When all you have is a hammer… Every problem looks like, lasix?

A few years ago I responded to a structure fire on the main engine out of my station. The fire was at a house that had been converted to a dog kennel and grooming shop just a few blocks away from the firehouse and was a short response time. It was a light-staffing day and we responded as a three person engine company. As the senior firefighter I was the acting company officer and my new girlfriend at the time, who just happens to be my wife now, was the backseat firefighter. Get ready for the “Awwww” moment… it was our first fire “as a couple”. There was a number of cool things that came out of the fire, but one of them was the fact that Gina grabbed *my* maul.

My wife and I fighting our first fire "as a couple" - We're the ones in turnout gear

On our main engine, there’s an 8-pound maul (big hammer) that I grab as my tool of choice every time I jump off the truck for a fire. It just tucks so neatly in my SCBA’s belt and is so compact yet handy that I make a beeline for it every time. This time, Gina had taken it, so I grabbed a pick-head axe.

It’s amazing that when I have my maul that every access problem looks like something that I can solve by whacking it with a hammer of some sort. On this fire, I learned that when one has an axe, every problem looks like it can be solved by some sort of chopping.

Moral of the story, Gina and I entered the structure, saved the pooches, and stopped the fire in its trucks with minimal damage. There’s actually a hilarious video that I believe is still on our department’s web site that I’d let you see if I didn’t hide the name of the department(s) I work for due to “I want to remain employed reasons”.

And, like a lot of things on here, I told you that so I could tell you this about an EMS call I responded to an indeterminate amount of time ago. I have the honor and privilege to be the senior medic on most shifts I work and I precept a lot of students on the ambulance. This shift was no different and this 0-dark-30 call illustrates a point that I’d like to explain to you.

The doggies were SHOCKED that Gina took MY maul

For this call, the primary ambulance out of our station responded because they were on the way back from another call and my partner and I responded in our ambulance because we were up on the alternating call rotation. They arrived at the poorly-accessible apartment complex a few minutes before we did and made first patient contact. As it turns out, the middle age patient had ran out of his/her prescription Lasix (a potent diuretic, or water pill) a week or so prior to the call and had been retaining a great deal of excess bodily fluid. The patient’s legs were markedly and grossly swollen and weeping fluid out of fluid filled blisters. The Patient called us because he/she could no longer stand the pain of the cellulitis (infection) that had developed. The patient had no respiratory compromise, his/her lungs were clear, and he/she really had no other complaints. The patient had an extensive medical history of organ failure and disease. He/she was fully alert and oriented, and was able to assist us as we simply picked him/her up and carried him/her to the cot.

As we were loading the patient up in the ambulance and I was about to get into the back to continue my assessment and treatment of the patient, the EMT from the other ambulance who happens to be an almost-done Paramedic student told me, “So those legs are the worst I’ve ever seen fluid wise, you’re going to push some lasix on this one”. I mumbled something and got into the truck. I was tired and wasn’t really able to form complete sentences at the time due to sleep deprivation. I got in the truck and continued my assessment where I found that the frail patient had a blood pressure in the 70 systolic range (Low!) and that in addition to retaining fluid in his/her legs, he/she was also retaining fluid in his/her abdomen and was probably in need of a paracentesis. I managed the patient with a (beautifully executed) IV stick into an impossibly small crooked vein, and gave just enough fluid to bring his/her BP up a bit without adding to his/her fluid overload all that much. I put the Pt on oxygen and a cardiac monitor, which revealed a normal sinus rhythm without ectopy. I obtained a 12-lead EKG as well, which was not indicative of any acute problems. The patient stated that his/her pain was managed by padding and positioning of his/her swollen legs and even though he/she complained of no breathing problems, I put him/her on a bit of oxygen via nasal cannula.

The transport was uneventful, although his/her blood pressure never did come up. The ER later diagnosed the Pt with complete liver failure and toxicity.

But the interesting part of the story is this, when I got back the medic student asked me about giving IV lasix to the patient, as we carry that in our medication stock and have it available as an emergency diuretic for patients in congestive heart failure and/or fluid overload with pulmonary edema and respiratory compromise. He was almost taken aback when I said that I didn’t give any.

I asked him if he did a full assessment. He said that he had tried… but that he didn’t have enough time before I arrived and we took the patient out to the ambulance. I gave him my assessment findings and the news of the very low blood pressure. He said that he agreed with me on not giving the lasix with the markedly low blood pressure but was curious when I explained that it wasn’t the reason I didn’t give the medication.

We in EMS, and especially new providers carry our own hammers… our treatments and medications that we’re able to give in the field. Medics that use these treatments more often are called “aggressive” and it is a badge of honor. In fact, in some cases, aggressive field treatment is indeed warranted and improves patient outcomes. However, in a lot of cases it is not indicated and patients benefit from what we don’t do more so than from what we could have done.

This patient didn’t have any respiratory compromise and while he/she obviously could have benefited from the dieresis or removal of the excess fluid, she didn’t meet the criteria for emergent field administration of lasix, which is respiratory compromise from pulmonary edema. I made the decision to let the physician evaluate the patient and determine the best treatment path that would fit in with the patient’s ultimate plan of care. I didn’t believe that the patient would ultimately benefit from my administration of lasix twenty minutes earlier than the ER could have done it if the physician so chose.

Every treatment we administer must be given with a full assessment of the risks and benefits to the patient for doing so. Every EMS person should familiarize themselves with the long-term care paths of the conditions we treat and try to maximize the long-term benefit to the patient with the acute and short-term care we give. Not every problem is “a nail” and sometimes the hammers we carry aren’t the best ultimate solution for excellent patient care. Remembering how we as EMS people fit into the grand scheme of the overall healthcare system and in the ultimate care paths of our patients will help us all to do what we’re supposed to do, which is to provide excellent and appropriate patient care.

It is also of note, I guess, that Gina rarely steals my maul anymore. Now that we’re married… I “give it freely” to her.. What’s mine is her’s, as they say.

  • Ambulance Driver

    It's distressing how many of our colleagues, even some with years of experience, think that wet lungs + CHF history = Lasix, and further dehydrate lots of febrile little old ladies with pneumonia.

    And I'd be willing to bet that Gina keeps your “maul” locked in her purse, and only lets you see it on special occasions.

    Metaphorically speaking, that is. 😉

  • Ambulance Driver

    It's distressing how many of our colleagues, even some with years of experience, think that wet lungs + CHF history = Lasix, and further dehydrate lots of febrile little old ladies with pneumonia.

    And I'd be willing to bet that Gina keeps your “maul” locked in her purse, and only lets you see it on special occasions.

    Metaphorically speaking, that is. 😉

  • Ambulance Driver

    It's distressing how many of our colleagues, even some with years of experience, think that wet lungs + CHF history = Lasix, and further dehydrate lots of febrile little old ladies with pneumonia.

    And I'd be willing to bet that Gina keeps your “maul” locked in her purse, and only lets you see it on special occasions.

    Metaphorically speaking, that is. 😉

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  • http://www.kslights.com led street lights

    Great, very interersting

  • http://lookingthroughapairofpinktraumashears.blogspot.com Medic Trommashere

    For this reason and many others, they took Lasix “away” from us. Now you have to pretty much play with the command physicians' “maul” to give it. We were taught in medic class to double the dose and you can do it twice (we carried a full gram and a half of Lasix between our drug box and first in bag) before calling the doc for another round or three. Medics would start freaking out when the patient didn't have to pee within a few minutes, so they'd keep pushing it. Little old ladies were pissing off more potassium than the body probably had in it.

    Phenominal article. I'll have to direct any precepting student this way after I smack the little brown vial of Lasix out of their hand for the fifth time.

    ~M. Trommashere~

  • http://twitter.com/MsParamedic MsParamedic

    *claps* I always enjoy your posts, CK. This had several things I adore. Clinical critical thinking, puppies, and YOUR WIFE <3 hahaha

  • Ginaleigh24

    Well, first of all dear, I don't go inside any fire without MY maul. Yes hunny, I did say mine. Since I started in the fire service it has been my tool of choice. You didn't give it to me I took it BTW ; ) I do have to say that you left out the best part…… Because you were trying to “vent” an already vented room with an open door and an already broken window to the fire room. I stole your nozzle and put the fire out myself : ) So moral of the story yes I did steal “your” maul which was mine in the first place but I also stole your nozzle.
    On the flip side, great article, as I student I can always count on learning from you….(lord help me)… xoxo

  • Anonymous

    Nasal Dilators to avoid collapse of the nostrils and allow more air into the nose. For details go to http://www.breatherightnasalstrips.com/ 

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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