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Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Competency-Based Continuing Education and License Renewal

Thu, 20 Jan 2011 06:30:42 -0500 by
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At Life Under the Lights Ckemtp asks, If You Could Have Anything You Wanted… what would it be.

My favorite response was not very aggressive sedation and pain management treatment options – all on standing orders and similarly aggressive IV NTG and CPAP options – also on standing orders. OK, that was my response. My favorite response was from Greg Friese, who blogs at Everyday EMS Tips –

When I was in New York, I had to do a refresher course. Everybody had to do the same things. The guy from New York City, who averaged more than an intubation a week, and the guy from the sticks, who might average an intubation a year.

What kind of EMS system would ignore the differences in experience?

Right?

How about all of them? Maybe that is unfair. Pennsylvania allows medics to decide what courses to take, as long as half of the year’s 18 con ed credits are in the medical/trauma category. That means most of the alphabet soup of merit badges.

Are merit badge courses the only way of demonstrating competence?

Do merit badge courses demonstrate competence?

Certainly not. And. Absolutely not.

I write that as someone who has made a lot of money teaching a lot of these merit badge courses.

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What does a classroom course tell me about the way someone behaves in a patient’s home?

That may depend on how much imagination I have and on how willing I am to engage in self-deception.

The best place to learn about the competence of the paramedic is probably in the ED (Emergency Department) at the time of transfer of patient care.

Does the treatment given by the paramedic match the patient presentation?

Does the treatment withheld match the patient presentation?

We understand that some patients will have dramatic changes in presentation –

Hypertensive CHF patients after a couple dozen NTG (NiTroGlycerin) and CPAP (Continuous Positive Airway Pressure).

Well sedated patients.

Patients with their severe pain decreased to the comfortable level.

Anaphylaxis patients.

Hypoglycemic patients.

Et cetera.

Medical directors should understand what the normal progression of these diseases is, and recognize when the patients have received appropriately aggressive care and when the patients have not.

Basing competency recertification on a classroom approximation of real patient care is just not appropriate.

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When a patient is in need of a pacemaker, is the pacemaker applied properly? Is the pacemaker actually pacing the heart, or just causing a lot of muscle twitching? Does the paramedic know the difference?

Conversely, if a patient, who should have a pacemaker applied, does not have a pacemaker applied, is there some good reason the paramedic did not apply the pacemaker?

When a patient is taken to a trauma center, does the patient actually have injuries that indicate the patient should be transported to the trauma center?

Conversely, when a patient, who should have been transported to a trauma center, is transported to the local non-trauma center, is there some good reason the paramedic did not transport to the trauma center?

There are many such examples. They require an involved medical director and emergency medicine group interested in good prehospital care/competence.

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If a paramedic has obtained at least 18 con ed hours each year for 5 years, but cannot tell the difference between a trauma patient and a non-trauma patient, how is the con ed requirement helping?

If a paramedic has obtained at least 18 con ed hours each year for 10 years, but cannot obtain capture with a transcutaneous pacemaker, how is the con ed requirement helping?

If a paramedic has obtained at least 18 con ed hours each year for 15 years, but gives Lasix to patients with pneumonia, how is the con ed requirement helping?

If a paramedic has obtained at least 18 con ed hours each year for 20 years, but needle decompresses a patient’s chest when the patient is talking with him in no apparent distress (at least before the harpooning), how is the con ed requirement helping?

We need to be much better at tailoring our recertification requirements to the needs of the paramedics.

X number of hours in a classroom ≠ competence.

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Filed Under: Critical Judgment, Education, Heresy, NTG, Physician Oversight

Do Drug Shortages Really Impact EMS? – Answer 4

Wed, 29 Dec 2010 06:30:46 -0500 by
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Here is part 4 of the details from the points I raised in commenting on the discussion of the drug shortages and the way these affect EMS. Do Drug Shortages Really Impact EMS? – EMS Office Hours and followed by Do Drug Shortages Really Impact EMS? – Answer 1, then by Do Drug Shortages Really Impact EMS? – Answer 2, and that is followed by Do Drug Shortages Really Impact EMS? – Answer 3. This is broken up by answer. There are many points covered for a podcast that lasts less than 40 minutes. Do Drug Shortages Really Impact EMS?

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4. Should CPAP (Continuous Positive Airway Pressure) be ALS (Advanced Life Support) only?

Somebody mentioned that CPAP is seen as invasive.

No. CPAP is not invasive.

CPAP falls into the category of NIPPV (Non-Invasive Positive Pressure Ventilation). CPAP has been used safely many places by BLS (Basic Life Support) personnel.

CPAP is a safe and effective BLS treatment for heart failure.

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What if we think that medical command permission should be required for BLS to use CPAP?

If that is the case, then we should give CPAP to BLS personnel, train the basic EMTs to use CPAP, even require our magic phone call. Then, after we realize that there was never any good reason to prevent basic EMTs from using CPAP and we realize that the magic phone call is doing nothing to improve safety, but is probably only discouraging appropriate use of CPAP, then we can eliminate the magical medical command phone call ritual.

CPAP should be used aggressively for heart failure by everyone.

If anyone disagrees, please provide some evidence of harm.

Treatments for CHF –

Lasix (furosemide)? Does not decrease the need for intubation, does not improve survival, does not help, but can harm CHF patients and can harm patients with other medical conditions (e.g. pneumonia) mistaken for CHF.

High Dose NTG? Decreases the need for intubation, but is ALS.

ACE Inhibitors? Decrease the need for intubation, but are ALS.

CPAP? Decreases the need for intubation and is BLS. Possibly the best and safest treatment for CHF.

Why would anyone want to do something as dangerous as give Lasix, when there is something as simple and as safe as CPAP available?

I will write about the evidence for CPAP in another post.

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Filed Under: Critical Judgment, Drug Shortages, EMS Office Hours, Heresy, NTG, Physician Oversight

Do Drug Shortages Really Impact EMS? – Answer 3

Sun, 19 Dec 2010 06:30:10 -0500 by
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Here is part 3 of the details from the points I raised in commenting on the discussion of the drug shortages and the way these affect EMS. Do Drug Shortages Really Impact EMS? – EMS Office Hours and followed by Do Drug Shortages Really Impact EMS? – Answer 1, then by Do Drug Shortages Really Impact EMS? – Answer 2. This is broken up by answer. There are many points covered for a podcast that lasts less than 40 minutes. Do Drug Shortages Really Impact EMS?

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3. Should we switch from Lasix to Bumex?

This presumes that filling the patient’s bladder is the best, or second best, or third best, or even just not the worst way for EMS to treat patients with heart failure.

Filling the bladder with fluid does not mean that we removed the fluid from the lungs.

Where is it taught that the lungs drain into the bladder?

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Where is the evidence that any diuretics are in any way beneficial for the pre-hospital treatment of the patient who does not have peripheral edema?

Where is any evidence that any diuretics should ever be used before any of the other treatments (CPAP, NTG, High-dose NTG, ACE inhibitors, et cetera) for the pre-hospital treatment of heart failure?

Why should EMS be giving so many different treatments to a single patient?

The more treatments we give, the more likely that we the patient will have complications.

The more treatments we give, the less likely that we can figure out what caused the complications.

Where is there any evidence that these complications are good for patients?

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One person on the show mentions the problems with kidney injury from Lasix. That is just one of the reasons for not using diuretics. Another problem is that medics too often give diuretics for pneumonia. This is a training and oversight issue, but that is just another example of where medical directors are failing patients.

If paramedics are treating pneumonia with diuretics, why aren’t the medical directors aware of it?

If medical directors do know that paramedics are treating pneumonia with diuretics, why aren’t the medical directors doing something about it?

How can paramedic schools graduate people who can’t tell the difference between pneumonia and heart failure?

How can paramedic schools graduate people who treat pneumonia with Lasix or Bumex?

While there can be problems differentiating between pneumonia and heart failure, if I am not able to clearly identify the condition as heart failure, I should never give Lasix or Bumex.

If I hear crackles, presume heart failure, and give Lasix, because Lasix can’t hurt, then I probably should not be a paramedic.

If I allow a medic to treat something that sounds like crackles as heart failure, because Lasix can’t hurt, then I probably should not be a medical director.

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We need better paramedics.

We need to ridicule the bad paramedics that we do have.

We need better medical directors.

We need to ridicule the bad medical directors that we do have.

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Continued in –
Do Drug Shortages Really Impact EMS? – Answer 4

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Filed Under: Critical Judgment, Drug Shortages, EMS Office Hours, Heresy, Lasix, NTG, Physician Oversight, Research

Capnography Use Saves Lives AND Money – Part III

Thu, 16 Dec 2010 06:30:59 -0500 by
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Continuing from Capnography Use Saves Lives AND Money – Part I and from Capnography Use Saves Lives AND Money – Part II.
 

The most common causes for EMS lawsuits are negligent vehicle operation and improper performance of medical procedures. Juries frequently award millions of dollars to patients, and legal fees are typically hundreds of dollars per hour, producing a significant unbudgeted expenditure to an agency. Therefore, capnography is one piece of clinical backup that can assist you in avoiding lawsuits.[1]

 

At one end – How many multi-million dollar law suits does it take to change that cost/benefit analysis that the managers were using to justify not using waveform capnography?

At the other end – How many thousands of dollars of legal fees, how much for expert witnesses, and how much distraction from running an EMS organization does it take to change the cost/benefit analysis based on no such thing as too cheap after even a small out of court settlement?
 

Now imagine that you use waveform capnography.

A lawyer shows up representing a patient who claims to have hypoxic brain damage due to a misplaced endotracheal tube. You go through your copies of charts and find the right chart. Part of the printout attached to that chart is copied below. The image is taken from Capnography for Paramedics, an excellent source of information about capnography.
 


 

What does this mean?

The sensor for waveform capnography is placed between the end of the endotracheal tube and the BVM bag.

The only way for carbon dioxide to pass through the sensor is for that carbon dioxide to be exhaled by the patient through the endotracheal tube.

At a minimum, I prefer to record the waveform as soon as possible after there is a good waveform, just before removing the patient from the ambulance, and just before moving the patient to the hospital stretcher. They can wait. They are going to pause everything to get a much less reliable confirmation of placement in the hospital, so there is not real rush.

Other times to record the waveform are with each movement. This demonstrates that I am paying attention to the tube placement and avoids the perceived need for a cervical collar. The use of a cervical collar just encourages people to ignore tube placement. Do your patients a favor, continually assess tube placement and leave the cervical collars alone.

If you use the piece of litmus paper in plastic color change device, which has an unreasonably high failure rate, what do you have to demonstrate placement of the tube? Only the medics description after the fact. How well does he document? How good a witness is he on the stand? You do realize that the hospital needs to convince the jury that the damage was done prior to arriving in the ED, right? Believe the doctor? Believe the medic?

With the printout of a good waveform from waveform capnography, the lawyer has no good reason to continue to go after your company for a misplaced tube. Without a printout of a good waveform, it all depends on whom the jury believes after a lot of legal expenses, or it results in an out of court settlement.

Waveform capnography is extremely inexpensive, if we understand patient care and risk management.
 

One of the most frequent EMS lawsuits involves undetected esophageal intubations. If the ET tube is improperly inserted into the esophagus and this error isn’t recognized and corrected expediently, the result is a devastating hypoxia that causes severe brain injury and, ultimately, death. Continuous monitoring of capnography is the standard of care for detecting esophageal intubations, as well as for detecting subsequent dislodgement of ET tubes.(3)

Settlements for injury and wrongful death resulting from undetected misplaced ET tubes are often in the multimillion-dollar range.[1]

 

We can avoid esophageal intubations in a few ways.

1. Stop using endotracheal tubes, which is not popular with paramedics, but is likely to be the future of the cut rate EMS services.

2. Provide excellent aggressive medical oversight, which involves a lot of practice on mannequins and the use of waveform capnography as just one critical part of the method of tube placement confirmation.

3. Ignore the problem. This is something we only read about happening to other people.

This is true – right up until it is not. Ask any doctor about being sued for malpractice. Almost all are concerned about malpractice suits. There are many ways of approaching the concern about malpractice, but almost all doctors understand that providing excellent care is one thing that they can do to modify their risk.

If I do what is best for the patient, my long-term liability is lower than if I do what is cheapest in the short-term.

I understand that we will not be able to provide any care for patients, if we cannot afford to stay in business. I also understand that –

1. If the care we provide is bad, then we are not helping patients.

2. Keeping the organization in business just long enough to do some really serious harm to patients, which results in being shut down by a large law suit, is a bad idea.
 

This focus on the short-term is not really different from the way we approach the use of epinephrine, and other drugs, during cardiac arrest. We act as if the short-term is all that matters, even though there is no reasonable expectation of a long-term benefit.
 

But aren’t unrecognized esophagal intubations extremely rare?

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To be continued in –

Capnography Use Saves Lives AND Money – Part IV
Capnography Use Saves Lives AND Money – Part V
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An excellent source of information about waveform capnography can be found at Capnography for Paramedics.

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Footnotes:

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[1] Capnography Use Saves Lives & Money
By Patricia A. Brandt, RN, BSN, MHR
JEMS.com
Article

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Filed Under: Assessment, Critical Judgment, Ethics, Heresy, Physician Oversight, Waveform Capnography

Do Drug Shortages Really Impact EMS? – Answer 2

Tue, 23 Nov 2010 06:30:08 -0500 by
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Here is part 2 of the details from the points I raised in commenting on the discussion of the drug shortages and the way these affect EMS. Do Drug Shortages Really Impact EMS? – EMS Office Hours and followed by Do Drug Shortages Really Impact EMS? – Answer 1. This is broken up by answer. There are many points covered for a podcast that lasts less than 40 minutes. Do Drug Shortages Really Impact EMS?

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2. How do we convince doctors that doctors should act as if they learned something in medical school?

Ridicule.

When doctors behave ridiculously, we should respond with generous quantities of ridicule to match the overly generous egos that act as if it is better to harm patients, than to write protocols that allow medics to provide better care to patients.

Ridicule is the best option for those medical directors who do not do what is best for patients.

It is ridiculous for doctors to harm patients with protocols that have no medical basis, but are based on the excuse I’m a doctor.

Yes, these medical directors are doctors, but they are dangerous doctors.

We need to ridicule dangerous doctors.

They may not care about their patients, but they tend to dislike looking like fools.

Real doctors try to avoid harming patients.

Real doctors do not come up with idiotic excuses for dangerous behavior.

Real doctors do not ignore evidence and hide behind, If you want to practice medicine, then you should go to medical school.

Real doctors know what is good medicine because they pay attention to the research.

Real doctors protect patients.

If your medical director does not have the ability to change the protocols directly, the medical director certainly has the ability to influence the way the protocols are written.

We need to demand that medical directors act responsibly.

When medical directors do not behave responsibly we need to make it clear that what these medical directors are doing is bad medicine.

Bad medicine is indefensible.

If you doubt me, just try to finish this sentence –

It is OK to unnecessarily endanger patients because ______________.

The answer is not, I’m a doctor.

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As paramedics, we do not have the ability to change our protocols on our own, but we do have the ability to let everyone know when our medical directors refuse to change protocols that endanger patients.

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People criticize me for not having enough respect for doctors. If doctors want respect, they need to demonstrate that they can write protocols that are not dangerous. These doctors have no respect for patients.

Why be shy?

When on line medical command responds with something idiotic, maybe we should say, I’ll try a different hospital.

Is doctor shopping a bad thing?

No, but doctors discourage it the same way that people discourage doing something about the neighbor who beats his wife. We are told to wait until he kills someone. Even bad patient outcomes do not seem to lead to improvements in medical oversight. Who wants to admit that he was aware of the problem, but remained silent?

These medical directors are ridiculous.

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Continued in –
Do Drug Shortages Really Impact EMS? – Answer 3
Do Drug Shortages Really Impact EMS? – Answer 4

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Filed Under: Critical Judgment, Drug Shortages, EMS Office Hours, Heresy, Physician Oversight, Research

Agitated Delirium Comment from RevMedic

Wed, 10 Nov 2010 06:30:25 -0500 by
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RevMedic added a great comment to A Naked Woman – TOTWTYTR – Part I.

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Great thoughts. I wonder how many medics are going to be concerned w/ accidental needle sticks when trying to chemically restrain such a patient.

Thank you.

I think hope that most medics are aware of the potential for a needlestick injury when wrestling with a violent patient in one hand and a syringe in the other. I can’t imagine covering this treatment without addressing the possibility of needlestick injury prominently. On the other hand, I can’t imagine covering this treatment without encouraging aggressive dosing. OK. I can imagine both. I can’t imagine is just a figure of speech.

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Personally, I’d consider the nasal administration route, assuming you can hold her head still long enough, but then the same goes for holding a limb still long enough for a needle.

The concerns I have about nasal administration of midazolam (Versed) are:

1. A. If you are squirting something up my nose, even if I am feeling cooperative, my first instinct is probably going to be to forcibly exhale through my nose.

According to Newton’s Third Law of Motion Violently Combative Patients – For every action there is an equal and opposite re-action. I squirt something up the patient’s nose. The patient sneezes it back at me.

When dealing with combative patients, the equal and opposite re-action is very important. We want the patient making the initial movements, while we just try to get him/her to a safe place for a takedown. Too often we do the opposite. We pick one spot to bring the patient and then the patient puts everything into avoiding that one spot. Not a recipe for success.

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1. B. If this forced exhalation of the large dose of midazolam does happen, how likely will it be that the protocols have an allowance for ignoring that dose?

If this does happen, how likely will it be that medical command will make an allowance for ignoring that dose?

If this does happen, how likely will it be that the DEA (Drug Enforcement Administration) will make an allowance for ignoring that dose?

If there is an adverse event, how likely is it that the large dose forcibly exhaled will not be considered to have been given to the patient and considered to have not just contributed to the adverse event, but to be the sole cause of the adverse event, even though the dose that entered the patient’s blood stream would be essentially zero?

Considering that I would use a starting dose larger than most medical directors are likely to be comfortable with as their total dose, this can be an important consideration.

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2. Where is the evidence of efficacy?

I have not seen any research on the use of IN (IntraNasal) midazolam with combative patients. While this is not a very common condition, I have not even seen a single case report.

Hey, if you’re gonna hold them still long enough for a needle, why not an IO?

🙂

If you have an already extremely agitated patient, pulling out power tools could be one thing that might make the patient even more agitated.

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Also something to consider is that Midazolam has a potential 20 minute onset of action if given IM…

Midazolam is not the drug of choice – not even close.

Midazolam is the default drug for many of us. Of course, there are some who do have to deal with the even more ridiculous limits of only having diazepam (Valium).

And 20 minutes can be a very long time – more than a lifetime.

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There are other drugs out there for us – Haldol & Inapsine just to name a few.

Haloperidol (Haldol) and droperidol (Inapsine) are much safer than FDA (Food and Drug Administration) Alert[1] and the FDA Black Box warning[2] suggest.

And then there are the many oddities about these documents. For example –

Because of this risk of TdP and QT prolongation, ECG monitoring is recommended if haloperidol is given intravenously

Haloperidol is not approved for intravenous administration.[1]

We might think that the FDA would at least separate such contradictory statements, but we would be wrong.

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Cases of QT prolongation and serious arrhythmias (e.g., torsades de pointes) have been reported in patients treated with INAPSINE. Based on these reports, all patients should undergo a 12-lead ECG prior to administration of INAPSINE[2]

If we can get the patient to sit still for a 12 lead ECG, is the droperidol (Inapsine) necessary? We just need to keep telling the patient to keep still for the 12 lead – all the way to the hospital.

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Yes, they have their dangers – just as any other medication we administer. But, as professionals, we are to be expected to know and deal with the potential side effects.

Absolutely!

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Footnotes:

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[1] Information for Healthcare Professionals: Haloperidol (marketed as Haldol, Haldol Decanoate and Haldol Lactate)
FDA Alert [9/2007]

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[2] Inapsine (droperidol) Dear Healthcare Professional Letter Dec 2001
Dear Healthcare Professional Letter

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Filed Under: Assessment, Critical Judgment, Ethics, Excited Delirium, Heresy, Malpractice, Physician Oversight, Sedation

A Naked Woman – TOTWTYTR – Part I

Tue, 09 Nov 2010 06:30:46 -0500 by
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Don’t let your imagination get the better of you, here. Too Old To Work, Too Young To Retire is not a naked woman, although he is rumored to do a great impression of Lili Von Shtupp.

However, TOTWTYTR does have a post titled, A Naked Woman. This post was inspired by Flashlights, a post by Burned-Out Medic. Go read both, then come back.

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My thoughts automatically go to the method of restraint – physical, rather than chemical.

Who benefits from having EMS use physical restraints, rather than chemical restraints?

The patient?

No.

EMS?

No.

The police?

No.

The advocates of restrictive EMS protocols?

Bingo.

The avoidance of sedation only benefits those who place protocols ahead of patient care.

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I couldn’t have a post with a title of A Naked Woman and not include at least one picture.

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If we were to inject people with boluses of epinephrine, would the effect on the patient’s body be much different from what happens when we physically restrain agitated delirium patients, but we do not provide any sedation?

This is where aggressive sedation protocols are very important.

How much do we want to increase the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient?

In what way is increasing the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient considered to be good for the patient?

In what way is increasing the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient considered to be good for the physical safety of police, EMS, family members, and by-standers?

In what way is increasing the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient considered to be good for the legal safety of police and EMS?

If limited to midazolam, what really are the difficult to manage problems, if we start with 10 mg IM for this 45 kg patient? 0.22mg/kg IM (IntraMuscular).

Yes, I do realize that this is much higher than the label recommends, but has anyone ever seen an agitated delirium patient respond, even a little bit, to the recommended doses of midazolam?

The recommended premedication dose of midazolam for good risk (ASA Physical Status I & II) adult patients below the age of 60 years is 0.07 to 0.08 mg/kg IM (approximately 5 mg IM) administered up to 1 hour before surgery.[1]

A whole bunch of unknowns vs. an NPO patient being given some sedation for routine surgery (not anesthetic dosing).

0.22 mg/kg midazolam vs. 0.07 to 0.08 mg/kg midazolam.

10 mg midazolam vs 3 1/2 mg midazolam.

I expect that one, or two, people will have anecdotes about the recommended dose of midazolam actually working. Anything is possible. However, why are we so hesitant to protect patients from the dangers of hypermetabolic states?

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PS – TOTWTYTR, are you sure that the feces was from the dogs?

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Continued in A Naked Woman – TOTWTYTR – Part II and later to be continued in A Naked Woman – TOTWTYTR – Part III.

I wrote about how others deal with this, including the death of a patient, in Excited Delirium: Episode 72 EMS EduCast.

Footnotes:

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[1] Dosage and Administration
Midazolam Hydrochloride (midazolam hydrochloride) Injection, Solution
[HOSPIRA, INC.]
DailyMed
Label with link to download of PDF of full FDA Label

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Filed Under: Assessment, Critical Judgment, Ethics, Excited Delirium, Heresy, Malpractice, Physician Oversight, Sedation

Furosemide and Drug Shortages 2

Thu, 30 Sep 2010 22:37:28 -0400 by

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Also posted over at Paramedicine 101, which is now at EMS Blogs. Go check out the excellent material there.

I will keep pointing out the problems with furosemide (Lasix) and the evidence against it. Let’s ignore the problems with giving furosemide to patients who actually have CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). Can medics correctly identify CHF/ADHF?

The EHS ePCR database identified paramedic reports in which furosemide was administered. As furosemide only appears in the CHF/pulmonary edema protocol, paramedic differential diagnosis of this was assumed by furosemide administration. Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard. Other data points collected included: demographic information; EHS treatment administered; treatment administered in the ED; adverse events and patient disposition.[1]

They do not describe their method of selecting the charts.

Was it completely random?

Was it sequential?

How did they select their sample?

There were three objectives of this study. The first was to determine agreement between paramedic administration of furosemide with EP diagnosis of CHF. The second was to examine differences in interventions administered by paramedics and in the ED by EP diagnosis of CHF. The third objective was to identify any adverse events that occurred during patient care.[1]

How much agreement on CHF/ADHF diagnoses?

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question, as it appears CHF may have been in the differential diagnosis for many patients not ultimately diagnosed with CHF. Secondary diagnoses were not sought out and included. Therefore, paramedic accuracy reported in this study may be falsely low, if CHF was part of the EP secondary diagnoses. It should also be noted that there were two patients with a diagnosis of “shortness of breath not yet diagnosed.” It is possible that these patients did indeed have CHF, but were not diagnosed until a later time during hospital care. This needs to be considered when determining paramedic diagnostic accuracy.[1]

OK. For some reason, the emergency physicians gave furosemide to 21% of the patients they diagnosed with something other than CHF/ADHF. That may be explained by the CHF/ADHF being a secondary diagnosis.

This is something that should have been included in the study. What was being treated and for what reason. From the way they describe their data, they had the actual ED physician chart, not just a diagnosis. This is something they should include in a follow-up study, especially with a larger sample size.

Since two of the patients had the diagnosis shortness of breath not yet diagnosed I will move them to the CHF/ADHF side of the graph. After all, most of the patients were diagnosed with CHF/ADHF.

That looks so much better.

On the other hand, there are problems with the way they conclude that some patients do not have CHF/ADHF. How much higher would things be if secondary diagnoses were included?

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It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question[1]

What does NTG (NiTroGlycerin) have to do with ACS (Acute Coronary Syndrome), when examining CHF/ADHF treatment?

NTG is the most effective medication for hypertensive CHF/ADHF. Go listen to the EMCrit CHF/ADHF podcast if you doubt me. For those not hypertensive, this research certainly suggests that NTG should be studied.

NTG is not just for chest pain.

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Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard.[1]

Maybe. Maybe not. And don’t get me started on Gold Standards.

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ED mortality was higher in patients with an alternate diagnosis than those diagnosed with CHF by the EP (2/60 vs. 6/34, p=0.017). As documented on ED charts, eight patients in this sample suffered adverse events other than death. These adverse events were: hypotension (n =3), heart rate problem (n =3), electrolyte imbalance (n =1), and respiratory effort decline (n = 1). All of the patients who suffered adverse events were diagnosed with CHF by the EP. Adverse events were not associated with the amount of nitroglycerin, morphine or furosemide administered.[1]

Adverse events in the ED were documented as occurring as often as death in the ED. Almost all of the deaths were in the group not diagnosed with CHF/ADHF, but all of the adverse events occurred in the group diagnosed with CHF/ADHF.

Of the six patients with an alternate diagnosis who had an outcome of death, three were diagnosed with pneumonia. Eight adverse events other than death were identified in this sample. Interestingly, all these patients were correctly identified as having CHF, which contradicts previous research which has found adverse events were more likely in patients incorrectly treated for CHF by paramedics.11,12 This indicates that furosemide should be administered with caution, even in cases where diagnosis of CHF is correct.[1]

Where is the evidence that furosemide should be administered, even if the diagnosis of CHF/ADHF is correct?

What would we want to know?

Did the patients have peripheral edema when given furosemide by EMS. Even with peripheral edema, furosemide is far from the first line drug, but without peripheral edema, it is not going to do anything good.

These patients need the best treatment possible, not the most persistent hold out from the Dark Ages.

We have known that CHF/ADHF is not primarily a fluid overload problem since the 1980s.

Why is EMS still using furosemide?

Is there any problem with a shortage of furosemide?

Not at all, but this isn’t the study to prove it.

I hope the authors use what they learned from this to design a definitive study of the prehospital use of furosemide.

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Updated 02-07-11 to correct the uselessness of the original charts I made for this post.

More details are in Corrections of Misleading Charts.

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Footnotes:

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[1] 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

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Filed Under: Critical Judgment, Drug Shortages, Heresy, Lasix, NTG, Paramedicine 101, Physician Oversight, Research Tagged With: , , , ,
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