GODZILLA MEETS THE LITTLE RED HEN

?

Godzilla Meets the Little Red Hen

Or, the Prescribing Cascade Meets the Bedside Observer

Johanna TrimblePatient Representative

Sponsored by: Community Engagement Advisory Network, Vancouver Coastal Health Authority

Member:World Health Organization Patient Safety Champion

BC Patient Voices NetworkPatients for Patient Safety Canada (CPSI)

The Characters

GODZILLA

Sometimes known as…

• The Prescribing Cascade• Polypharmacy (stand-alone risk)• Overmedication (dose, treating test)• Too many (9 drugs average in RC, 0-55)

The Little Red Hen

Sometimes known as…

• The family member• The friend• The puzzled visitor• The staff member• The bedside observer

Fervid Trimble, the patient

Fervid’s admission to the Health Centre

• After a ‘flu and dehydration episode, admitted to the Health Centre for a few days recuperation

• Instead she became bedridden, confused, delirious, unable to recognize family plus other puzzling symptoms

• SSRI anti-depressant had been prescribed• Other drugs had been changed or prescribed

Why is this not making

sense!??

Trust your instincts and press for answers

Hmmm, I wonder if

it’s the drugs?

Why don’t we ask questions of the professionals?

• “They’re the professionals, they must know” – Wrong! they know medicine -- you know the patient

• “They’re busy and we’ll annoy them” – Wrong! this is your loved one, make an appointment!

• “We’ll make them mad and they’ll call us difficult and take it out on her” – Wrong! Do your research, be clear, respectful and persistent

• “I’m part of the team!” – RIGHT! You can help because you’re nearby observing, comparing against baseline and asking questions.

Fervid’s “family care team”Johanna, Dale, Fervid and Kathie

I’ll consult my sources…

I used the internet…reputable sources only!

Another UTI? What

the…!?

Serotonin Syndrome:

SSRI antidepressant (citalopram)

+Tramadol (serotonergic pain medication to replace Vioxx)

= Unrecognized serotonin syndrome

UTI or Serotonin Syndrome?

• Fervid was repeatedly prescribed antibiotics for urinary tract infections

• Delirium, elevation of white blood cells, frequent urination and fever of SS mistaken for a UTI

• Now we’ve got lots of antibiotics prescribed and eventually we’re going to see c. difficile

Treating UTI’s and c. difficile

• Starting to be addressed in BC• Both VCH and Fraser Health are

working on improving UTI treatment protocols to address antibiotic overuse & c. difficile

Serotonin Syndrome

• Symptoms include cognitive, autonomic and somatic effects & range from barely perceptible to fatal

• Clonus, hyperreflexia and flushing are the most specific signs.

• Fervid was delirious, making unexplained repetitive arm movements (clonus), sometimes “asleep” and we couldn’t wake her

Fervid’s Prescribing Cascade

Unrecognized drug adverse effects, symptoms of Serotonin Syndrome, were treated with additional drugs as if these symptoms were new conditions.

DIGOXIN!? But the rapid heart beat was caused by the the drugs...!?

A Common Mistake? Fervid’s Cascade:

• SS onset can be either dramatic or insidious making it harder to recognize

• Symptoms of SS were treated as a common UTI (with nitrofurantoin, Beer’s list antibiotic)

• Rapid heartbeat, symptom of SS, was treated with heart medication digoxin (Beer’s list)

• Delusions, hallucinations, confusion were about to be addressed using Aricept

• The family declined it and any other prescriptions unless consulted first.

ARICEPT!? But this delirium

was caused by the drugs...

What the…??

A picture is worth a thousand words…

Over-medicated After the “drugectomy”

Being bedridden resulted in loss of function, Fervid could not return to independent living!

Here we go again…

Yes, it can happen twice…

• 3 years later Fervid was admitted to hospital with a stomach bleed

• Several new drugs prescribed in hospital• On return, confusion and delirium ensued• A new doctor prescribed remeron (serotonergic) • Symptoms of SS started JUST like 3 years ago • Antibiotics were prescribed “for UTI” -- again• Remeron was stopped and Fervid quickly returned

to normal

Polypharmacy & c. difficile

• Fervid had many antibiotic treatments for UTI’s or respiratory infections

• Probably other residents did too • 5 other residents had c. difficile• Cleaning & infection protocols substandard or

inconsistent• Frequent transfer of staff and patients• 5 or 6 courses of vancomycin weakened Fervid greatly• No fecal transplant offered except in Australia

Fecal transplant in 2008? (only in Australia) Now, in 2013, it is in the news:

• The US Centers for Disease Control has issued an urgent plea for fecal transplant donors after the recent studies show its efficacy

• After much deliberation, CDC Vice-Director Dr. Steven Gerrard has announced that the drive for fecal donors is being launched with the slogan:

“Save a life. Get your shit together.”

C. difficile

• Fervid may not have died OF c. diff but she was greatly weakened and died WITH c. difficile• The important factor is the overuse

of antibiotics and the growing resistance of organisms

Let’s DO SOMETHING about

polypharmacy!

BC Polypharmacy Initiative (Shared Care)www.bcma.org/polypharmacy-initiative

“It’s (about) quality of life…for my residents. I've seen dramatic differences in the quality of their life when the BURDEN of their medication is reduced...”

A picnic in the garden with Fervid

Dedicated to Fervid Trimble 1917 - 2008

Contact:johanna@daletrimble.com