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

- Rogue Medic

Ipecac for Tricyclic Antidepressant Overdose

Maybe I should have titled this, How to Kill Patients Without Really Thinking, but I am sure I will have many other uses for that title.

In one high performance system, I found out quickly that I would never fit in. I was riding along with them to be signed off for authorization to work in the county as a medic, because that was the way things worked back then. A bunch the medics were sitting in the EMS room at the hospital, when in walked on of the new good ol’ EMS mythology boys.[1]

This new good ol’ EMS myth boy was bragging about how he had given ipecac to a patient. The medical director (who was also the county medical director) had ordered the medic to give ipecac to a patient who stated she had taken an overdose of a tricyclic antidepressant. I mentioned that ipecac is contraindicated for tricyclic OD (OverDose). He insisted that ipecac was not contraindicated. Another good ol’ EMS myth boy stated that the doctor would never have ordered it, if the treatment were contraindicated.


Image credit.

Having an EMS Field Guide – the old laminated paper version of the electronic EMS Field Guide advertised in EMS Blogs sidebar – I was able to quickly flip to the page that included ipecac and I read off the contraindications, which included tricyclic antidepressants. The most recent EMS Field Guide that I have also includes this, but the electronic version does not. It appears that they take it for granted that nobody uses ipecac anymore. I hope that they are correct, but I doubt it. These guides can be helpful for checking indications/contraindications/side effects/doses of a hundreds of medications we use on a regular basis.

I hope that nobody still uses ipecac in EMS, but do your protocols include ipecac?

That medical director ordered ipecac. The medic had no idea that ipecac was contraindicated, since this was in a high performance EMS system that focuses on speed and stupidity, more of both, but did not focus on any criteria of performance that might improve outcomes.

The medical director told me, “I did not think that it was a serious overdose.”

In that case, the wise course of treatment would be benign neglect, not iatrogenic poisoning.

This decision that patient abuse was the best course of action was based on the report the medical director received over the phone/radio from a medic too clueless to think. Did the medic recognize that the doctor was ordering him to give a treatment to punish the patient? I don’t remember.

Why would a doctor trust a clueless person to give accurate, or even useful, information? This cycle of stupidity is repeated too many times.

How do these clowns ever graduate from paramedic school?

That is not really a question. The reason for such pathetic paramedics is our ridiculously low standards in EMS.

Routinely improperly administered by caregivers[2]

Even the places I regularly criticize appear to recognize that ipecac is bad treatment and that EMS routinely makes things worse when we use ipecac.

Footnotes:

[1] good ol’ EMS mythology boys
Those more interested in coming up with excuses to avoid, or harm, patients, rather than help them. Those who think that a doorway diagnosis is in any way adequate. Those who do not understand why they do what they do, but remember that in medic school they were told that this is the only way to do things.
Further information

[2] EMS Protocols
MIEMSS (Maryland Institute of Emergency Medical Services Systems)
2005 revision
p 71/163
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