Consider the Alternative

     When you and your partner are dispatched to a law firm for a person down, dispatch advises a BLS engine company is also en route. On arrival, a receptionist directs you to the third floor, where the first responders have already obtained a first set of vital signs: BP 140/80, HR 130, RR 18. They have just started administering oxygen at 10 lpm via a non-rebreather and report a blood glucose of 130 mg/dL.

     An administrative assistant tells you the patient had been struck by an SUV while riding his bicycle the previous evening but refused EMS assistance on the scene. The patient told him this morning that he had an appointment with an alternative healer because he was unable to see his family physician. The man returned from lunch with a bottle of "homeopathic" medicine and his arm in a sling. About 15 minutes ago, he threw up and then passed out.

     Upon initial survey, you notice the patient's skin is hot, dry and flushed. His pupils are dilated and he seems confused and is hallucinating. Your cardiac monitor shows a sinus tachycardia at 140 bpm with no ectopy noted. As you continue a rapid trauma survey, you note a dressing on his right shoulder and the arm is secured in a sling and swathe. As the administrative assistant hands you the bottle of homeopathic medicine, the patient begins having a seizure.

     A comprehensive patient assessment is vital to providing the most appropriate and necessary treatments required for better patient outcomes. It becomes imperative to investigate all possible mechanisms or natures of the patient's condition and avoid tunnel vision when presented with what could appear as the obvious. The purpose of this case study is to provide insight into the use of alternative therapies and highlight potential adverse effects of nontraditional care.

     Alternative medical practices have become increasingly popular with the public, with nearly 50% of the U.S. population seeking some form of alternative care annually. Homeopathic and herbal remedies are more readily available and often cheaper than conventional medicines. This increased use of alternative medicine creates a unique challenge to EMS providers, necessitating a need to better understand their likenesses and differences, as well as the possibility that an ingredient in their makeup could be the cause of a patient's condition.

WHAT DO WE KNOW?
     Your patient was involved in a bicycle vs. SUV collision and is unable to tell what injuries he sustained due to an altered mental state that includes hallucinations and confusion. We know he has an arm/shoulder injury that has been splinted with a sling and swathe. Ventilations are within normal limits; however, his heart rate is rapid, blood pressure is elevated and skin color and condition are not consistent with possible traumatic injuries. His administrative assistant witnessed one emesis followed by what appeared to be a syncopal episode. There is a dressing on his right shoulder and his pupils are dilated. What do you suspect is going on: trauma, medication or both?

TRAUMA
     EMS providers are trained to recognize the many signs and symptoms related to trauma, some of which may develop many hours or days following the initial event. Do this patient's signs and symptoms indicate they stem from injuries the patient sustained from being stuck by an SUV?

     Traumatic brain injury (TBI), as well as internal bleeding, could be suspected as a result of this type of accident. Complete and comprehensive treatment requires that EMS investigate all possible causes of this patient's current condition.

     Based on Table 1 on page 82, can trauma be accurately ruled out as the cause of his current chief complaint?

MEDICATIONS
     What about that visit to the "alternative" medicine practitioner? What is that bottle of medication he brought back with him?

HOMEOPATHY AND HOMEOPATHIC MEDICATIONS
     Homeopathy is a 200-year-old therapeutic system developed at the end of the 18th century by German physician Samuel Hahnemann that uses small doses of various substances to stimulate self-healing. Its basis was to treat a disease with a substance which, in large doses, could reproduce the symptoms of that disease in a healthy person. It provided an alternative to the sometimes abusive treatments of conventional medicine of that era, such as bloodletting, vomiting and purging. The University of Iowa had a College of Homeopathic Medicine from 1887 to 1919.

     Hahnemann theorized that if a large amount of a substance caused certain symptoms in a healthy person, smaller amounts of the same substance could treat those symptoms in someone who is ill ("like is cured by like"). On the belief that a substance's strength and effectiveness increased the more it was diluted, miniscule doses were prepared by repeatedly diluting the active ingredients by factors of 10. In later years, when these dilutes were run through testing, there was often no evidence of the original extract present in the dilute. This created an atmosphere of suspicion and doubt for some concerning the effectiveness of homeopathic practices.¹

     Why is homeopathic medicine so attractive to patients in this era of modern medicine? Homeopathic treatments are very individualized, based on a person's genetic history, personal health history, body type and symptoms—physical, emotional and mental. Homeopathic practitioners spend an hour or more with each patient, asking such individualized questions as food preferences and sleep patterns to make the match between person and remedy. Homeopathic and herbal remedies are available without a formal prescription and are usually less expensive than conventional medications. Individualized attention, treatment, cost and availability, as well as the natural and spiritual elements of treatment, have made homeopathic medicine a popular alternative to conventional medical practices.

     Homeopathic medications can evoke a positive, calming influence on the body for many individuals. Chamomile, marigold, daisy and onion are just a few of the natural plants used in homeopathic medicines.

     Chamomile is a well-known herb used primarily in tea to help people relax. It is used in homeopathic medicines to aid individuals who are having difficulty sleeping, loss of appetite, menopausal depression, anxiety, motion sickness and the aches and pains of flu.

     Onion is considered at least somewhat effective against colds, heart disease, diabetes and osteoporosis, and contains anti-inflammatory, anticholesterol, anticancer and antioxidant components.

     A number of dangerous substances, such as poison ivy, mercury, arsenic, hemlock and belladonna, are used in some homeopathic treatments.

     Belladonna is a plant that was used widely 200 years ago for many ailments. Belladonna alkaline (commonly known as deadly nightshade) was used as a narcotic, diuretic, sedative and antispasmodic, and was valuable in treating eye diseases. In the earlier centuries, women used belladonna drops to dilate their pupils to create the wide-eyed look considered a mark of beauty. Atropine, an extract of the belladonna plant, is currently used in eye surgery to dilate the pupil and in treating cardiac arrhythmias and arrest. Poultices containing belladonna are often applied to injuries or sprained limbs following a fall. Belladonna is considered a valuable treatment for acute sore throat and is believed to alleviate congestion. Locally applied, it appears to lessen inflammation, irritability and pain in neuralgia, gout, rheumatism and sciatica. Belladonna alkaline (atropine) is an anticholinergic that can be toxic when taken in high doses.

     Poison ivy, used in an ointment with equal parts poison ivy vine, prickly ash bark and alfalfa seeds, is purported to be effective for arthritis when applied topically. Poison ivy is often used for skin problems when given in the dilution prescribed by homeopathy.²

HOMEOPATHIC VS. HERBAL REMEDIES
     Homeopathic and herbal remedies are not the same thing. Though many homeopathic remedies are based on herbs or other ingredients, they are then diluted until there is only the smallest, if any, amount of the original substance left. Herbal remedies are millions of times less dilute and differ in the way they are prescribed. Homeopathics are given according to the law of similar (the remedy produces the same symptoms as the patient is already experiencing). Herbal remedies are given like conventional medications. Alternative medicine practitioners may produce their own remedies or purchase them from a health store. Many of these mixtures contain a stronger concentration than is found in true homeopathic medications.

     An example of this difference is the onion. Onions are used homeopathically for treating hayfever, as inhaling onion fumes produces symptoms similar to hayfever. In herbal medicine, onions are used for their antioxidant properties in treating colds and flu.

     Let's return to our opening scenario:

     The patient is having a seizure. You have established an IV and administered 5 mg of Valium, which has proven effective in stopping the seizure, and O2 is in place via NRB at 10 LPM. The patient has been rapidly packaged using full spinal immobilization, and rapid transport to the nearest trauma center is determined. The airway remains patent; however, you are prepared to intubate if necessary. While en route, you expose the patient and perform a full head-to-toe assessment.

     You find no swelling or deformity to the head or neck, and breath sounds are clear and equal bilaterally. You note swelling and bruising over the right side rib area, with numerous abrasions and crepitus present. Previous deformity to the right shoulder is noted; however, you also notice what appears to be a poultice applied over the joint. The abdomen is soft with no bruising noted, the pelvis is stable, swelling and ecchymosis are present on the right thigh with no deformity and pedal pulses are present bilaterally. There is no injury noted to the left upper extremity, but there is previously noted injury to the right shoulder, with additional contusions and abrasions on the lower right arm. Radial pulses are present bilaterally. You remove the poultice to expose the injury below, noting an ointment residue over the shoulder. You place the poultice in a biohazard bag to give to the ED physician.

     Reassessment of vital signs determines a blood pressure of 110/68; RR 16 shallow; HR 122; skin flushed, hot and dry; Sp0₂ at 94%; and a temperature of 101.7°F. The patient begins to regain consciousness and appears confused but is no longer hallucinating. You are giving a second fluid bolus of 250 cc. The patient is complaining of pain in his right shoulder and continues to be confused over previous events.

     Upon arrival at the ED, you transfer him into the care of ED staff and provide a follow-up patient report. At that time, you also turn over the bag containing the poultice and the bottle of medication the patient's administrative assistant gave you. As the ED physician listens to your report, he begins reading from the bottle. As you reach into the bag to get the poultice, he notices you have taken your gloves off and stops you from taking it out.

     You are completing your documentation when the ED physician returns from his initial examination to explain that the medication the patient has taken was most likely not a homeopathic dilute, but an herbal mixture that contained belladonna alkaline. He further explains that belladonna, a natural form of atropine, can be used for a variety of ailments. In this patient's case, it was applied externally and ingested orally to relieve the inflammation and pain from the injuries he sustained in his accident. Belladonna will cause an anticholinergic response of warm, flushed skin with dry mucous membranes, fever and dilated pupils. In the case of extreme toxicity, seizures are possible. He further explains that as true homeopathic medications are usually diluted to the point of having the extract undetectable in the final product, this medication appears to be an herbal mixture that is many times more concentrated. Examination of the poultice determined the ointment on the poultice and shoulder was a topical mixture containing belladonna. In this case, the patient had received an overdose of belladonna through the internal dose and external absorption of the ointment. The physician stresses that belladonna in an ointment base is easily absorbed through the skin, and anyone who touched the poultice without gloves could have also gotten a dose.

     He commends you for removing the poultice, therefore eliminating any additional absorption, as well as treating the patient for both anticholinergic toxicity and a possible traumatic brain injury. He tells you an easy way to remember the signs and symptoms of anticholinergic toxicity is: "Hot as an oven, dry as a desert, red as a brick, mad as a hatter, blind as a bat."³

     Later that night, you call the ED to check on the patient and are told he had a severe dislocation of the right shoulder, as well as several fractured ribs on the right side. No other serious injuries were found and the CAT scan of his head was negative for a TBI. The patient was admitted to further monitor the toxicity and is responding well to fluid therapy with full mentation at this time.

SUMMARY
     Homeopathic medications and treatments are becoming increasingly popular in this day of modern medicine. Patients are often unable to tell us if they are taking homeopathic or herbal therapy, or they don't think such treatments are important to mention. The continued growth and use of alternative medications indicates a strong need to ensure that patients include these treatments and medications in their responses during the SAMPLE history assessment. EMS providers must look at the whole scene for clues indicating a response to alternative medication. Being familiar with homeopathic medicine and herbal medications, as well as asking specific questions regarding use of alternative medicine, ensures a complete and comprehensive patient assessment followed by appropriate interventions in the prehospital setting.

References

1. Barrett S. Homeopathy: The Ultimate Fake, www.quackwatch.com.
2. Brill S. Poison Ivy & Its Relatives: Identifying & Harvesting Edible & Medicinal Plants in the Wild (and Not So Wild) Places. William Morrow Publishers, New York, NY, 1994.
3. Belladonna Poisoning Associated with an Herbal Tea (Tisane) (Mate, Yerba Mate), New York City, 1994, www.nobleharbor.com/tea/health/belladona.htm.

Bibliography

1. ABC Homeopathy: Introduction to Homeopathics and Remedy Finder. www.abchomeopathy.com/homeopathy.htm.
   "Belladonna (Atropa belladona). History and Description of Belladonna" www.a1b2c3.com/drugs.
   Brain Trauma Foundation. Prehospital Management of Traumatic Brain Injury.
   Brill S. "Jewelweed-(Impatiens species)." Identifying and Harvesting Edible and Medicinal Plants in Wild (and Not So Wild) Places. William Morrow Publishers, New York, 1994.

2. Grieve M. "Nightshade, Deadly"—A Modern Herbal, www.Botanical.com

3. IPCSINTOX Databank. Dr. J. Szajewski, Director, Warsaw Poison Control Centre.

4. Jonas WB, Kaptchuk TJ, Linde K. A critical overview of homeopathy. Ann Intern Med 138(5): March 2003.

5. Stehlin I. "Homeopathy: Real Medicine or Empty Promises?", www.fda.gov.

6. Wesley Ogilvie, MPA, JD, EMT-B, Austin Texas, Initial Scenario.

Julie (Jules) Scadden, NREMT-P, PS, is an EMS instructor from Iowa, as well as a staff paramedic and CQI/IT/Data Coordinator for Sac County Ambulance. She is a founder and past secretary of the National EMS Museum Foundation, and has served on numerous boards and committees advocating for EMS. Jules has presented at regional, state and national EMS conferences and is currently coauthoring Fundamentals in Basic Emergency Care, third edition.