11. No More Lasix

My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

In our 2012 Regional Protocols, Lasix has been removed from our med kits. I stopped using it several years ago — even when I was reasonablely sure my patient had CHF. I had CPAP and I had nitro and I relied on them, as I do now.

The first rule of medicine is “Do No Harm.” Lacking chest x-rays and the ability to do BNPs in the field, time and again, EMS (myself included) has done harm to our patients by giving patients we thought we in CHF, Lasix when in truth they had sepsis or pneumonia.

Below is excerpted from a 2010 post about Lasix.

Dear EMS Medical Control-

I am an 87-year -old man with pneumonia and sepsis laying in a hospital bed, feeling rather miserable. Two days ago one of your paramedics gave me Lasix believeing the junky sounds in my lungs were a sign of pulmonary edema. He was wrong. As a consequence my blood pressure dropped from 170/90 at my house to 90/40 in the ED where they gave me two liters of fluid in addition to several very strong antibiotics, and I am told my kidneys are not functioning so well. I know I am old and approaching the end of my life, but I was once a vibrant man who taught school for many years and often demonstrated for various causes such as civil rights and against the slaughter of baby seals. If I were able, I would make a sign and demonstrate in front of your house. I would lean against my walker and hold my sign up for passing cars and the news cameras to see. “Stop the Horror! Ban Lasix!” I know I am not the first victim. I wish to be the last. Those of us with pneumonia and sepsis are sick enough without Lasix making us worse.

Respectively
Patient X.

***

As you know for the last year I have been a clinical coordinator at a local hospital. Our EMS Medical Director and I have had lengthy discussions about taking Lasix off our sponsored services’s trucks. The problem is we are part of a larger region and we try to do all our protocols regionally. The region just finished up its 2009 protocols, and wonít be addressing changes until later this year with an implementation target date of sometime next year. We both agree we should take Lasix away. We donít want to act unilaterally. But I am thinking (with each imaginary letter we recieve) that maybe we ought to act now.

In 2006, a study appeared in Prehospital Emergency Care that revealed that Lasix was given inappropriately to 42% of prehospital patients.

Evaluation of prehospital use of furosemide in patients with respiratory distress.

For the last two years I have been keeping track of all prehospital use of Lasix from our various sponsored services using similar criteria to the mentioned study. I have found a 37% inappropriate rate, a rate that has improved only marginally with education.

Looking closely at the patient data, it is clear just how difficult the diagnosis can be (lacking a chest X-ray and a BNP blood test). The indicators that many of us were taught in paramedic school donít always hold up. Some patients with fevers had CHF, while some patients who were not febrile had pneumonia. Some patients on Lasix had pneumonia and some patients not on Lasix had CHF. Some pneumonia patients had significant edema and some CHF patients didnít have any edema. The only sign that at all was suggestive of CHF was blood pressure. In general if a patient had a BP over 170 systolic they were more likely to have CHF (Except for patient X here). Speaking of blood pressures when I tracked BPs in the ED, nearly every patient, CHF or not, who received Lasix prehospitally experienced a huge (although sometimes transient) BP drop in the ED.

I know about misdiagnosing CHF myself. In 2006, the very day after reviewing the before mentioned article at a journal club meeting, I had a patient in severe respiratory distress who sounded like a washing machine. I gave Lasix. She turned out to have pneumonia. Díoh!

When I was a newer medic in the last 1990ís, one year I gave Lasix 21 times. If I thought I heard rales, I gave Lasix. I was told by another paramedic (be careful of your infomation sources) that Lasix was basically harmless. How many of those patients had pneumonia or sepsis? At least 40% is probably a close starting guess. This past year I didnít give Lasix at all.

Several years back, we added the following caution to our regional protocols:

CHF vs. Pneumonia: If the clinical impression is unclear and transport time is not prolonged, consider using Nitroglycerin and withholding Lasix or Bumex or contact medical control.

Yet people continue to give Lasix to patients who are not in CHF. I think it stems from our natural incliniation to want to do something to help, particuarly if the patient’s respiratory distress is severe.

With CPAP and Nitro now the hallmarks of CHF treatment, I think it is clearly better to deny Lasix to someone who might have CHF than give it to someone with pneumonia or sepsis.

That seems to be the clear direction EMS is headed in. Check out this article from JEMS.

Meds Under Scrutiny

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

1 Comment

  • Bob says:

    Ive always had a hard time justifying the administration of Lasix, it can do so much harm and I dont have all of the resources to determine CHF with high cerntinty.

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Peter Canning

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  • Comments
    BH
    Assembly Line
    Two of my major hospitals now employ scribes that accompany their assigned MD all day for the sole purpose of recording their H&P with the patient. It not only makes the doctor/patient interaction more... interactive, but since all the scribes have to worry about is documentation and not patient care, the reimbursements for the doctor's…
    2015-08-26 19:17:52
    Patricia Landmesser
    Patient Follow-up
    I agree with these two... thank you for writing. Your work is inspirational, entertaining and down-to-earth informative. Seems it should be a must read for any who are interested in the EMS field. Many Thanks!
    2015-08-22 11:24:54
    A35EMR
    Patient Follow-up
    I just want to thank you for doing what you do. Your book "Rescue 471" is what inspired me to start my career in EMS. I am currently 16 and working for an urban ambulance service as an EMR, and your blog has been really insightful into skills and knowledge that any healthcare provider should…
    2015-08-18 05:38:41
    Foster
    Patient Follow-up
    You're absolutely right. We don't grow if we don't see the outcomes of our work. ...Or at least, we're less likely to grow in the right direction. You're in a pretty good spot to change some of this in your hospital job. Why not set up a system where paramedics can flag patients they'd be…
    2015-08-04 19:07:22
    Jon Kavanagh
    #1 Pain Management and Comfort Care
    We comfort and take care of pain when we remember that the patient is a person. A touch on the hand or shoulder, a compassion for his situation, a desire to do the right thing (vs the easy)... We need to be actively turning his bad day into something less lousy, even when the solution…
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