VMC

VMC
VMC Renton, Washington: where death happens and no one seems to care

THE OTHER TOXIC MEDICATION ERRORS

VMC ICU Doctors and their Pharmacy should have understood all the toxic drug interactions that would occur with Mark – they didn’t. Why not? Maybe they need to go back to community college and take a refresher course?
   
The below is a detailed list of medication errors VMC made. This is not a complete list (Per VMC “Again, it may be the nurse did not give it for some reason or that the nurse did not remember to record it on the MAR (Medication Administration Records – the best information on what drug the patient received and when).

VMC’s shotgun approach to not only administering the wrong antibiotics (Dr. Michael Hori was said to be in charge of antibiotics) but for administering medications that caused Mark’s liver to fail is appalling. I counted every entry of a medication VMC billed us for – 2599 entries costing $293,790.98.

Is VMC and/or their doctors involved with the pharmaceutical industry in some way? I’ll be checking this out to ensure a conflict of interest doesn’t exist.

As a sample of what you will be reading in this section:

Antibiotics stopped when the “new bug” Pseudomonas is found

December 10: Dr. Michael Hori stops by I ask if the Tracheotomy cultures came back, he says they are positive, I ask if it’s the same bugs in his lungs, he says yes. I find out the next day from Dr. Richard Wall that it is a new bug pseudomonas, not the same one as told to me by Dr. Michael Hori. Dr. Michael Hori tells me that these bugs are common in patients that have been in the hospital for many days. Antibiotics are now off. Why on earth did Dr. Michael Hori stop the antibiotics? 

December 10: Dr. Frank Fung comes back by this time looking very concerned at 2:20 pm. I ask Dr. Frank Fung earlier why the antibiotics were stopped when they found Pseudomonas growing in the Tracheotomy culture. Dr. Frank Fung leaves, calls Dr. Michael Hori, then comes back and says they will start the antibiotics again.

Drugs that can cause Pancreatitis – Gallstones / Contraindicated

Note that on November 26 VMC performs an ultrasound that documents Mark has gallstones (a major cause of pancreatitis - Mark does not drink alcohol). None of the VMC ICU doctors read this report. When VMC finally gives me some of Mark's medical records (after telling me to get a lawyer to procure these - then they finally give me because I call a lawyer from Mark's room) I locate the record and show them.

In a meeting with
Dr. Richard Wall on December 21 (he wants to put Mark on comfort care and end his life - remember Mark wakes up within hours of this happening) we discuss having a private autopsy. Dr. Richard Wall states "it would be interesting to find out if there was in fact a gallstone that caused the pancreatitis." He never bothered (like all the other VMC Doctors) to read the ultrasound report.

Gemfibrozil (December 5 to January 15) treatment should be discontinued if gallstones are found (gallstones found November 26). Pancreatitis, abnormal blood liver tests, as well as reduced red blood cells (anemia), white blood cells (leukopenia) and blood platelets (thrombocytopenia) also have been reported. Gemfibrozil is a 2C9 inhibitor.

Note: Dr. Frank Thomas tries to discontinue this drug, a drug contraindicated with pancreatitis/gallstones, his orders are ignored.

Metronidazole (November 23 to November 27; December 12 to December 16; January 7 to January 16) Metronidazole is a 2C9 inhibitor,

Fluconazole (November 30 to December 1) Fluconazole is a 2C9 inhibitor.

Quetiapine (December 29 to January 14)

Ondansetron (November 9 to November 10; November 19)

Pantoprazole (November 10 to November16)

Propofol (December 2) and others have all been associated with causing pancreatitis.

Why did the VMC doctors prescribe drugs contraindicated with Pancreatitis and Gallstones? Why didn’t the VMC pharmacy prevent this from happening? Why is there no check and balance system between what the doctors prescribe and what the pharmacy allows for the safety of the patient?

2C9 Inhibitors given to Mark

Cytochrome P450 2C9 (CYP2C9): Mark is a documented poor metabolizer and should avoid Inhibitors (this if for liver metabolism). As an example, if one drug inhibits the CYP-mediated metabolism of another drug, the second drug may accumulate within the body to toxic levels.

I try to give the following doctors Mark’s 2C9 genetic study:

November 17: I show
Dr. Suzanne Krell the CYP2C9 genetic study; she is not concerned with it and doesn't want a copy.

November 20: I show
Dr. Stefanie Nunez the CYP2C9 genetic study; she reviews and gives it back to me.

November 24: I show
Dr. Michael Hori the 2C9 genetic study; he says this has to do with psychiatric drugs.

November 30:
Dr. Michael Hori to start Fluconozole; On my way home I think about the 2C9 genetic test and think about the Fluconozole the nurse just started. I race home, verify that Fluconazole is a 2C9 inhibitor, then call the nurse and ask her to stop the iv and call the doctor. She does.

December 1: Fluconozole is given to Mark again, per the bill. Michele Bohl, the Social Worker, tells me later this day that
Dr. Richard Wall said the 2C9 was brought up in daily rounds and that Dr. Richard Wall said it has to do with transplant and immunosuppressive drugs. Dr. Richard Wall is wrong and I correct him in the daily rounds the next day. Mark is not on immunosuppresives (they would know this if they looked at his medications THEY were giving him). I see Dr. Michael Hori this morning - he will not make eye contact with me and does not come to Mark's room while I am there.

December 1: The VMC pharmacist calls me and wants copies of the 2C9 because they are significant.

December 8: I show
Dr. William Park the CYP2C9 genetic study; he does not look at it.

The following 2C9 inhibitors/inducers were given to Mark on the following dates:

Fenofibrate inhibitor (prescribe by Swedish
Dr. Robert Winrow before VMC hospitalization)

Fluconazole inhibitor November 30 to December 1 (prescribed by VMC): the VMC hospital bill also shows that they give Mark this the very next day.

*Gemfibrozil inhibitor December 5 to January 15 (prescribed by VMC)

Dexamethasone inducer December 26 to January 17 (prescribed by VMC)

Metronidazole inhibitor November 23 to November 27, December 12 to December 16, January 7 to January 16 (prescribed by VMC)

*Note (from above): Gemfibrozil is not removed by hemodialysis and is a 2C9 inhibitor.

Dr.’s
Michael Hori, Lindy Klaff, William Park and others ignore the 2C9 inhibitor study and prescribe medications Mark should not have received - Why didn’t the VMC pharmacy prevent this from happening?

Drugs contraindicated with abnormal liver function tests, disease

Metronidazole is extensively metabolized by the liver to both pharmacologically active and inactive compounds. Therapy with metronidazole should be administered cautiously at reduced dosages in patients with severe liver disease. Metronidazole is a 2C9 inhibitor.

Gemfibrozil: Those who have severe kidney or liver disease or abnormally high liver enzymes should not be prescribed Gemfibrozil at all. Gemfibrozil is used for reducing elevated triglyceride levels that are high enough to cause pancreatitis. Pancreatitis, abnormal blood liver tests, as well as reduced red blood cells (anemia), white blood cells (leukopenia) and blood platelets (thrombocytopenia) also have been reported. Gemfibrozil is a 2C9 inhibitor.

Dexamethasone (December 26 to January 7): Contraindications: Bacterial, viral, and fungal disease may progress more easily and can become life-threatening. Dexamethasone is known to cause elevated liver enzymes, fatty liver degeneration (usually reversible), muscle atrophy, negative protein balance (catabolism). Dexamethasone is a 2C9 inducer.

Ondansetron (November 9 to November 10; November 19): Hepatic side effects have included mild elevations of liver function tests. The clinical significance of these elevations is unknown. Cases of jaundice have also been reported rarely. One case of pancreatitis was reported in a patient using ondansetron long-term.

Pantoprazole (November 10 to November 16): Common side effects of Pantoprazole may include headache, nausea, insomnia, vomiting, and abnormal liver function tests.

Drugs contraindicated with dialysis patients

Zosyn (November 11 to November 16; January 3 to January 11):

WARNING: Prescribing Zosyn (piperacillin and tazobactam) in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of development of drug-resistant bacteria. This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Nosocomial pneumonia caused by P. aeruginosa should be treated in combination with an aminoglycoside.

Note 1: Zosyn is started on November 11 BEFORE any bacteria is found (from blood cultures, etc.)

Note 2: January 3 is the only day Mark is given Zosyn with an aminoglycoside (Amikacin).

Gemfibrozil is not removed by hemodialysis. If you have severe kidney disease, gemfibrozil can make your condition worse. Therefore, it's recommended that you do not take gemfibrozil if you have severe kidney disease.

Hydromorphone/Hydrocodone Use cautiously and monitor patient carefully for symptoms of opioid overdose. The parent drug can be removed, but metabolite accumulation is a risk.

Fentanyl appears safe. Metabolites are inactive, but use caution because Fentanyl is poorly dialyzable.

Respiratory and Blood Pressure Depression
VMC doctors continually told me that Mark was having problems maintaining his blood pressure and was unable to be weaned off the ventilator. I wonder why (after reading the below):

Dilaudid (hydromorphone) and MAO’s: CONTRAINDICATED: may rarely result in hypotension, respiratory depression, or coma. Do not take Dilaudid with other narcotic pain medications, sedatives, tranquilizers, muscle relaxers, or other medicines that can make you sleepy or slow your breathing. Dangerous side effects may result. Alcohol, other Opioids and Central Nervous System Depressants (Sedative-Hypnotics) potentiate the respiratory depressant effects of Hydromorphone, increasing the risk of respiratory depression that might result in death.

Lorazepam: can cause side effects that may impair your thinking or reactions. Cold or allergy medicine, narcotic pain medicine, sleeping pills, muscle relaxers, and medicine for seizures, depression or anxiety can add to sleepiness caused by Lorazepam.

Lorazepam and MAO’s: MONITOR: Central nervous system and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.

Fentanyl and MAO’s: Do not use Fentanyl if you have used an MAO inhibitor in the last 14 days. May rarely produce severe and potentially fatal adverse reactions. Side effects: agitation, headache, diaphoresis, hyperpyrexia, rigidity, hypertensive crisis, hypotension, Bradycardia, seizures, respiratory depression, hypotension, and coma. Death has occurred in some cases.

Fentanyl and Neurontin (Gabapentin): MONITOR: Central nervous system and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.

Midazolam/Versed: Among the medications that may potentially cause drug interactions with Midazolam are seizure medications, antidepressants, and antipsychotic medications. Some of these drug interactions can increase your risk of side effects, such as drowsiness, confusion, memory loss, or difficulty breathing. Midazolam is known to cause respiratory depression. In healthy humans, 0.15 mg/kg of Midazolam may cause respiratory depression, which is postulated to be a CNS effect. When Midazolam is administered in combination with Fentanyl, the incidence of hypoxemia or apnea becomes more likely.

Midazolam can decrease blood pressure and should be used with caution when a patient has low blood pressure, whether it is the cause of shock, sepsis or a normal state health for the patient. Versed is excreted more slowly in patients with diminished kidney function and may have longer lasting effects in those patients.

Midazolam/ Versed can also increase the respiratory depression effects of other medications, including opioids. Due to this respiratory depression effect, patients with respiratory conditions such as COPD may not be good candidates for Versed.

Morphine and MAO’s: Severe allergic reactions; confusion; disorientation; fainting; fast, slow, or irregular heartbeat; hallucinations; mental or mood changes (eg, agitation, exaggerated sense of well-being). Avoid taking Morphine if you have used an MAO inhibitor within the past 14 days.

Haldol (Haloperidol) and Fentanyl: MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.


3 comments:

  1. Anonymous1:39 PM

    fentanyl is pain medication, not a sedative

    ReplyDelete
  2. You must be in the medical profession and because you mentioned this I went back out to the internet and did some additional research on Fentanyl. What I have discovered is that VMC should have never given Mark Fentanyl because Mark had been taking a MAO inhibitor within 14 days prior to his hospitalization.

    I will add this into the Medication Errors section and bring up with the proper regulatory agencies. Thanks for bringing this to my attention.

    Dr. Krell told me that pain meds are also sedatives and I do believe her comment. Here is what the internet says about Fentanyl:

    Intravenous fentanyl is extensively used for anesthesia and analgesia, most often in operating rooms and intensive care units.

    Fentanyl is often administered in combination with a benzodiazepine, such as midazolam, to produce procedural sedation (or conscious sedation). Mark was also given the midazolam (Versed) which has similar drug interaction precautions listed.

    Fentanyl i.v. (intravenous) is very widely used method for both analgesia (pain relief) and anesthesia (sedation) for adult and pediatric patients.

    ReplyDelete
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