Time to restock the doctor’s bag

Editor, – The National Health Act 1953 made provisions for certain drugs to be provided to prescribers, which in turn could be provided to patients free of charge in emergency circumstances. The most recent update to this list was in May 2010, when methoxyflurane was added.

The article by John Holmes (Aust Prescr 2012;35:7-9) suggests that the list is outdated. Many drugs listed are no longer first-line treatments for specific emergencies, and special populations are not considered.

An excellent example of this is the failure to include parenteral magnesium sulfate for an eclamptic seizure. Eclampsia is uncommon with an estimated incidence of 1 in 2000 maternities. When it occurs it is associated with high maternal morbidity and mortality.

Magnesium sulfate is a safe and effective therapy that reduces morbidity and mortality when given to a pregnant woman who is fitting due to eclampsia (National Health and Medical Research Council level I evidence). Multiple high-quality systematic reviews have compared magnesium sulfate with other treatments for eclampsia such as lytic cocktail (chlorpromazine, pethidine and promethazine), diazepam and phenytoin. These trials demonstrated that magnesium sulfate was more effective than historical therapies and when compared with diazepam, it reduced the risk of maternal death.

Some drug choices do not matter, but in the case of a pregnant woman with pre-eclampsia who is fitting, giving the best available drug may save her life. Magnesium sulfate is not available in the current emergency doctor’s bag. We submit that it should be.

Lachlan F Miles
Anaesthetic registrar

Alicia T Dennis
Director of Anaesthesia
Research Staff specialist anaesthetist
Clinical associate professor University of Melbourne
The Royal Women’s Hospital
Melbourne

John Holmes, author of the article, comments:

I agree that magnesium is the treatment of choice for eclampsia. However, in my view it does not meet criteria for inclusion in the doctor’s bag. Magnesium is not necessarily as safe as Drs Miles and Dennis state – excessive blood levels of magnesium may be associated with respiratory depression or cardiac conduction abnormalities. This would contravene the principles that the safety of drugs available in the doctor’s bag should be commensurate with the skills of general practitioners and should be administered only in settings where there are appropriate monitoring and resuscitation facilities.

Further, it could be argued that general practitioners are highly unlikely to be treating full blown eclampsia in the community. Even in home birth situations it is likely that patients with signs of pre-eclampsia would have been transferred to hospital well before progression to convulsive eclampsia was likely.