Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

What do I expect to see less of in EMS in 2013?

 

What are the trends that are fading away because more of us are demanding evidence of safety and efficacy?

Traditional spinal “immobilization.”

Does it work?

Nobody knows. Wishful thinkers claim that the people who end up with neurological disabilities, but who were not “immobilized,” are proof that “immobilization” works.

When asked for any evidence that “immobilization” ever protected anyone from deterioration of a spinal injury, they cannot provide anything except excuses. They tell us that we just need to believe – just like homeopathy, Reiki, bleeding to remove bad humors, ESP (ExtraSensory Perception), rotating tourniquets for CHF, antiarrhythmics for PVCs (Premature Ventricular Contractions), atropine for asystole, atropine for PEA (Pulseless Electrical Activity), et cetera.

Asking for evidence is blasphemy to the religion of Wishful Thinking.

Asking for evidence of improved outcomes is essential for ethical treatment of our patients.
 


 

Furosemide (Lasix) for CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure).

Evidence of benefit?

Where are the studies comparing furosemide with placebo for CHF/ADHF?

They do not exist.

In Pennsylvania, furosemide is not a standing order. I would need to call medical command for permission to give furosemide. If medical command does order me to give furosemide, I do not follow that order.
 

Since written protocols cannot feasibly address all patient care situations that may develop, the Department expects EMS providers to use their training and judgment regarding any protocol-driven care that in their judgment would be harmful to a patient under the circumstances.[1]

 

If someone can provide evidence of benefit from furosemide, I will change my approach. There is evidence of harm, but not evidence of benefit.[2],[3],[4],[5]

But I am working under the doctor’s license! I have to do what I am told!

I am legally liable for my behavior. I am responsible for choosing to follow a doctor’s order to give a treatment that is expected to be harmful.[6]
 

My responsibility is to the patient.
 

My responsibility is not to the doctor.
 

Should we try to fill the bladder to try to remove fluid from the lungs?

If there is some evidence of improved outcomes from this, then we should consider using furosemide, but there is no evidence that we are improving outcomes.

Is it as simple as just removing fluid?

Of course not.

Asking for evidence of improved outcomes is essential for ethical treatment of our patients.
 

We rely on oversimplified physiology to justify treatments that do not work.

They make sense, but only if we limit the questions we ask.

Rotating tourniquets makes perfect sense, as long as we do not ask for evidence of improved outcomes.

There was a good superficial physiologic argument for rotating tourniquets, but no evidence of improved outcomes.[7],[8],[9]

Trendelenburg position makes perfect sense, as long as we do not ask for evidence of improved outcomes.

There was a good superficial physiologic argument for trendelenburg position, but no evidence of improved outcomes.[10]

Antiarrhythmics to eliminate PVCs after a heart attack makes perfect sense, as long as we do not ask for evidence of improved outcomes.

There was a good superficial physiologic argument for antiarrhythmics to eliminate PVCs after a heart attack, even good evidence that antiarrhythmics do eliminate PVCs, but no evidence of improved outcomes that matter. Do you care if the drugs eliminated PVCs, if the drugs killed you?[11]

There are many treatments that used to be accepted in medicine.

These treatments were not based on anything remotely resembling good science.

These were just GOBSAT treatments.

They were based on the hunches of a bunch of Good Old Boys Sitting Around a Table.

GOBSAT is not science.

GOBSAT is not evidence.

GOBSAT is witchcraft.

GOBSAT is evidence of the way experts constantly fail, when experts do not demand evidence.

In 2013 I expect to see less treatment based on this kind of witchcraft.

Our patients deserve treatments that work.

Footnotes:

[1] Pennsylvania Statewide Advanced Life Support Protocols
2008 protocols page 6/121
2011 protocols page 6/128
Page with links to protocols

[2] Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure
Thomas Dobson, Jan Jensen, Saleema Karim, and Andrew Travers.
Journal of Emergency Primary Health Care
Vol.7, Issue 3, 2009
Free Full Text . . . . . . . Free Full Text PDF

[3] Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis.
Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R.
Ann Emerg Med. 2007 Aug;50(2):144-52. Epub 2007 May 23.
PMID: 17509731 [PubMed - indexed for MEDLINE]

Free Full Text PDF Download from Ferne.org

[4] Blood volume prior to and following treatment of acute cardiogenic pulmonary edema.
Figueras J, Weil MH.
Circulation. 1978 Feb;57(2):349-55.
PMID: 618625 [PubMed - indexed for MEDLINE]

Free Full Text Download from Circulation in PDF format

[5] Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema.
Hoffman JR, Reynolds S.
Chest. 1987 Oct;92(4):586-93.
PMID: 3115687 [PubMed - indexed for MEDLINE]

Free Full Text Download in PDF format from Chest

[6] Malice/gross negligence.
Thornton RG.
Proc (Bayl Univ Med Cent). 2006 Oct;19(4):417-8. No abstract available.
PMID: 17106507 [PubMed]

Free Full Text from PubMed Central.
 

despite the fact that the medication was ordered by a physician, each of these individuals knew from the Advanced Cardiac Life Support guidelines that the medication could have “lethal,” “disastrous” consequences when administered to someone like the plaintiff, and they recognized that the standards of care applicable to them required that they exercise independent judgment and not just “blindly follow a doctor’s order that they knew posed an extreme degree of risk to the patient”

Columbia Medical Center of Las Colinas v. Bush, 122 S.W.3d 835 (Tex. App.—Fort Worth 2003, pet. denied).

[7] Effectiveness of congesting cuffs (“rotating tourniquets”) in patients with left heart failure.
Habak PA, Mark AL, Kioschos JM, McRaven DR, Abboud FM.
Circulation. 1974 Aug;50(2):366-71. No abstract available.
PMID: 4846643 [PubMed - indexed for MEDLINE]

Free Full Text Download in PDF format from Circulation.

[8] Rotating tourniquets do not work in acute congestive heart failure and pulmonary oedema.
Bertel O, Steiner A.
Lancet. 1980 Apr 5;1(8171):762. No abstract available.
PMID: 6103171 [PubMed - indexed for MEDLINE]

[9] Are rotating tourniquets useful for left ventricular preload reduction in patients with acute myocardial infarction and heart failure?
Roth A, Hochenberg M, Keren G, Terdiman R, Laniado S.
Ann Emerg Med. 1987 Jul;16(7):764-7.
PMID: 3592330 [PubMed - indexed for MEDLINE]

[10] Myth: the Trendelenburg position improves circulation in cases of shock.
Johnson S, Henderson SO.
CJEM. 2004 Jan;6(1):48-9. No abstract available.
PMID: 17433146 [PubMed - in process]

Free Full Text from CJEM.

[11] Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al.
N Engl J Med. 1991 Mar 21;324(12):781-8.
PMID: 1900101 [PubMed - indexed for MEDLINE]

Free Full Text Article from N Engl J Med.

.

Comments

  1. We should all advocate for paramedics to think more about evidence-based patient management and to take an active role in influencing their protocols and training along those lines, but are you sure it’s beneficial to advocate that we pick and choose which protocols or which parts of protocols we’ll follow?

    Not only are there potentially serious legal issues at hand, but ethical ones as well, since an argument can be made that a paramedic is ethically bound to follow orders given by appropriately trained physicians, as long as the order isn’t clearly harmful or unnecessary.

    Most importantly, are paramedics really qualified to make judgments about which therapies reflect the best and most current evidence, or to judge when complicated clinical situations may or may not reflect those scenarios presented in the literature? How many paramedic programs include training on statistics or on critically evaluating research? For that matter, how many programs even include university-level physiology or pharmacology courses? How many paramedics read a peer-reviewed journal regularly?

    Of course I’m not suggesting that we should never question an order or should blindly follow every protocol to the letter. But choosing to omit a part of a protocol because it is clearly unnecessary or harmful in a specific situation is very different than choosing to routinely omit part of a protocol because you, as a paramedic, disagree with the physician(s) who authored your protocols on whether the available evidence supports a favorable risk/benefit ratio to the patient.

    I’m not bashing paramedics at all – I know some who are very bright and are excellent clinicians – but let’s be honest and realistic about the background of most paramedics. A 2 or 3 semester program just doesn’t provide the education necessary to be effectively writing our own protocols. That’s a level of autonomy in clinical decision making that even EM residents don’t enjoy.

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