495
Letters to the Editor
Unfortunately, no enzyme levels were obtained to confirm this suspicion. and the patient was lost to follow-up. This case illustrates an unusual complication of drugs commonly used to treat patients in the ED. Although this patient may have had an underlying enzyme deficiency, physicians should be aware that methemoglobinemia can occur following the use of lidocaine and nitroglycerin. The development of cardiac or respiratory symptoms in addition to cyanosis following the administration of these agents should prompt physicians to consider methemoglobinemia in their differential diagnosis. Steven G. Rothrock, MD Department of Emergency Medicine Carolinas Medical Center, Charlotte, North Carolina Steven M. Green, MD Department of Emergency Medicine Riverside General Hospital, Riverside, California
REFERENCES 1. White CD, Weiss LD. Varying presentations of methemoglobinemia: two cases. J Emerg Med. 1991;9(supp 1):45-50. 2. Marshall JB, Ecklund RE. Methemoglobinemia from overdose of nitroglycerin. JAMA. 1981;244:330. 3. Fibuch EF, Cecil ET, Reed WA. Methemoglobinemia associated with organic nitrate therapy. Anesth Analg. 1979;58:5213. 4. Geffner ME, Powers DR, Choctaw WT. Acquired methemoglobinemia. West J Med. 1981;134:7-10. 5. Deas TC. Severe methemoglobinemia following dental extraction under lidocaine anesthesia. Anesthesiology. 1956;17:204. 6. Burne D. Methemoglobinemia following lignocaine. Lancet. 1964;2:921. 7. O’Donahue WJ, Moss LM, Angellilo VA. Acute methemoglobinemia induced by topical benzocaine and lidocaine. Arch Intern Med. 1980;140:1508-9. 8. Jakobsen B, Nilsson AZ. Methemoglobinemia associated with prilocaine-lidocaine cream and trimethoprim sulphamethoxazole: a case report. Acta Anesthesiol Stand. 1985;29:453-5. 9. Weiss LD, Generalovich T, Heller MB. Methemoglobin levels following intravenous lidocaine administration. Ann Emerg Med. 1987;16:323-5. 10. Saxon SA, Silverman ME. Effects of continuous infusion of intravenous nitroglycerin on methemoglobin levels. Am J Cardiol. 1985;56:461-4. 11. Ellenhorn MJ, Barcelouz DG. Medical toxicology: diagnosis and treatment of human poisoning. 1st ed. New York: Elsevier Science Publishing; 1988:844-52.
0 The English System Socialized medicine has been touted as a cost saving mechanism to provide health care. One may ask how and why.
As an ex-Englishman, and a doctor, I outline how these savings are achieved. My father, as I write, lies dying in a hospital in England. After two weeks sedated in bed, no diagnosis and no prognosis have been given his wife or children. No doctor has discussed the case with them. Through trans-Atlantic phone calls, I have pieced the story together. My father, a heavy smoker for many years until I persuaded him to quit, suffered from acute debilitating back pain for the last two months. His English doctor visited him once or twice and assured him that he pulled a muscle digging in his garden. The pain drove my father to call an ambulance. He was admitted. His x-rays were read as a ruptured disc at the thoracic level. A “shadow” was noted in his lung and his serum calcium was elevated. The nurses told my father he had a ruptured disc. He remained sedated and disoriented. For one whole week little else was done. Upon my urging, a bronchoscopy was done and a comparison of old chest x-rays performed. No CT scan of the brain can be performed, as the major hospital for a town of 50,000 people does not have one. Such tests require ambulance rides to Liverpool or Manchester. After one week he was sent by ambulance for a bone scan at a Liverpool hospital. My family was told again by nurses (their only contact) that this was normal. It was not. A “hot” lesion in the bone is present in the thoracic spine. No repeat x-rays were done as the x-ray department closes at 11:30 A M each morning. From my conversations with the attending doctors and this clinical picture, lung cancer with poor prognosis is likely. This has not been communicated by any physician to my family, simply because no doctors are ever on the floors to review cases with patients’ relatives. Heavy sedation, together with late and apparently reluctant administration of antibiotics for his associated pneumonia, leaves one with the impression that my father would have been left to slip away without further intervention had I not called. Compare this with the U.S. Early referral from private doctor, with rapid workup on an outpatient basis, could have detected the lung lesion early. The possibility of resection of the cancer with a 35% five-year survival rate existed. During the whole U.S. process, the doctors would have had almost daily discussions with the immediate kinfolk. As I make my plans to fly home, at this date, two weeks after hospital admission, no diagnosis has yet been made. But here in the U.S., three or four days would suffice and the family be told. Yes, nationalized medicine is cheaper than the U.S. system. Money is saved by lack of doc-
496
The Journal
tors, mostly government employees, inadequately equipped and inadequately staffed hospitals, and a propensity to let the old die rather than evaluate and treat them. Americans won’t stand for such cruel privations. They expect and demand high quality care, from well-staffed, well-equipped private hospitals. Robust, speedy, and vigorous workup and treatment is the U.S. standard. Nationalized health is synonymous with delays, waiting lists, rationing, and high taxes. There is no free ride. Reform of the U.S. system requires nationwide tax reduction with job stimulation, empowering the young to set earnings aside in individual lifelong health insurance accounts. Such medical accounts will be tax deductible. Incentive for individual responsibility for one’s own health is built in by allowing tax free cash-out from medical accounts after survival in good health to retirement age. Christopher Lyon, MD, PhD Newport Beach, California
Cl To the Editor: Dr. Vince Markovchick and I recently reported the treatment of an accidental injection of a thumb by an automatic epinephrine injector syringe in the article entitled “The Reversal of the Ischemic Effects of Epinephrine on a Finger with Local Injections of Phentolamine” [ JEM, September/October 1991;9:323-41. The discussion section of the article refers to a study by Berben and colleagues (1) that demonstrated the prevention of sloughs up to 12 hours after sympathomimetic extravasation by phentolamine injection. In a recent case phentolamine was administered 13 hours after another accidental epinephrine injection. A 40-year-old female nurse accidentally injected 0.15 mg epinephrine from an automatic injector syringe into the tuft of her left thumb. The area became blanched and numb. She sought care in an emergency department approximately 30 minutes after the injection had occurred. The patient reported that despite the presence of a white area, the examining physician stated “the site looks fine.” No treatment was provided. The following morning the thumb had become ecchymotic, swollen, and remained numb. The patient returned to the emergency department where she was given phentolamine injections. Phentolamine 0.5 mg in 1 mL 1% lidocaine was injected on each side of the thumb in the manner of a digital block
of Emergency
Medicine
at 12 hours postinjection. Thirty minutes after the injection the patient reported that her thumb felt warm and less swollen, but remained numb. Therefore, one hour after the first phentolamine injection an additional 2.5 mg was administered in the same manner, but without lidocaine. Within a minute sensation returned to the thumb. No change in the vital signs occurred. The patient described a mild persistent numb sensation that reminded her of a local anesthetic wearing off. This sensation resolved over the next two days. There was no slough of the tissue. In follow-up 4 months after the incident, the patient reported no residual deficits in thumb function. She does report a cramping or achy sensation along the ulnar side of the first metacarpophalangeal joint. This pain did not occur until 1.5 months after the incident when she began prolonged typing during a computer course. She does, however, localize the discomfort to the site of the digital phentolamine injections. The benefits of local infiltration as treatment for digital epinephrine autoinjector injury were first reported in a letter to the editor by Deshmukh and Tolland (2). Treatment was provided 6 hours after the original injury. In the report by Markovchick and myself, treatment occurred within one hour postinjection. Since that submission, another report and excellent review by McCauley and colleagues describes treatment by local infiltration 3 hours postinjection (3). Maguire and colleagues reported the successful treatment of a patient by 2 digital phentolamine injections approximately one hour postingestion (4). This latest report describes the benefit of phentolamine injections despite a treatment delay of 13 hours. Keith K. Burkhart, MD Assistant Professor of Medicine Central Pennsylvania Poison Center Medical Director
REFERENCES I. Berben JY, Bryant MF, Howard JM. Etiology and prevention of slough produced by L-norepinephrine (Levopheda ). Ann Surg. 1957;146:1016-20. 2. Deshmukh N, Tolland JT. Treatment of accidental epinephrine injection in a finger. J Emerg Med. 1989;7:408. 3. McCauley WA, Gerace RV, Scilley C. Treatment of accidental digital injection of epinephrine. Ann Emerg Med. 1991;20:6658. 4. Maguire WM, Reisdorff EJ, Smith D, Wiegenstein JG. Epinephrine-induced vasospasm reversed by phentolamine digital block. Am J Emerg Med. 1990;8:46-7.
Letters to the Editor
Unfortunately, no enzyme levels were obtained to confirm this suspicion. and the patient was lost to follow-up. This case illustrates an unusual complication of drugs commonly used to treat patients in the ED. Although this patient may have had an underlying enzyme deficiency, physicians should be aware that methemoglobinemia can occur following the use of lidocaine and nitroglycerin. The development of cardiac or respiratory symptoms in addition to cyanosis following the administration of these agents should prompt physicians to consider methemoglobinemia in their differential diagnosis. Steven G. Rothrock, MD Department of Emergency Medicine Carolinas Medical Center, Charlotte, North Carolina Steven M. Green, MD Department of Emergency Medicine Riverside General Hospital, Riverside, California
REFERENCES 1. White CD, Weiss LD. Varying presentations of methemoglobinemia: two cases. J Emerg Med. 1991;9(supp 1):45-50. 2. Marshall JB, Ecklund RE. Methemoglobinemia from overdose of nitroglycerin. JAMA. 1981;244:330. 3. Fibuch EF, Cecil ET, Reed WA. Methemoglobinemia associated with organic nitrate therapy. Anesth Analg. 1979;58:5213. 4. Geffner ME, Powers DR, Choctaw WT. Acquired methemoglobinemia. West J Med. 1981;134:7-10. 5. Deas TC. Severe methemoglobinemia following dental extraction under lidocaine anesthesia. Anesthesiology. 1956;17:204. 6. Burne D. Methemoglobinemia following lignocaine. Lancet. 1964;2:921. 7. O’Donahue WJ, Moss LM, Angellilo VA. Acute methemoglobinemia induced by topical benzocaine and lidocaine. Arch Intern Med. 1980;140:1508-9. 8. Jakobsen B, Nilsson AZ. Methemoglobinemia associated with prilocaine-lidocaine cream and trimethoprim sulphamethoxazole: a case report. Acta Anesthesiol Stand. 1985;29:453-5. 9. Weiss LD, Generalovich T, Heller MB. Methemoglobin levels following intravenous lidocaine administration. Ann Emerg Med. 1987;16:323-5. 10. Saxon SA, Silverman ME. Effects of continuous infusion of intravenous nitroglycerin on methemoglobin levels. Am J Cardiol. 1985;56:461-4. 11. Ellenhorn MJ, Barcelouz DG. Medical toxicology: diagnosis and treatment of human poisoning. 1st ed. New York: Elsevier Science Publishing; 1988:844-52.
0 The English System Socialized medicine has been touted as a cost saving mechanism to provide health care. One may ask how and why.
As an ex-Englishman, and a doctor, I outline how these savings are achieved. My father, as I write, lies dying in a hospital in England. After two weeks sedated in bed, no diagnosis and no prognosis have been given his wife or children. No doctor has discussed the case with them. Through trans-Atlantic phone calls, I have pieced the story together. My father, a heavy smoker for many years until I persuaded him to quit, suffered from acute debilitating back pain for the last two months. His English doctor visited him once or twice and assured him that he pulled a muscle digging in his garden. The pain drove my father to call an ambulance. He was admitted. His x-rays were read as a ruptured disc at the thoracic level. A “shadow” was noted in his lung and his serum calcium was elevated. The nurses told my father he had a ruptured disc. He remained sedated and disoriented. For one whole week little else was done. Upon my urging, a bronchoscopy was done and a comparison of old chest x-rays performed. No CT scan of the brain can be performed, as the major hospital for a town of 50,000 people does not have one. Such tests require ambulance rides to Liverpool or Manchester. After one week he was sent by ambulance for a bone scan at a Liverpool hospital. My family was told again by nurses (their only contact) that this was normal. It was not. A “hot” lesion in the bone is present in the thoracic spine. No repeat x-rays were done as the x-ray department closes at 11:30 A M each morning. From my conversations with the attending doctors and this clinical picture, lung cancer with poor prognosis is likely. This has not been communicated by any physician to my family, simply because no doctors are ever on the floors to review cases with patients’ relatives. Heavy sedation, together with late and apparently reluctant administration of antibiotics for his associated pneumonia, leaves one with the impression that my father would have been left to slip away without further intervention had I not called. Compare this with the U.S. Early referral from private doctor, with rapid workup on an outpatient basis, could have detected the lung lesion early. The possibility of resection of the cancer with a 35% five-year survival rate existed. During the whole U.S. process, the doctors would have had almost daily discussions with the immediate kinfolk. As I make my plans to fly home, at this date, two weeks after hospital admission, no diagnosis has yet been made. But here in the U.S., three or four days would suffice and the family be told. Yes, nationalized medicine is cheaper than the U.S. system. Money is saved by lack of doc-
496
The Journal
tors, mostly government employees, inadequately equipped and inadequately staffed hospitals, and a propensity to let the old die rather than evaluate and treat them. Americans won’t stand for such cruel privations. They expect and demand high quality care, from well-staffed, well-equipped private hospitals. Robust, speedy, and vigorous workup and treatment is the U.S. standard. Nationalized health is synonymous with delays, waiting lists, rationing, and high taxes. There is no free ride. Reform of the U.S. system requires nationwide tax reduction with job stimulation, empowering the young to set earnings aside in individual lifelong health insurance accounts. Such medical accounts will be tax deductible. Incentive for individual responsibility for one’s own health is built in by allowing tax free cash-out from medical accounts after survival in good health to retirement age. Christopher Lyon, MD, PhD Newport Beach, California
Cl To the Editor: Dr. Vince Markovchick and I recently reported the treatment of an accidental injection of a thumb by an automatic epinephrine injector syringe in the article entitled “The Reversal of the Ischemic Effects of Epinephrine on a Finger with Local Injections of Phentolamine” [ JEM, September/October 1991;9:323-41. The discussion section of the article refers to a study by Berben and colleagues (1) that demonstrated the prevention of sloughs up to 12 hours after sympathomimetic extravasation by phentolamine injection. In a recent case phentolamine was administered 13 hours after another accidental epinephrine injection. A 40-year-old female nurse accidentally injected 0.15 mg epinephrine from an automatic injector syringe into the tuft of her left thumb. The area became blanched and numb. She sought care in an emergency department approximately 30 minutes after the injection had occurred. The patient reported that despite the presence of a white area, the examining physician stated “the site looks fine.” No treatment was provided. The following morning the thumb had become ecchymotic, swollen, and remained numb. The patient returned to the emergency department where she was given phentolamine injections. Phentolamine 0.5 mg in 1 mL 1% lidocaine was injected on each side of the thumb in the manner of a digital block
of Emergency
Medicine
at 12 hours postinjection. Thirty minutes after the injection the patient reported that her thumb felt warm and less swollen, but remained numb. Therefore, one hour after the first phentolamine injection an additional 2.5 mg was administered in the same manner, but without lidocaine. Within a minute sensation returned to the thumb. No change in the vital signs occurred. The patient described a mild persistent numb sensation that reminded her of a local anesthetic wearing off. This sensation resolved over the next two days. There was no slough of the tissue. In follow-up 4 months after the incident, the patient reported no residual deficits in thumb function. She does report a cramping or achy sensation along the ulnar side of the first metacarpophalangeal joint. This pain did not occur until 1.5 months after the incident when she began prolonged typing during a computer course. She does, however, localize the discomfort to the site of the digital phentolamine injections. The benefits of local infiltration as treatment for digital epinephrine autoinjector injury were first reported in a letter to the editor by Deshmukh and Tolland (2). Treatment was provided 6 hours after the original injury. In the report by Markovchick and myself, treatment occurred within one hour postinjection. Since that submission, another report and excellent review by McCauley and colleagues describes treatment by local infiltration 3 hours postinjection (3). Maguire and colleagues reported the successful treatment of a patient by 2 digital phentolamine injections approximately one hour postingestion (4). This latest report describes the benefit of phentolamine injections despite a treatment delay of 13 hours. Keith K. Burkhart, MD Assistant Professor of Medicine Central Pennsylvania Poison Center Medical Director
REFERENCES I. Berben JY, Bryant MF, Howard JM. Etiology and prevention of slough produced by L-norepinephrine (Levopheda ). Ann Surg. 1957;146:1016-20. 2. Deshmukh N, Tolland JT. Treatment of accidental epinephrine injection in a finger. J Emerg Med. 1989;7:408. 3. McCauley WA, Gerace RV, Scilley C. Treatment of accidental digital injection of epinephrine. Ann Emerg Med. 1991;20:6658. 4. Maguire WM, Reisdorff EJ, Smith D, Wiegenstein JG. Epinephrine-induced vasospasm reversed by phentolamine digital block. Am J Emerg Med. 1990;8:46-7.
