condition beyond his complaint of chest pain. The patient needs to be fully assessed, and a decision should be made given that information. Not every patient who complains of chest pain is "decompensating" or requires emergent transport. A complete assessment will help to differentiate who needs what.

[PCP]

Here in BC at the PCP level we are NOT trained on how to read a 3 lead. I have done some of my own research, but no way I am able to diagnose anything or do I fully understand the different rythms.

Patient hx was the night before she woke up for a bowl movement and she developed chest pain. After the bowel movement the pain got worse and called EHS. She was transported to the hospital and was sent to the CCU due to having a first degree heart blockage.

No previous hx of any cardica issue. pack a day smoker and chronic fatigue was the only other medical hx we had. She was being transported by us along with the nurse due to having a STEMI which I just looked up to understand what STEMI stands for now. The patient was given a thrombolytic medication two hours before our transport time which was at 0600 am. Not sure the name of the Thrombolytic (sorry)

That is all the information I received from the attending nurse.

When asked, the nurse stated that her vitals where all within normal range before we did the transport. I am not sure what the vitals where when the patient experienced the onset of chest pain while enroute, as the patient was under the nurses care at this time.

I over heard the nurse talking to the attending dr. at the receiving hospital that the patient had elevated Traponine levels. When I asked, I was told that by having elevated Traponine levels it indicates the patient has suffered damage to the heart due to her having a STEMI.

That is all the information and hx I had on the patient.

All and all it went well and we did not go code 3 and the patients pain went away after the squirt of Nitro and the pain never came back.

My feeling is, if we did not have the nurse on board and since we do not have the capability of using a 3 lead we would have upgraded to code 3.

[uglyEMT]

While I echo others statements of need more info I will add my two cents LOL

Increasing to Code 3 is really not going to do much it sounds like. Would doing so decrease travel time significantly? I know your in BC and I hear the roads are winding up that way so speed shouldn't be a factor. What was the time of day? Would being Code 3 alleviate a traffic situation? If not then staying non-emergent was the right thing to do. Now of course if the situation changed or the patient's condition deteriorated then Code-3 would be fine.

One thing that concerns me just a little, the low batteries on the unit. Both the main and the backup were low on juice? Did you have another AED available just in case? I would be watching my levels more closely or at least carry a spare battery just in case. Being you were doing a cardiac transport I would have double checked the batteries, dont want to have that pucker factor moment at the worst time.

[Richard B the EMT]

I see a "Fail" here, but I can't point fingers. Yet.

Who's EKG machine was it, sent on a trip of that known duration, without sufficient power; the OPs service, or the sending facility? There should have been both a fully charged EKG unit at the transport's start, as well as a fully charged backup battery.

The event described took place in Canada, eh? (Sorry, couldn't resist) In the medical pecking order, who is higher medical authority, the tech, or the RN, riding this particular call? If it is the RN, the RN had the authority to elevate the call status, or not, and took such option. Otherwise, the Tech could have made the decision.

Original Poster, what was the outcome?