In Reply to Drs Fink and Brant-Zawadzki

To the Editor:

We would like to thank Drs Fink and Brant-Zawadzki ¹ for their interest in our recently published case report. ² We appreciate their critique and agree with many of their points but would like to address these further. Although not specifically mentioned in our initial report, informed consent was obtained from both patients. It is also worth mentioning that the care described in the report occurred in a region of significant geopolitical instability, military rule, and natural disaster, which provided additional restrictions in an already resource-limited environment.

The first concern expressed by Drs Fink and Brant-Zawadzki was regarding the tinnitus experienced by both patients. This adverse effect was transient and is considered to be a minor one that occurs at low serum lidocaine concentrations. ³ We agree with both the author and current guidelines that during administration of systemic lidocaine, it is ideal to have lipid emulsion available for the treatment of local anesthetic systemic toxicity (LAST). As mentioned in our report, since temperature control was not available, a supply of lipid emulsion could not be maintained. To further reduce the risk of LAST in these cases, a low-dose infusion of 1 mg·kg⁻¹·h⁻¹ was used. Previous literature suggests that much higher infusions rates have been safely used. ⁴

Clinicians must acknowledge that the constraints of a humanitarian crisis or resource-limiting healthcare crisis often alter the risk-benefit ratio of various interventions and force providers to change their practices to conserve resources. ^{5 -7} In fact, the US Department of Health and Human Services recognizes that the challenges provided by such situations often require “altered standards of care” in order to do “the greatest good for the greatest number” while respecting each patient. ⁸ Additionally, the American College of Emergency Physicians best defines these “altered” standards of care as crisis care. Crisis care is the management that a reasonable practitioner would provide given the present resource limitations. ⁹ Equitably, these 2 cases occurred in a complex protracted humanitarian crisis setting in which resource limitation and resupply uncertainty forced the healthcare providers to use reasonable alternatives to conventional analgesic techniques.

Recently, there has been wide recognition of the need for ethical guidance on crisis standards of care as part of disaster response plans. ⁸ At the very least, the Sphere Handbook, an internationally recognized tool for delivery of minimum humanitarian standards, sets a framework for crisis standards of care on a global scale. ¹⁰ These standards were met in these 2 cases, but more ethical guidance is needed on the international scale. When describing health systems, this tool suggests that even medication management practices may need to be adapted to the emergency context as they were in the case report. Currently, the precedent of whether a particular treatment has ethical worth is probably best set by national law, local healthcare providers, and hospital policy as long as it exceeds the minimum standards set by the Sphere Handbook.

The second concern described was that appropriately applied regional anesthetics would have likely provided effective analgesia with fewer risks. As stated in our report, neither of the providers present at the clinic had the training or experience required to safely perform these procedures. Moreover, procedures such as the intercostal block are certainly not without risk; it is a procedure with a high rate of systemic absorption of lidocaine ¹¹ and an incidence of pneumothorax that may be >5%. ¹² When weighing the risks and benefits of various analgesic modalities while also considering patient safety, provider training, and resource constraints, the providers felt that using intravenous lidocaine was the most suitable option for these patients.

Last, we would like to restate the closing message from the discussion in our initial report. We do not currently support the widespread use of systemic lidocaine in austere and resource-limited environments. Instead, we merely suggest that further investigation might determine a safe method for employing this alternative analgesic modality in such settings when other options have limited availability.