upgrade to code 3 or not?

[PCP]

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?

The EKG machine belonged to the sending facility, as we don't carry EKG's on our BLS cars. Yes the patient was under the nurses care so she had the authority to upgrade to code 3 at any time and she felt it was necessary.

Not sure of the outcome, all I know is we got our patient to the other facility safely and she was scheduled for surgery later that day or early next morning.

Yes this event did take place in Canada eh! LOL, I know it is hard to not make fun of us Canadians as we seem to say eh after every word!!

[DwayneEMTP]

I think you're getting a little tunnel visioned based on a complaint of chest pain in a cardiac patient. Not all chest pain is equal.

I would also most likely not have upgraded this call, but I would have ripped someone a new asshole, myself likely, for not having charged batteries in the monitor.

As Fiz said, she needs an evaluation, a new one, as she's not in the same state as when she was picked up. But if the pain resolved with treatment then I don't see any reason to get froggy here. You need to also consider that though you might save a few minutes with L/S, what are the physiological effects of those things on the pt that you believe may be having a cardiac event?

Lots more info necessary to decide, but as you can see, the overriding majority are against.

Good question though!

Dwayne

[rock_shoes]

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.

I also did my PCP in BC and we were instructed on both placement and interpretation of 3-lead ECGs (yes I realise it isn't currently in the licensed BC SOP). If you were not also so instructed your school failed to deliver the education promised to you when you signed up for a CMA accredited program. That is not your fault. Unfortunately it does leave you with the task of catching yourself up on that material.

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.

So most likely the patient was headed to Royal Jubilee for either CABG or PCI. Already treated with thrombolytics and the chest pain was completely relieved with 0.4mg SL nitro. I would not have stepped up to L/S either.

Just a couple of hints for next time. The LP500 AED batteries we do carry also fit the Lifepack 12 (unless of course your unit has been switched over to the LP1000 AED). Additionally I would insist on using a LP12 that can be plugged into the ambulances inverter next time. All little things you learn from experience. At least you’re a PCP. I started out in Lillooet as an EMR (equivalent to EMT- B for our US members).

[HERBIE1]

The last time I had to worry about whether or not to use lights and siren was 25 years ago on the privates. We always transport and respond with lights and siren- with the occasional special case transport at our discretion. Archaic? Maybe, but as I have noted before, if we get in a crash, that is the first question our safety officer asks: Were the emergency devices activated?

I sense a major reluctance on the part of many to run with emergency lights and siren, and so many seem to be looking for any reason to justify NOT using them. We can debate all day the amount of time saved vs risk to a crew, the public, and the patient, but in the end, certain truisms are at work here- at least in our case. We are a busy system, and there is always another call waiting. In heavy traffic, in my case, running silent would probably add an average of 10-15 minutes to each transport, and in some areas, that number would be much higher. Now add those numbers up city wide, and see what impact there would be on an already overtaxed system which is short on units. Now factor in delays in obtaining an ER bed, longer transports because of hospital diversions, and those numbers would quickly add up. There is a bigger picture to consider than simply the benefit for one particular patient.

For our call volume, it is also worth mentioning that our rate of any type of accidents is incredibly low- despite the fact that we always respond and transport in emergency mode.

[tniuqs]

Richard B the EMT I see a "Fail" here, but I can't point fingers. Yet.

Well I do and I LOVE NEW YORK CITY cause no BS !

Agreed and quite embarrassed actually, but why ? That is because I voted to re title EMT and/or the P1 (in BC) to PCP with Paramedics Association of Canada (that was 16 years ago) and here we are today and now a "PCP" cannot interpret a farking lead 3 ECG first degree block and admit to this on an international forum for EMS professionals ? <insert head slapping noise> Well I guess I failed so many years ago to believe that "what was accepted at that time in Alberta was the standard Nationally" so FAIL SQUINT bad, bad SQUINT ! And here and now the Ontario PCP are most likely better at interpreting a STEMI that I am.

I FAILED to recognise that the government(s) would prostitute this title to cause less confusion I was so wrong .. I have allowed the general public to be under an illusion that when a truck has "BC Emergency Paramedic Ambulance" on its side but does not have an ECG that can not display a rhythm is simply terrifying for the future of Paramedic profession, btw PCP "nitro" is in actually your scope of practice too ... you know just in passing.

Major link worth reviewing.

http://www.paramedic.ca/Content.aspx?ContentID=4&ContentTypeID=2

Link to competencies.

http://www.paramedic.ca/Uploads/Area%204%20Assessment%20and%20Diagnostics.pdf

Link to medications lists.

http://www.paramedic.ca/Uploads/Appendix%205%20Medications.pdf

rock _shoes: Sorry man no mercy here on this stupidity and bring on the negative reps from the politically I should be more correct crowd. I feel a complete shred just maybe tough love is what is needed here as a tune up, yeah think EH ? no LOL at all.

So Best Advice their BC PCP: READ and EDUCATE yourself before continuing to embarrassing yourself and MY country, YES see above rock_shoes is 100% correct, interpretation of basic ECG rythum's is a National standard for PCP, first degree block is a basic arrthymia, therefore logic dictates that you are sub standard please pull up your damn socks.

DwayneEMTP

I would also most likely not have upgraded this call, but I would have ripped someone a new asshole, myself likely, for not having charged batteries in the monitor.

Agreed absolutely no excuses allowed, I believe some ripping is needed too ! This in Kanukistan is a legal responsibility called "due diligence" or in fact criminal negligence so FAIL HUGE besides as rock_shoes states there is an 110 inverter on board that truck, or was that broken ? ps BCAS is damn near completely standardized in every unit throughout the province.

<snip> But if the pain resolved with treatment then I don't see any reason to get froggy here. You need to also consider that though you might save a few minutes with L/S, what are the physiological effects of those things on the pt that you believe may be having a cardiac event?

Excellent point(s) Dwayne an unwanted and unneeded adrenergic response, (ie Adrenergic means "having to do with adrenaline (epinephrine)and can lead to a fast heart rate this is called tachycardia and increasing myocardial oxygen demand, btw Dwayne that explanation is not intended for a pararescue ninja. Now one shot of nitro pain resolved chest pain with elevation in STEMI and an elevated "TROPONIN" level, and transported with an RN, BC is such an interesting place.

No information provided in this senario indicates any life threatening distress, the patient is NOT in extremis and to pick it up L+S .. well this just increased your speed and statistical increased incidence 20 % for an MVC is that a good practice ... fill in the blank.

Lots more info necessary to decide, but as you can see, the overriding majority are against.

Good question though!

Disagree ... an absolutly Stupid Rhetorical question did PCP ever ask the RN if L+S was required ? PCP do some "thinking" and "personal research" on the terms you wish to quote BEFORE asking questions because this thread is exactly that, rhetorical. You have failed in every thread where I have taken my efforts and sometimes extensive amount's of my time invested in YOU to be polite and educational, unfortunatly you have yet to answer one basic question, don't believe for a second that this culmulative effect speaks volumes.

PCP

Posted Today, 12:38 PM

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.

FAIL in legal knowledge and understanding of your scope of practice, and pure observation, that being that cold, clammy and pale says a lot about a DX when a patient is complaining of Chest Pain, you don't need a machine to tell you someone is circling the drain and needs diesel bolus.

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

.

So ok teaching point just what was the underlying ventricular rate ? You are trained in taking pulses as a PCP aren't you as that would be a vital sign or perhaps look at the pulse oximiter reading, also scope of practice, so normal B/P ? hmmm .. so why am I getting an impression that we are talking with an OFA level 3 ?

No previous hx of any cardiac issue. pack a day smoker (ok how many pack years ?) 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.

So If this patient died when under when your care and in your truck (no matter the RN present) you would look the fool @ fatalities enquiry, possible criminal negligence as well. Did you write a PCR report with no information on it too ? this is absolutely no joke, EH !

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.

Wrong answer the RN stated and again you are as responsible for that patient's condition and knowledge of vital signs as the RN, you must perform to the level of your training, period, and only if you had an MD or ACP on board assuming responsibility written and signed would you NOT get slammed in a "shotgun legal suit" just saying.

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.

Good job something learned, you can have a non STEMI and have elevated troponin levels as well, just because one has elevated ST segments does not "absolute indicate" that one is having an MI, a prior Bundle Branch Block would be one of the exceptions.

TROPONIN :http://en.wikipedia.org/wiki/Troponin_test

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.

When chest pain via SL nitro relieves chest pain, this is typically be called angina, now if the call went well all in all then why generate a question ?

Should I mention I am trying to quit smoking, nah that would just be an "excuse" myself for being pointed and opinionated and have pride about my profession as a "PARAMEDIC".

cheers

Edited December 30, 2010 by tniuqs

[Richard B the EMT]

My "Fail" comment was to the condition of the EKG/Defib batteries at the start of the transport. A good point of having a model that could be plugged into either the 120 Volt AC inverter, or the vehicle's 12 VDC, however.

[Happiness]

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

So I decided to just read the original post.

Why would a nurse upgrade YOUR ambulance to code 3 if you felt that it was needed then that is your call. But once you decide to do that you cant down grade.

Why wasn't this pt on O2 from the beginning as she should have been

Was this equipment yours or the hospitals, if not yours then not your problem but it would be in your best interest to make sure anything going into your ambulance works properly.

You are a PCP and can administer Nitro, In your post you havent said what the vitals were or if the pt was pale and sweaty so it would be hard to say whether going code 3 would have been of any benift.

Happy

[tniuqs]

Why would a nurse upgrade YOUR ambulance to code 3 if you felt that it was needed then that is your call.

But once you decide to do that you cant down grade.

Why wasn't this pt on O2 from the beginning as she should have been.

Was this equipment yours or the hospitals, if not yours then not your problem but it would be in your best interest to make sure anything going into your ambulance works properly.

You are a PCP and can administer Nitro, In your post you havent said what the vitals were or if the pt was pale and sweaty so it would be hard to say whether going code 3 would have been of any benefit.

Happy

Yup I am Happy now

cheers

[PCP]

Richard B the EMT I see a "Fail" here, but I can't point fingers. Yet.

Well I do and I LOVE NEW YORK CITY cause no BS !

Agreed and quite embarrassed actually, but why ? That is because I voted to re title EMT and/or the P1 (in BC) to PCP with Paramedics Association of Canada (that was 16 years ago) and here we are today and now a "PCP" cannot interpret a farking lead 3 ECG first degree block and admit to this on an international forum for EMS professionals ? <insert head slapping noise> Well I guess I failed so many years ago to believe that "what was accepted at that time in Alberta was the standard Nationally" so FAIL SQUINT bad, bad SQUINT ! And here and now the Ontario PCP are most likely better at interpreting a STEMI that I am.

I FAILED to recognise that the government(s) would prostitute this title to cause less confusion I was so wrong .. I have allowed the general public to be under an illusion that when a truck has "BC Emergency Paramedic Ambulance" on its side but does not have an ECG that can not display a rhythm is simply terrifying for the future of Paramedic profession, btw PCP "nitro" is in actually your scope of practice too ... you know just in passing.

Major link worth reviewing.

http://www.paramedic...ContentTypeID=2

Link to competencies.

http://www.paramedic...Diagnostics.pdf

Link to medications lists.

http://www.paramedic...Medications.pdf

rock _shoes: Sorry man no mercy here on this stupidity and bring on the negative reps from the politically I should be more correct crowd. I feel a complete shred just maybe tough love is what is needed here as a tune up, yeah think EH ? no LOL at all.

So Best Advice their BC PCP: READ and EDUCATE yourself before continuing to embarrassing yourself and MY country, YES see above rock_shoes is 100% correct, interpretation of basic ECG rythum's is a National standard for PCP, first degree block is a basic arrthymia, therefore logic dictates that you are sub standard please pull up your damn socks.

Agreed absolutely no excuses allowed, I believe some ripping is needed too ! This in Kanukistan is a legal responsibility called "due diligence" or in fact criminal negligence so FAIL HUGE besides as rock_shoes states there is an 110 inverter on board that truck, or was that broken ? ps BCAS is damn near completely standardized in every unit throughout the province.

Excellent point(s) Dwayne an unwanted and unneeded adrenergic response, (ie Adrenergic means "having to do with adrenaline (epinephrine)and can lead to a fast heart rate this is called tachycardia and increasing myocardial oxygen demand, btw Dwayne that explanation is not intended for a pararescue ninja. Now one shot of nitro pain resolved chest pain with elevation in STEMI and an elevated "TROPONIN" level, and transported with an RN, BC is such an interesting place.

No information provided in this senario indicates any life threatening distress, the patient is NOT in extremis and to pick it up L+S .. well this just increased your speed and statistical increased incidence 20 % for an MVC is that a good practice ... fill in the blank.

Disagree ... an absolutly Stupid Rhetorical question did PCP ever ask the RN if L+S was required ? PCP do some "thinking" and "personal research" on the terms you wish to quote BEFORE asking questions because this thread is exactly that, rhetorical. You have failed in every thread where I have taken my efforts and sometimes extensive amount's of my time invested in YOU to be polite and educational, unfortunatly you have yet to answer one basic question, don't believe for a second that this culmulative effect speaks volumes.

FAIL in legal knowledge and understanding of your scope of practice, and pure observation, that being that cold, clammy and pale says a lot about a DX when a patient is complaining of Chest Pain, you don't need a machine to tell you someone is circling the drain and needs diesel bolus.

.

So ok teaching point just what was the underlying ventricular rate ? You are trained in taking pulses as a PCP aren't you as that would be a vital sign or perhaps look at the pulse oximiter reading, also scope of practice, so normal B/P ? hmmm .. so why am I getting an impression that we are talking with an OFA level 3 ?

So If this patient died when under when your care and in your truck (no matter the RN present) you would look the fool @ fatalities enquiry, possible criminal negligence as well. Did you write a PCR report with no information on it too ? this is absolutely no joke, EH !

Wrong answer the RN stated and again you are as responsible for that patient's condition and knowledge of vital signs as the RN, you must perform to the level of your training, period, and only if you had an MD or ACP on board assuming responsibility written and signed would you NOT get slammed in a "shotgun legal suit" just saying.

Good job something learned, you can have a non STEMI and have elevated troponin levels as well, just because one has elevated ST segments does not "absolute indicate" that one is having an MI, a prior Bundle Branch Block would be one of the exceptions.

TROPONIN :http://en.wikipedia.org/wiki/Troponin_test

When chest pain via SL nitro relieves chest pain, this is typically be called angina, now if the call went well all in all then why generate a question ?

Should I mention I am trying to quit smoking, nah that would just be an "excuse" myself for being pointed and opinionated and have pride about my profession as a "PARAMEDIC".

cheers

Well, I am sorry I posted this question as I was just curious to know if we should have upgraded to code 3 that was all. I am not sure where you took your PCP training, but where I took mine part time course we where not instructed how to read the different rythms or placement of leads, sure we read about it, but it is alot different when a person spends a two weeks just on cardiac stuff compared a few hours reading a section on Cardiac.

Being a NEW PCP I learn something new every day and by reading your post it has made me realize that even though the patient was in the Nurses care I need to ask more questions before taking a patient. Also I did do a PCR including vitals before we transported. Thanks for pointing out that chest pain is called angina I did not see anything wrong with saying chest pain guess I should have said angina.

On another note I did ask the nurse if she wanted L/S and she said no.

Seems as though I have let you down with my posts and here I thought this site was for learning and that is what I am attempting to do. Thank you again for giving being so hard on me and pointing out where I have FAILED as a PCP and where I have failed by asking a simple question.

I do read my books still and try to learn on every call and while sitting in my first aid office Yes OFA level 3 that does not mean I don't have the smarts to be a Primary Care Paramedic.

Any how, I don't want to say something that I don't mean, so I am just going to leave it at this as I am taking your post towards me as a learning tool.

SORRY FOR MAKING YOU SOO UPSET THAT WAS NOT MY INTENTION AT ALL!!

OH, VITALS SIGNS BEFORE TRANSPORTING

BP 110/75 R-18 EASY P-72 REGULAR-SPO2 97 RA

If I had known that this post would have turned out like this I guess I would have mentioned as well that I did attempt to take a set of vitals while on route, but the attending nurse told me not to worry about at as she is stable and that the patient is in HER CARE.

[PCP]

Happiness,

I now realize after reading your post and the one from Richard that there are things that should have been done and asked by me as the attending paramedic even when there is a nurse going on the tranport.

I am not sure why the patient was not on O2 from the beginning. It is my dumb mistake for not asking if and why the patient was not on O2 from the beginning and it was also my dumb mistake for not doing a better job at jumping in when the patient stated to the nurse she was having chest pain (angina). The nurse was taking care of the patient and I did what she asked me to do. I do know that giving Nitro is in my scope of practice and I would have administered it myself, but as mentioned the patient was being transfered with a nurse and she was in charge of the patient.

SO I THOUGHT!

I now know for next time that any time a nurse is along for the ride that I will do a better job of asking questions and making sure their equipment is in good working order, as well as if the patient develops any problems while in the back of the car I will not just let the nurse take care of it. I will do what I would normally do as if there was not a nurse escort.

I have only been working in a busier station now for 4 weeks and previous to the that I was in a station where I never did transfers and very little patient contact as I was a driver only for 2 half years and did only about 20 calls in that time.I am learning very quickly how things should be done.