Sticks in the Throat: Boxology

Editorial Note: This is a follow up post from John Scheel to his Sticks in the Throat piece earlier in the week. The theme here fits very well with two posts in the last week on davidhealy.org – Guilty and Psychiatry Gone Astray by Peter Gøtzsche.

Often in life it is the very simple things we overlook and when tradition and protocols and procedures get locked in people are reluctant to go back to rethink them in light of technological changes or new information. Pill administration is akin to walking – no one tells you how to walk as it comes naturally. The act of providing medicine in itself is overwhelmingly a good thing and completely washes over how the pills are actually given.

The implications below are a logical fallout of what happened to me. Governments and consumer lobby groups try to push problems like I encountered into adverse reactions when in fact they are nothing of the kind. Pharmaceutical firms just sit in the bushes – the more confusion the better. These firms know that pills are badly administered but do not want to make waves for fear that less pills will be given if a rigorous “take with 8oz of water” program is created.

Implications

1)  While pills such as Plavix may do wonders for the body’s acceptance of stents, when badly administered they can cause all kinds of havoc. Properly ingested, Plavix may cause nausea or skin rash but unlikely will cause ulcers in an esophagus.

2)  I was told by Health Canada and a consumer group to file drug reaction complaints against Plavix. That would have been wrong. Drug manufacturers should be up in arms on reading this. So should Health Canada which approves the drugs (but not the way they are taken!). It may not always be adverse drug reactions that are at the root of problems – it could be the way they are physically delivered!

3)  In my case once the initial damage had been done, my body’s ability to repair the ‘ulcer’ was hindered by the Plavix/ASA which prevented platelets from coagulating and protecting the damaged area. The ability of a body to effect repairs depends on the mix of drugs continued by patients.

4)  Credible web sites (e.g. Mayo Clinic) are emphatic about pill administration:

• Drink an entire glass of water with a pill (unless you’ve been told by your doctor to restrict your fluid intake because of another condition, such as kidney disease)
• Sit or stand for at least 30 minutes after taking a pill

Many medication administrative procedures never mention “water” at all. They are so preoccupied with patient identification and rights, verification of pill and dose, liability, etc., that they don’t address the actual pill-giving/taking routine. The word “water” appears nowhere in these procedures.

5)  Our hospitals have become very cavalier and nonchalant about actual pill administration practice which is usually handled by the least-trained nursing staff. Further, rarely did I see or have anyone run the various drugs I was taking to identify drug interactions.

6)  Once ER and ward patient care protocols are established, they are accepted as gospel and rarely if ever challenged. Why? They protect staff rather than patients. Even though hospitals sell protocols as being there for patient safety, as long as a doctor or nurse follows a protocol, he/she cannot be questioned whereas departures from protocol can lead to liability. There is no reason to use logic when it takes the decision maker away from the protection of a protocol i.e. why take a risk?

7)  Protocols are rigid – they may not have caught up to current medical technologies, take into account recent patient records or even prior relevant findings.

8)  Despite asking for generalist input, I could not get away from the cardiologists. Specialists have a limited range of interests and experience, especially when bounded by time constraints. It was impossible to escape the protocol loop I was forced into. I was trapped in a vicious game of “snakes and ladders”. We need more Dr. House types to stand-back and rethink problems.

9)  Once “branded” as a heart patient, there was nothing I could do. Doctors refused to read my typed “symptom” notes. The protocol system is so rigid that getting a different viewpoint was impossible. Being in the hands of specialists can prove disastrous when your problem is not of their understanding and experience. In my case the doctors focused 100% on my heart, tested and blessed it and believed they had provided good service. Their consciences were 100% clear.

10)  Where protocol has overwhelmed sanity, people face continued suffering which is often minimized with a blanket of secondary medicines to relive pain, nausea, etc. Many who cannot think or fight for themselves end up in mysterious negative health spirals. They are openly cared for but without a proper understanding of the causes.

11)  While my estimated treatment costs have exceeded 50 times the initial procedure cost, I may have continuing detrimental effects (e.g. Barrett’s Esophagus). Maladministration of drugs can have life-long costs in both dollars and patient health. Think of my problems as an annuity fed by an initial medical error. One “man-made” disease like mine leads to other real ones e.g. esophageal damage causes high pain causes high blood pressure causes strokes or organ failure as well as brings on a whole variety of compensating medications each of which comes with its body damaging adverse reactions.

12)  In Canada under the BNA Act, the Federal Government controls drug efficacy and acceptance while provinces establish protocols, procedures and health care worker norms. Adverse drug reaction reporting means little to provincial ministries as they have no responsibility while issues with protocols mean nothing to Health Canada. The overall system is therefore full of holes.

13)  Adverse drug reporting systems are so general and privacy conscious that they are almost unusable, save for generating dated and suspect statistics. Reports by doctors, drug manufacturers, patients and others are either voluntary or biased or replete with errors and purposeful cover-up misinformation. The government simply passively transcribes what it receives. Another Thalidomide disaster is looming. Using passive, limited, biased data and slowly building history to flag drug recalls is a drug manufacturer’s dream control system, especially when their input goes in 100% as written without questions.

14)  The many patients who lay on their backs 24 hours a day are at huge risk from bad pill etiquette. Bedsores won’t kill them – pills will. Such patients usually do not or cannot drink sufficient liquids at any time. Any pills which get “stuck” in the throat/esophagus will do more latent damage than the good they are intended to provide.

15)  Anyone with aged parents in Long Term Care facilities should investigate how those parents receive their medications. Be there, watch and leave written instructions e.g. 1 pill session needs 8 oz. of water.

Editorial Note: From Government to Education, Ticking Boxes is the Zeitgeist. Health is at particular risk of descending into Boxology because of its focus on diagnosis. Diagnoses are useful when they help make someone more functional. But as these two pieces by John Scheel show, the goal is to make people functional not to get the label right. To serve them rather than serve the system.

The temptation at the end of this piece was to add another box to the list. But this defeats the purpose. We’d like comments from anyone who can see how to save us from being Boxologists.