Memorable Misdiagnosis

[UMSTUDENT]

My understanding of the thought process behind removing lasix is not that's it's not a good drug to use but that's often times given when the provider mistakes pneumonia for CHF.

Lasix to a pneumonia patient doesn't do him/her much good. Not that this needs saying in this crowd.

-be safe

I remember being presented information that stated that, given clinical manifestations alone, EMS providers were only about 40% effective in differentiating between CHF and pneumonia. Physicians are only something like 60%. The exact numbers may be a little wrong, but the point is the same.

Anyway, many hospitals treat CHF with high-dose nitro. Granted they have access to drips to tailor their results, but Lasix still seems to be falling out of favor for every incidence of CHF with pulmonary edema.

[paramedicmike]

I remember being presented information that stated that, given clinical manifestations alone, EMS providers were only about 40% effective in differentiating between CHF and pneumonia. Physicians are only something like 60%. The exact numbers may be a little wrong, but the point is the same.

Anyway, many hospitals treat CHF with high-dose nitro. Granted they have access to drips to tailor their results, but Lasix still seems to be falling out of favor for every incidence of CHF with pulmonary edema.

That's exactly my point. It's falling out of favor simply because providers both pre- and in hospital are having trouble diagnosing the difference.

What's more, (I'm playing devil's advocate here), why are you going to give a diuretic to a CHF-er anyway? CHF isn't a fluid problem. Most of these patient's are borderline dehydrated anyway. With that dehydration their electrolytes are potentially, or close to being, out of whack. So why push the patient that much closer to the edge when you don't have to?

We had an interesting discussion with the MCP at one of the places at which I work. He's not for removing lasix entirely. But he does support greatly reduced usage except for cases like a long transport where choices of treatment are limited.

-be safe

[pyroknight]

I vote for REPLACING furosemide with CPAP or BiPAP, not just removing furosemide. I think paramedicmike was partially right. This IS a fluid problem, but it's WHERE the fluid is, not the quantity. PEEP will keep the alveoli open (and the patient oxygenated) until the pump problem can be dealt with AND it will GREATLY reduce the likelihood of the patient requiring intubation.

This violates my belief that we thwart Darwin too often as a profession, BUT, by reducing intubations we will reduce nosocomial infections and thereby reduce the number of gomers we send to an early (by a few months?) grave.

[katbemeEMT-B]

Thanks, Doc. I was thinking along the same lines as you but just wanted to make sure I wasn't missing something.

I also considered that it was just what the patient's family member said without realizing s/he had no idea what was being said.

Sorry it took so long to get back here. I talked to the patients daughter today and she is still saying the doctor said carbon monoxide. I'm thinking carbon dioxide would make more sense also. The patient did have a depressed resp. system as she was on 3L O2 via nasal. I believe she had emphyzema and COPD. I have not been able to talk to the actual doc that treated her as I haven't seen him. If I do I'll ask just to confirm that it was carbon dioxide.

Thanks for bringing this to my attention. See, a person learns something new every day here, (or at least can confirm what they suspected).