When bloopers aren’t that funny…

This is a follow on piece from the ‘Bloopers’ topic of the other night. One of the bloopers turned sour in a big way, so I thought I should complete the picture. I guess it shouldn’t be a shock that bloopers in healthcare aren’t too funny, mostly. Some are interesting, some awful, and a few hilarious; that’s about how it works out, it seems.

You know that guy I was telling you about, the one with shoulder bursitis? The one whose wife and daughter gave him too much ibuprofen and paracetamol unintentionally, dosing him every 4 hours on the hour for several days due to his excruciating pain without observing the 24 hour maximum doses because they weren’t told about it by their doctor? And obviously they weren’t told about the maximum doses by pharmacy staff either if they bought the medication in a pharmacy, or maybe they bought it from the supermarket; this is my strong argument that these “simple” pain killers not be available from the supermarket. I guess the family never read the packet either, although English as a second language was a factor here for the wife, but not the daughter. This is the patient who was brought into ED after he started coughing up blood as a side effect of ibuprofen which irritates the stomach lining. You’ll remember that the family who wouldn’t give him the stronger pain killer Endone in case he got constipated, but had given him toxic doses of weaker pain killers. The patient who is an example of people being given incomplete advice about how to take their medications, and blindly following that advice without taking any initiative themselves.

Well, he died.

I saw him Saturday, he died early Monday morning. I was shocked when I found out!! I knew what they’d done was bad, and that he was going to suffer the consequences, but I never expected him to die! Not that fast, certainly. I planned on looking up which ward he was in in Monday morning so that I could handover the story to the ward pharmacist, but then it said: DECEASED. I had to read it twice. I thought I’d picked the wrong patient. But no, deceased, 0600 hours, 16-4-2018.

Wow!

So I looked into it. And right there as the cause of death: acute on chronic renal failure precipitated by NSAID use. That’s non-steroidal anti-inflammatory drugs: ibuprofen (Nurofen), diclofenac (Voltaren) etc. Acute on chronic means he had a degree of chronic permanent kidney failure that couldn’t be reversed, not unexpected at 77 yo, but it was made acutely much worse by something, in this case medication.

There are a few things you can do to help reverse acute kidney failure: give IV fluids to flush toxins out, stop all medications that are toxic to the kidneys, manage blood pressure with medication and fluid so that the kidneys have optimal perfusion, but at the end of the day there’s only so much that can be done without the patient going to the intensive care unit and being put on dialysis. Once the kidneys go off, fluid accumulates in the body. This patient already had heart failure which causes fluid to gather around the heart and lungs, and the kidneys failing to clear fluid adds additional pressure on the heart. This was listed as the secondary cause of death: heart failure. In fact 4 causes of death were described in more detail than the overall cause as I’ve put it above, acute on chronic kidney failure precipitated by NSAIDs: kidney failure, heart failure, NSAIDS and age. Once the snowball got kicked off it gathered momentum from pretty much every other medical condition that the patient already had, unsurprising since the whole body is in a delicate balance. But if that trigger hadn’t been there…

In this case because of his age and many other medical conditions, the family did the sensible thing and let things be as they would be; and in this case death is what would be. It’s a shame that kind of common sense thinking hadn’t prevailed any earlier in the case. I feel like this death could be listed as preventable.

If a patient asks me generally whether ibuprofen is good for them, there are several medical conditions I’d want to be sure the patient didn’t have before recommending it: asthma, stomach problems like previous ulcers or gastritis and even reflux, heart failure and kidney failure. So the ibuprofen probably shouldn’t have been started in the first place; a steroidal anti-inflammatory like prednisolone would have been more appropriate. Although sometimes we say cautiously, take it but for no more than x days. Of course we then also tell the patient the maximum dose and how best to take it. In this case I’m pretty sure if you had asked the patient’s cardiologist or nephrologist before hand whether this man should have been given a NSAID they would NEVER have signed off on it.

Then maybe he’d still be here, a bit fuzzy headed or nauseous on Endone, taking paracetamol less regularly than actually happened, and blood sugars high from prednisolone, but alive, his bursitis improving and his life going on at home.

RIP.

I’m sorry the system let you down.

Bloopers

Sometimes you wonder what is going on in the world. A few things at work today made me shake my head.

[Edit: And I’m not exempt from bloopers, far from it. In photography as much as anywhere, as you can see!

 

An ED doctor called a renal physician, a specialist, asking advice about treating an immune compromised patient with antivirals. This was a perfectly reasonable request because the patient presented with severe diarrhoea which could be caused  by the cytomegalovirus (CMV) and to quote Australia’s Therapeutic Guidelines, the antiviral she wanted, ganciclovir, “is the cornerstone of therapy”. The specialist doesn’t sound like he really knew what he was talking about, or hadn’t come across the drug much before. That’s still no excuse for him to say, “just give her Tazocin, it covers just about anything”!! Tazocin is a broad-spectrum antibiotic that yes, does cover just about anything…bacteria-wise. It most certainly never has and never will treat viruses however, and if doctors are saying antibiotics treat viruses, how on earth can we expect our patients to be informed?? That was some poor advice!

Nick something-opoulos (name disguised for privacy not racism) keeps his meds in two Decor containers, one for the morning and one for the night. I was getting quite confused because it seemed that his medications were prescribed at weird and something plain wrong times…cholesterol tablet and warfarin being taken in the morning, anti-depressant and fluid tablets being taken at night, and others. I was about to go in there and have something to say, but lucky I asked a question first and found out that whoever went through the meds before me had inadvertently switched the lids. Obviously they didn’t realise how important it is to the patient that they are organised the correct way. Or how confusing and possibly dangerous it could be to have the meds prescribed at the wrong time if a health professional, like me, thought they were usually given at the wrong time and went with it, no questions asked. Luckily its my job to think about these things and we got it sorted. What could have been the consequences? Diuretics, frusemide in particular, are always given first thing in the morning so that the diuresis (fancy name for peeing out the excess fluid!) happens during the day, most particularly during waking hours. Diuresis with frusemide can be hard and past, patients often need to pass urine several times with urgency after taking their medication. Often patients won’t leave the house after taking it, or only if they go to familiar places where location of toilets are known, or they’ll skip it if they have to go out. It can be a significant nuisance. The aim of giving frusemide in the morning is to prevent patients needing to get up hurriedly and repeatedly to the toilet at night time which presents a falls risk, so its very rare to see patients take it at night; the first red flag. The second red flag was desvenlafaxine or Pristiq, an antidepressant, apparently being taken at night. It doesn’t have to be given in the morning but it is an energising medication that can cause insomnia so usually patients start taking it in the morning when its first prescribed, and maybe change it up of their own accord if it works for them to take it differently, but usually it stays as first prescribed. Next up is simvastatin, an anti-cholesterol medication, which must be given at night to work. Simple as that. That’s when cholesterol is manufactured from fats and being the relatively weakest drug in its class, it just must be given then so it can interrupt that process. Some others are stronger and can be taken any time. Then the last but no means least red flag, warfarin in the morning. It doesn’t have to be given at any specific time of day to be effective, but for practical purposes its always given at night. This way you can have your INR blood test taken in the morning, and there’s time for you to be contacted before your dose in case it needs to be increased or decreased. I have never seen a patient take it in the morning. So a whole lot of confusion made a whole lot simpler by switching lids on two containers!

But this was NOT the most confusing thing about this patient. This patient has bursitis of the shoulder and has been in intense pain for 2 weeks!! They’ve been seeing doctors and gradually getting a CT scan, then an xray, now awaiting MRI and has had a cortisone injection over that time. But the cortisone is slow onset and long acting so it hasn’t kicked in. They were told to take paracetamol (Panadol) and ibuprofen (Nurofen) every 4 hours, good advice, but not told to limit paracetamol to 8 tablets per 24 hours, or to limit ibuprofen to the same. This was a massive oversight!! Yeah, sure, it “only” Panadol, and “only” Nurofen but this is exactly how accidental paracetamol poisoning happens. As it turns out this is also how gastritis develops with the patient coughing pink-tinged mucous suggesting stomach irritation and low grade bleeding, VERY bad for a patient on warfarin, a blood thinner; this could get out of hand!! And he’s suffering now not only from bursitis pain, but gastric discomfort and bloating!! Great! Good healthcare. But wait, there’s more!! As I was walking out, the daughter tells me they were also prescribed oxycodone (Endone), a morphine derivative on Tuesday. This is great news, so how has he been going with that? Oh we never gave it to him. Um, why? Excruciating pain, 2 weeks worth, needing paracetamol/ibuprofen every 4 hours?? “Oh we thought it might be constipating”…

…Wait. Let me get this straight. You’ve been telling me how terrible its been watching your father in such bad pain needing pain meds so often…and you withheld medical treatment for 5 days because it might cause constipation;?? That might not even happen!! Excuse me for being incredulous!! Bar one or two, every single treatment for constipation is found on a shelf in your local pharmacy. Most of those are found in your supermarket!! You might never need them, but do have access to them 24 hours a day anywhere across Melbourne. So just give the drug! I think I communicated this point adequately. The daughter then back tracked and said she was worried about addiction!! Seriously, you haven’t given a single dose, and you’re worried about dependence which takes weeks or months to develop, if it does at all while you watch your father writhe!!! It was all I could do to not strangle her!! So because you never gave the drug, he ended up first with a cortisone injection (usually last resort) probably because the doctor thought you’d tried and failed with Endone which you hadn’t, and now he’s being hospitalised because he’s in too much pain, because you didn’t give the prescribed medication!! Constipation, dependence, these are issues that we can work through as we go along. Failing to give appropriate medication, withholding medical treatment; health professionals have been de-registered for these crimes. Yet people in their own homes can get away with it any old day!! What a scandal! If this were a nursing home or hospital it would be labelled “elder abuse” and there would be an investigation and heads would roll!

I shake my head!