"Poisons and medicines are often times the same substance given with different intents."-Peter Mere Latham, General Remarks on the Practice of Medicine
As I sit here deciding what pain reliever to take for my backache, I do some mental figuring. If two Tylenol tablets will eliminate this pain in an hour, will four tablets get rid of it in a half-hour? If I follow this permutation further, then eight tablets should take care of the pain in 15 minutes. If I take this far enough, I might be able to prevent the pain completely.
Are medications good? Sure. Example: Insulin enables many diabetics to live relatively normal lives. But insulin can also be less than helpful to patients. Ever seen the movie Reversal of Fortune? It's the 1990 dramatization of the Claus von Bulow trial in which von Bulow was accused of killing his wife with an insulin overdose. Her blood glucose went into single figures, irrevocably damaging her brain. So let me ask you again, are drugs good or bad? The answer is both. Read on to find out why.
Scenario
As you drive around your response area, dispatch breaks the silence: "Elderly male, weak and dizzy at Joseph Nursing Home, 129 Hicks Street, corner of Rubin Avenue. Time out is 1328."
Great-another lift-and-leave call. As your partner negotiates the city streets on the way to the nursing home, you wonder what happened to the calls you used to see crews respond to on Paramedics or Emergency 9-1-1. You tell your partner you didn't spend more than 1,200 hours in paramedic training to taxi old-timers from the nursing home to the hospital. He agrees, but reminds you that at least this particular nursing home does a good job of telling you the patient history and remains on top of its patients' medications.
On scene, the front desk directs you to a patient's room on the sixth floor. The patient is semi-conscious. The nurse tells you he began to slip in and out of consciousness an hour ago. He has complained of weakness, palpitations, a mild headache and experienced some diarrhea and occasional vomiting during the past 24 hours. The nurse also tells you the patient complained of blurry and double vision. He has not experienced chest pain or had difficulty breathing.
The patient has a history of congestive heart failure and high blood pressure. Vital signs: pulse 98; respiratory rate 24; and blood pressure 108/76. Pupils are equal and reactive. He doesn't have a fever. His lung sounds remain clear.
As your partner places the patient on an ECG monitor, you get his medications data. He takes IsoptinSR (verapamil hydrochloride sustained release), digoxin, Lasix (furosemide) and a multivitamin. He started on the Lasix last week.
The ECG shows an accelerated junctional rhythm of about 96. You administer oxygen via a non-rebreather mask and establish an IV of saline with an 18-gauge catheter in the patient's wrist. You and your partner elect not to aggressively treat the patient because he seems stable. You monitor the patient closely during the 15-minute transport.
On arrival at the emergency department, the origin of the patient's problem still eludes you. The only medication you think could have precipitated this reaction is the Lasix, which the patient started only days before he decompensated. But Lasix doesn't cause these symptoms. You would expect hypotension and dehydration with a Lasix overdose. You transfer patient care to the ED staff and go back into service.
Discussion
At a call review session days later, your patient's case comes up. You learn the final diagnosis was digoxin toxicity. You're still puzzled-you learned dig toxicity patients see yellow/green halos in their visual fields, and this guy didn't. The physician says that less than 50% of digoxin overdose victims experience those particular visual disturbances. Blurry vision is a much more common symptom. Also common are the symptoms you observed: weakness, palpitations and headache.
This guy became toxic because Lasix can increase plasma digoxin levels. The physician points out that only 1.1% of all outpatients develop toxicity, but 10-18% of nursing home patients develop it. Advanced age (80 or older) is an independent risk factor associated with increased morbidity and mortality. He tells you to consider toxicity in any nursing home or outpatient taking digoxin.
Medicine isn't an exact science-as if you needed any proof of that. In this case, your patient properly took a prescribed medication. However, when he added another medicine to the mix, his condition deteriorated quickly. This case points out the need for a complete understanding of the actions and reactions caused by medications-alone and when combined with other medications. Despite each medicine's therapeutic value, when mixed incorrectly, they may become a lethal cocktail.
Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.
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