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 III

Continuing from Part I and Part II.

They brought Davis, 57, to the hospital after he was cut down from a rope tied around his ankle on a challenges course at Greenway Farms. Davis said he had been hanging there for two days.[1]

This suggests that there is some sort of muscle break down going on. Even if the patient is only lying on the ground with his leg tangled in something, this is a possibility. Even in a patient with a hip fracture, unable to move after falling and still in the same place long after falling, this is a possibility.

One concern with prolonged muscle break down is coincidentally the subject of Today’s featured article at Wikipedia – Rhabdomyolysis.[2] The treatment is fluids. The treatment can include medication if the patient is showing signs of hyperkalemia. For hyperkalemia the treatment is calcium.[3] I know that a lot of us have been told that we should give bicarb (sodium bicarbonate), but bicarb for hyperkalemia is just another EMS myth. I will explain that in detail in a later post.

What drug was given?

Citing privacy laws, Wilkerson would not disclose what medication was administered to Davis.[1]

The next quote shows that this supposed concern for privacy didn’t last very long. There does not appear to have been any serious attempt at privacy at any point, except when it is the privacy of the ambulance company.

A drug that is as useless as bicarb for hyperkalemia, but a drug that is also more likely to be dangerous than bicarb.

“The lidocaine that was used is a pre-mixed lidocaine that comes in an I-V bag, and our investigation shows it was the wrong IV bag that was used.”[4]

The wrong IV bag? A simple mistake that would be easy for anyone to make. That is the impression this gives me. No reason to consider the possibility that there is a systemic problem that might make this kind of mistake more likely than it should be, but we will punish the medic and publicize the punishment.



Caution should be employed in the repeated use of lidocaine hydrochloride in patients with severe liver or renal disease because accumulation may occur and lead to toxic phenomena, since lidocaine hydrochloride is metabolized mainly in the liver and excreted by the kidneys. The drug should also be used with caution in patients with hypovolemia and shock, and in all forms of heart block (see CONTRAINDICATIONS and WARNINGS).

In patients with sinus bradycardia or incomplete heart block, the administration of lidocaine hydrochloride intravenously for the elimination of ventricular ectopic beats without prior acceleration in heart rate (e.g., by isoproterenol or by electric pacing) may promote more frequent and serious ventricular arrhythmias or complete heart block (see CONTRAINDICATIONS).

Most potent anesthetic agents, local anesthetics of the amide type, which includes lidocaine, and muscle relaxants of both depolarizing and non-depolarizing types, have been associated with malignant hyperthermia.[5]

Even when lidocaine might be the right drug, there are a lot of things to consider first, such as drug interactions. There is also the problem of a complete lack of expectation of benefit when given when not indicated. On top of that is the problem that lidocaine is unlikely to produce any benefit, even if given when the protocols state that lidocaine is indicated.


Systemic reactions of the following types have been reported:

Central Nervous System: Light-headedness; drowsiness; dizziness; apprehension; euphoria; tinnitus; blurred or double vision; vomiting; sensation of heat, cold or numbness; twitching; tremors; convulsions; unconsciousness; respiratory depression and arrest.

Cardiovascular System: Hypotension; cardiovascular arrest; and bradycardia which may lead to cardiac arrest.

Allergic reactions may occur but are infrequent. There have been no reports of cross sensitivity between lidocaine hydrochloride and procainamide or between lidocaine hydrochloride and quinidine.

Management of Adverse Reactions:

In the case of severe reaction, discontinue the use of the drug.

Institute emergency resuscitative procedures and administer the emergency drugs necessary to manage the severe reaction. For severe convulsions, small increments of diazepam or an ultrashort-acting barbiturate (thiopental or thiamylal) or if those are not available, a short-acting barbiturate (pentobarbital or secobarbital); or if the patient is under anesthesia, a short-acting muscle relaxant (succinylcholine) may be given intravenously. Muscle relaxants and intravenous medications should only be used by those familiar with their use. Patency of the airway and adequacy of ventilation must be assured.

Should circulatory depression occur, vasopressors may be used.


Reported adverse reactions are due to overdosage (see ADVERSE REACTIONS).


Therapy of ventricular arrhythmias is often initiated with a single IV bolus of 50 to 100 mg of lidocaine hydrochloride injection. Following acute treatment by bolus in patients in whom arrhythmias tend to recur and who are incapable of receiving oral antiarrhythmic agents, intravenous infusion of Lidocaine Hydrochloride and 5% Dextrose Injection, USP is administered continuously at the rate of 1 to 4 mg/min (20 to 50 mcg/kg/min in the average 70 kg adult). The 0.4% solution (4 mg/mL) can be given at a rate of 15 to 60 mL/hr (0.25 to 1 mL/min). The 0.8% solution (8 mg/mL) can be given at a rate of 7.5 to 30 mL/hr (0.12 to 0.5 mL/min). Precise dose is determined by patient response.[5]

twitching; tremors; convulsions; unconsciousness; respiratory depression and arrest.

Hypotension; cardiovascular arrest; and bradycardia which may lead to cardiac arrest.

Could any of these be the symptoms noted by the doctor at the hospital?


Could the symptoms be related to the patient hanging by the circulation to his leg compromised for a couple of days and then having sudden reperfusion?


Wilkerson said the investigation did not take into account Davis’ condition after being given the incorrect medicine.[1]


I will continue with this, but 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.


[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

[2] Rhabdomyolysis
Today’s featured article 9/20/2011

[3] EMS 12 Lead Bradycardia Post – Part II
Rogue Medic

[4] Update: Paramedic Gave Wrong Medication
September 14, 2011 5:16 PM

[Baxter Healthcare Corporation]

FDA Label
Free Full Text with link to Full Text PDF Download from DailyMed



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