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

- Rogue Medic

Do Drug Shortages Really Impact EMS? – Answer 4



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?

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.

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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Comments

  1. The reason we gave Lasix (and in many instances continue to give it) to CHF patients is because it is an ALS treatment. We can’t we be super-medics if all we do is provide BLS level care that any run of the mill basic EMT (or normal John Q. Public can provide for himself for that matter).

    • damn internet …..

      what I was saying was this….

      We can’t be super-medics if all we do is provide BLS level care that any run of the mill basic EMT (or normal John Q. Public can provide for himself for that matter) can do just as easily. Remember, it’s all about the procedures and drugs we can use, that thinking crap through is over-rated.

      • unit12medic,

        The reason we gave Lasix (and in many instances continue to give it) to CHF patients is because it is an ALS treatment.

        I share your sarcastic view of EMS psychopathology. In most cases, I would agree with you.

        Treatment of CHF is not just Lasix or BLS treatments. We can give NTG, and a lot of it, if we are interested in what is best for patients. We can give ACE inhibitors. We can even give IV NTG, for example as 1 mg boluses. We can keep CPAP classified as ALS, just so medics can be the ones saving the day.

        The problem with Lasix for CHF is not that Lasix is the only ALS treatment choice.

        No, Lasix is the worst ALS treatment choice.

        The problem is that there are too many doctors, who do not understand enough about patient care to realize that they are harming patients.

        These doctors seem to me, completely anecdotally, to be overwhelmingly in favor of on line medical command permission requirements. How did they get to be doctors? How many doctors can graduate at the bottom of their class in medical school? Why is Lasix and different from removing the bad humors by bleeding a patient?

        Ironically, for some patients, therapeutic phlebotomy (bleeding) may seem to improve symptoms, but only if they are dramatically and systemically overloaded. Most CHF patients are not fluid overloaded. They just have the fluid in the wrong place – the lungs. If we systemically dehydrate the patient (give Lasix), rather than redistribute the fluid (use effective treatments), we kill patients by trying to make them urinate more.

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