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

- Rogue Medic

What is the Right Response to a Treatment Error – Part IV

Continuing from Part I, Part II and Part III.

Wilkerson said the investigation did not take into account Davis’ condition after being given the incorrect medicine.

“It’s hard for us to know what is the effect of the medication and not be able to account for other stuff,” he said. “What was taken into account was what occurred.”[1]

That is odd phrasing, as has been mentioned at both Too Old To Work, Too Young To Retire and Life Under the Lights.

Is that because there would be difficulty determining what might have been due to lidocaine and what might have been due to the medical condition?

Did they obtain a lidocaine level on the patient?

Picture credit

Lidocaine toxicity occurs with unintended intravascular administration or with administration of an excessive dose. When lidocaine is used for regional nerve blocks, plasma levels are usually 3-5 mcg/mL. Toxicities may be observed at 6 mcg/mL, but more commonly occur once levels exceed 10 mcg/mL.[2]

Lidocaine hydrochloride is commonly infused intravenously to prevent ventricular arrhythmias. In some patients, elevations in serum lidocaine levels can cause serious toxic effects.[3]

Considering the side effects, should we even carry lidocaine?

We do not yet have the ability to test drug levels in EMS.

Is lidocaine even effective as a treatment for PSVT (Paroxysmal SupraVentricular Tachycardia) or for VT (Ventricular Tachycardia)?

Traditionally, the treatment of a regular wide-complex tachycardia began with lidocaine and proceeded to adenosine under the presumption that a lidocaine-unresponsive arrhythmia could only be PSVT. More recent data have suggested that lidocaine is not only virtually 100% ineffective in the treatment of PSVT, but also up to 90% ineffective when used to treat VT.38-41[4]

We could rephrase this statement as –

 

For PSVT – Lidocaine is 100% the wrong drug.

 

For VT – Lidocaine is 90% the wrong drug.

 

I could do as well with homeopathy, acupuncture, chanting, Reiki, or any other placebo.

At the very least – 10% of the time VT resolves spontaneously. Maybe the lidocaine is actually prolonging the VT.

Why are we carrying this dangerous placebo?

Who benefits?

Wilkerson said Hamilton County paramedics respond to about 29,000 emergency calls each year and cases like this one are extremely rare.

“Our goal is 100 percent success ratio and this is not the norm,” Wilkerson said.[1]

Carrying, and occasionally using, a drug that is 90% ineffective, especially when doing nothing is more effective, is not the way to meet any goal of 100% success. Not that 100% success is possible, except when dealing with very small numbers.

All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.

I am almost done. You should also read what others are writing about this –

Too Old To Work, Too Young To Retire writes about this in Scratching My Head.

At Life Under the Lights, Chris Kaiser writes A Medic Roast in Tennessee. This post by Chris includes the Damoclean artwork to the right.

Footnotes:

[1] Tenn. paramedic demoted after drug mistake
On Wednesday, Timothy Waldo, 46, was demoted to EMT after being a paramedic for as many as nine years
By Beth Burger
Chattanooga Times Free Press
Article

[2] Lidocaine Toxicity
Author: Ruben Peralta, MD, FACS; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM
Medscape Reference
Article

[3] Simple method for maintaining serum lidocaine levels in the therapeutic range.
Wong BY, Hurwitz A.
Arch Intern Med. 1985 Sep;145(9):1588-91.
PMID: 4026487 [PubMed – indexed for MEDLINE]

[4] Prehospital management of acute tachyarrhythmias.
Slovis CM, Kudenchuk PJ, Wayne MA, Aghababian R, Rivera-Rivera EJ.
Prehosp Emerg Care. 2003 Jan-Mar;7(1):2-12. Review.
PMID: 12540138 [PubMed – indexed for MEDLINE]

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