It was September 24th at 12:45AM, one week from end of chemo cycle-7. I was in the Emergency Department (ED) at Albany Medical Center in a corner room staring at a sign with the room number 3A4/5. For any pharmacy nerds, I’m thinking; Is that where they put drug interaction disaster patients, considering that over 20% of all hospital admissions are to medication issues. If anyone is interested in this private joke, look up cytochrome P450 3A4/5. I was behind a curtain in the corner room, and when I walked in, it looked like there was a mass shooting – blood on the walls to the right and left, and puddles of blood beneath my feet everywhere.
One hour and thirty minutes earlier, I was carefully walking my father to the top of our home staircase, his “wife” of 16 years following behind us. We’ll call her “Dee”. I heard a shout out, and when I turned, I was watching Dee fall from the top step as she continued to slide down the entire staircase. It reminded me of the sled scene in Home Alone when Kevin McCallister rode his sled all the way down the staircase and out the opened front door. But for Dee, she was not on a sled, she was on her back, faceup, and her spine was the sled. I’ll spare you the gory details, but she did not hit her head at the end. There was lots of blood, bruising, three good size gashes including one on her forehead, and a broken nose. My wife Robin called 911 as I carefully stabilized her head and kept pressure on the forehead wound to stop the continuous flow of blood.
When the police and ENTs arrived, the first thing that happened following a neck brace was to clamp the nose to stop the additional nosebleed. If any readers are trauma clinicians, I sure would like to know the reasoning behind that versus a few sprays of oxymetazoline into the nose. My concern here would be swallowing a lot of blood (especially since Dee was receiving a blood thinner). Upon presentation to the ED, guess what happened? Dee was turned to the left. Positioning made her nauseous probably because of head trauma and a belly full of blood (hmmm – nose clamp). This caused a projectile bloodbath to all the cabinets and glass windows on her right. She was then turned to her left; guess what? Yeppers, blood bath to floor and left wall. God bless the nurses that were there to help Dee! Seriously, to any clinicians that do emergency medicine or critical care, if I’m missing something here regarding that nose clamp, pleased teach me and the readers.
Short Lesson: If you have a wound that won’t stop bleeding (typical on fingertips – like a knife cut), any drug that has a catecholamine ring structure (think epinephrine / adrenaline), will stop the bleeding almost immediately. Examples of such medications are oxymetazoline and tetrahydrozoline nasal sprays, albuterol asthma inhaler or nebulizer solution, tetrahydrozoline (Visine) eye drops, etc. I would not use any of these if they have been previously been opened and used as indicated because they could be contaminated. Health professionals well know that epinephrine is often commercially added as a dual product to injectable lidocaine to make it last longer (think dental chair), because these drugs constrict blood vessels and ultimately reduce blood flow to the area (sort of like pinching off a hose that is carrying blood instead of tap water). These drugs are not well-absorbed into the adult bloodstream.
Before leaving the ED at about 1:15AM, I met with a nurse and shared Dee’s medication list, doses, and dosing intervals. She entered these into the electronic record as I spoke. How did I have such a list? I had to go through her pill boxes before leaving the house. Nothing was labeled because the medications were not in the original vials. So, I had to identify each tablet/capsule and assume that based on the number of tablets/capsules per compartment that if Dee took two tablets in a day, they were either at once or one tablet twice a day.
Another quick Lesson: DO NOT leave town without a complete list of your medications in an easy to find place. Original prescription bottles or a picture of them (make sure your significant other knows how to access those pictures) are also helpful. A suggestion is to save your previous prescription bottles and travel with a shorter supply. And, make sure you have at least two weeks supply, even if you are traveling for just a few short days. Why you ask? Well, turns out my Dad had a few days supply of his meds, not enough to get him through Dee’s hospital stay before traveling back to Florida. This entailed a call to United Health, then referred to Wellcare, then turfed to 4 different agents… You get the picture. The purpose for this call was to get a prior authorization for early fills on his prescriptions that were filled in FL just a few days earlier. Then we had to transfer his prescriptions from his FL pharmacy to Albany NY area, but then we learned that half of them had no refills so they couldn’t be transferred. Next we had to contact the prescriber for new prescriptions, then they didn’t send the prescriptions to the local pharmacy as promised at 10:30AM, then we had to make 7 calls to the answering service, and finally the RX’s were called in. But wait, controlled substances cannot be called in, so if the covering doctor does not have access to the electronic prescription portal (which was the case), you cannot get that medication. Nightmare? Yes – think ahead when traveling.
Then there were the visits to the hospital. COVID-19 restrictions dictate no more than two visitors within a 3-hour visitation span, and you can’t mix and match. Two visitors only, no exchanging visitors. This entailed traveling to the hospital with my father, navigating the parking garage, stabilizing him and helping him walk across the garage, or leaving him while I secured a wheelchair, pushing a 2oo-pound man up a concrete incline inside the garage, and getting him to Dee. Don’t get me wrong, I was happy to do it!
BONUS: Although the garage scene alone was an endurance test for my own condition, the activities leading up to cycle-8 of chemo with a new medication (bevacizumab) all made me forget I had cancer – hence the title, “I forgot I had cancer”. That’s a good thing, right?!?!
The next morning after very limited sleep, we returned my Dad’s rental car to the airport because he and Dee were scheduled to fly out of Albany last week followed by a trip to DC (see below) – no dice there!
Dee’s first day in the hospital I was called because they “didn’t have her med list”. I’m like, what?!?! I gave it to them yesterday in the ED, but now again over the phone. The evening of hospitalization day 2, she had continued dizziness and she couldn’t sleep because they did not order alprazolam for sleep which she had been taking for years. She also had an elevated pulse. Whether or not alprazolam is an optimal choice for a chronic sleep disorder is a topic for another blog. Generally, standard of care is no sedating drugs after a head injury or major trauma. One reason is because the neurosurgeons want to see if there are any changes in mentation (ability to understand and answer questions) from the trauma. In this case though, the individual needs to be assessed too, as this is not so black and white. I pointed out three things. 1. Taking away alprazolam in a person who is clearly tolerant and who has been unable to sleep for more than 24-hours is more likely to cause changes in mentation than withholding the medication. It could also elevate her pulse, a problem that was being monitored. 2. The hospital had not started sertraline. This could result in serotonin withdrawal symptoms leading to dizziness and elevated pulse. 3. I learned that she had not been taking her full dose of gabapentin at home, but they were giving her full dose in the hospital. Gabapentin needs to be carefully titrated upwards, especially in the elderly. Why? Because it can cause dizziness and confusion – the way to fix this would be to reduce the gabapentin dose to 100mg once per day at bedtime and perhaps discontinue it until she is more stable.
An additional lesson can be learned from what happened the next day. I was informed that Dee was placed on tramadol for pain. This has become the new standard across the United States in an effort to reduce traditional opioid use for pain. The problem is that tramadol has a high incidence of poor tolerability, needs to be titrated up slowly, and has a high incidence of causing agitation, heart rate increase and palpitations, and is more constipating than any traditional opioid (hydrocodone, oxycodone, etc.). They also started her on meclizine (Antivert) for dizziness. Let’s look at the potential issues here.
- Tramadol and sertraline both block reuptake of serotonin which can increase various risks and side effects.
- Tramadol is constipating. Meclazine and sertraline both have anticholineric properties which add to tramadol’s constipation, dizziness, and fall risk.
- As I recommended the previous day, the gabapentin dose was reduced, the sertraline was added (left off med list previously), and much of the dizziness resolved, although that may or may not have been related to the medication adjustments.
Lessons learned: Before repeating fancy expensive tests, and in addition to the standards of care, there needs to be a careful assessment of medications because an incomplete medication reconciliation and assessment could be detrimental, add to discomfort, and extend the hospital stay. This is a reason for incorporating a clinical pharmacy team into direct patient care at the hospital.
So what’s up with me, since this is after all a cancer lemonade blog? I’m happy to report that with all the commotion the lemonade pitcher continued to flow!
Today I replaced oxaliplatin with bevacizumab (Avastin), a monoclonal antibody. As mentioned in my last post, unlike oxaliplatin, this is not a typical antineoplastic drug. It is pharmacologically a vascular endothelial growth factor (VEGF) inhibitor. Specifically, it affects the binding of VEGF to cell surface receptors, the result of which is reduction in microvascular growth of tumor blood vessels because of diminished tumor tissue blood supply. YEAH – choke off the suckers!!!
LEMONADE: One of the side effects of bevacizumab is sudden death! Well, that infusion just finished up 5-minutes ago as am writing this blog post. So, good news – I’m still here!!!
What’s on the upcoming to do list?
Well, immediately following my last chemo cycle, my wife and I traveled to NYC and spent a few days with new granddaughter Emily, big sister Anna (aka Silbie), and of course my daughter Sarah and hubby Andrew. I took Silbie to get her ears pierced (with Sarah) and told her if she was brave, I’d buy her anything she could fit in her arms. Just a sweet new memory because I took all three of my daughters to get their ears pierced at 2 years old. For a moment, I forgot I had cancer.
Upon return, one of my neighbors arranged to block off the circle where their house is located and his band played music for a few hours – tons of our neighbors were there. I played a set with them, and guess what? I forgot I had cancer.
Plans for the next several weeks: Our immediate goal is that Dee is well enough for hospital discharge this week so we can get her and my dad to the airport headed back to FL. Then we have a visit planned to DC to see my son and his wife (my fourth “daughter”) plus our two DC grandchildren. Middle daughter Hannah is flying in from Salt Lake City to visit for a month. Hannah is the other “Dr. Fudin”, a PharmD specializing in Women’s Health at the George E. Wahlen Department of Veterans Affairs Medical Center – they were kind enough to let her see patients via video-health for a month so that she could spend time with this guy. Gotta love the VA for embracing technology and humanistic concepts. Together with Hannah, we will attend a wedding in Long Island (about 3.5 hour drive from here in Robin’s new dream car), and then Hannah will join us and work remotely from our Florida home where her husband Kris will meet us for a week or R and R (although Hannah will be seeing patients remotely. We will also plan a trip to New York City to visit oldest daughter Sarah so that Hannah can meet her new niece. Then I suppose we will start planning for Thanksgiving. Really, although this year has been difficult, I am thankful for all the good that surrounds me. And to wrap up the year, we are headed to Disney World in December with our NY/NJ clan Andrew, Sarah, and our two granddaughters Silbie and Emily – thank you Andrew and Sarah for confidently anticipating my health so far in advance and encouraging me to agree to this trip at a time when I could barely lift my head up.
I’d be remiss not to mention that my wife Robin has been a saint throughout this whole ordeal. I especially appreciate her physical therapy expertise in transporting my father up and down the stairs. But also, her cooking, feeding dad, laundry, errands, and multiple caregiver activities have been a lifeline the entire week.
I think you can see the theme here! Healing and immunocompetency are dependent in large part on a positive outlook, staying busy (an understatement these last two weeks), exercising (think parking garage wheelchair marathon) and being surrounded by love in good times and difficult times. If you do that, you can live life and maybe even forget I have cancer.
Until next time, stay safe and keep your elderly visitors far away from stairs.
As always, comments are welcome with enthusiasm!
P.S. Any medical and personal information discussed herein are with the explicit permission of the “patients”.