Pneumonia vs CHF

[ccmedoc]

Please share any insight you may have concerning the use of Solu-Medrol in a CHF pt vs Pneumonia pt.

I believe the nurse was grilling you due to one of the side effects of solu-medrol being sodium/fluid retention. I also believe that the Methylprednisolone treatment, given the respiratory distress with this symptomology, was correct. The immediate effects would be beneficial and the sodium/water retention could be addressed with Furosemide, which you alluded to in your post, and observation. This patient would most likely me admitted after this episode anyway...The nurse had no right to question your differential Dx or treatment, as your responsibility is to the patient. The physicians on shift ultimately dictate your treatments, not the nurses. Any question of treatment should come from the doctor as she has no more of a right to diagnose than you do as a medic.IMHO...

She's gettin a little big for her britches...

[goofymedc8]

Fiznat...

I'm sorry if my last post seemed a bit sharp, which is not my intent at all...I read your post and did take it to heart. It certainly bids a re-look on my part to make certain my understanding of the pathos is as it should be. I never EVER take offense to constructive critiquing, which you were kind enough to give. Another perspective on a call like this can only serve to broaden my own understanding of the pathos of these patients.

Again Fiz...THANKS!!

[fiznat]

haha hey man dont worry about it at all. I've taken my fair share of grilling here as well-- I understand how ya feel. As long as in the end we all learn something and nobody's feathers get *too* ruffled. :wink:

[Doczilla]

I think this nurse should mind her own business. Until she learns to read an x-ray or give medications independent of direct verbal order, she can take her (incorrect, by the way) Monday-morning-quarterbacking and shove it someplace that can't be reached by a tube.

The patient had bronchospasm as evidenced by wheezes. This is caused by an inflammatory process, whether by asthma, COPD, RAD, pneumonia, or fluid overload. A single dose of solu-medrol in this patient who is critically ill will not do any appreciable harm, or at least the risks are far outweighed by the potential benefits to this imminently deteriorating state.

This nurse has quite a bit of gall to write you up and question your field treatment of CHF, particularly when the patient didn't have CHF. Staffing must be pretty good at that hospital if she's got time to jump your s&it AND write you up with your supervisor.

Punt this to the medical director. He or your supervisor should get into contact with the hospital's EMS coordinator on this.

'zilla

[fiznat]

The patient had bronchospasm as evidenced by wheezes. This is caused by an inflammatory process, whether by asthma, COPD, RAD, pneumonia, or fluid overload. A single dose of solu-medrol in this patient who is critically ill will not do any appreciable harm, or at least the risks are far outweighed by the potential benefits to this imminently deteriorating state.

I agree with you that the nurse needs to back off. ...But about this inflammatory process, I would like to clarify.

Correct me if I am wrong of course, but I didnt think that wheezing in CHF is related to an inflammatory process. I was sure that the so-called "cardiac wheeze" is different from other wheezes in that it comes from partial fluid obstructions rather than bronchospasm and inflammation.

Assuming that this was CHF (which may or may not be true), then wouldn't it be advisable to allow routine CHF treatments to work before we go after an inflammatory pathology? Solu-Medrol takes quite a while to work in the body IIRC, while nitrates, loop diuretics, CPAP, broncodialators, etc work fairly quickly. Why not give them a shot first and see...

[ccmedoc]

Correct me if I am wrong of course, but I didnt think that wheezing in CHF is related to an inflammatory process. I was sure that the so-called "cardiac wheeze" is different from other wheezes in that it comes from partial fluid obstructions rather than bronchospasm and inflammation.

Assuming that this was CHF (which may or may not be true), then wouldn't it be advisable to allow routine CHF treatments to work before we go after an inflammatory pathology? Solu-Medrol takes quite a while to work in the body IIRC, while nitrates, loop diuretics, CPAP, broncodialators, etc work fairly quickly

In the assessment it was stated that there was no pedal edema or JVD appreciated. If this patient had a long progression of the difficulty in breathing, a CHF pt. would most likely present with a fair amount of dependant edema, and most probably have some periorbital edema to show. Without a CXR and other diagnostics it would be, and was, prudent to follow the assessment and think some inflammatory etiology was present. As Doczilla pointed out, one dose of steroids will not do appreciable harm to this critical pt, and most likely will help. Risk vs. benefit ...benefit in this circumstance. Fluid in the airways will cause an inflammation in and of itself. The symptomology of the progression, cough, no edema, sleeping throughout the night, episodic nature of the dyspnea, no cardiac history and history of recent bronchial infection all strongly support an inflammatory process leading to any fluid in the airways, not the reverse (fluid leading to inflammation). The big picture says non-cardiogenic, the treatment was accurate and prudent given the circumstances, I believe....

Again I go back to discarding any and all comments given you by this arrogant nurse...Maybe she is in need of some remedial training in regards to respiratory ailments?? Not the best example of nurse professionalism..I'm embarrassed for her!! :oops:

.

[1EMT-P]

I agree with your treatment given the patient's history & physical exam. If she had CHF I would expect her to have some edema. Plus given the fact that her sputum is a greenish or yellowish color.

I don't think the nurse was right to question your assessment or treatment... What made her think that it was CHF? Did she do a Basic Metabolic Panel, Chest X-Ray, Ecg or Pro-BNP?

[iMac]

Full respects to nurses but it seems it's always easier for them to make a judgement on what is going on when they are sitting in their cushy hospital. I can almost guarantee you it would have been a lot different if she had been on there on scene with you.

[AnthonyM83]

When a nurse disagrees with something I've done for the patient, I usually ask why. If she seems like she'd take my question as confrontational, I'll add "so I know next time". The conversation that follows usually leads to a finding a miscommunication earlier in the report and it works out OR I learn something new and know for next time OR it ends up being a problem with a protocol I had to follow and not an actual mistake. But at least next time you come in, they at least (hopefully) remember you're not a moron even if you make mistakes and are interested in patient discussions.

[dean83]

With any pneumonia you want to be cautious about using immunosuppressive doses of glucocorticoids/corticosteroids.

Was the pt. febrile?

I agree with the above posts also in regards to open communication, however sometimes nurses or other paramedics are not as receptive to the other side of the story as one would think.