1. GODZILLA MEETS
THE LITTLE RED HEN
?

2. Godzilla Meets the
Little Red Hen
Or, the Prescribing Cascade
Meets the Bedside Observer
Johanna Trimble
Patient Representative
Sponsored by:
Community Engagement Advisory Network, Vancouver Coastal Health Authority
Member:
World Health Organization Patient Safety Champion
BC Patient Voices Network
Patients for Patient Safety Canada (CPSI)

3. The Characters

4. GODZILLA

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

6. The Little Red Hen

7. Sometimes known as…
• The family member
• The friend
• The puzzled visitor
• The staff member
• The bedside observer

8. Fervid Trimble, the patient

9. 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

10. Trust your instincts and press for answers
Why is
this not
making
sense!??

11. Hmmm, I
wonder if
it’s the
drugs?

12. 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.

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

14. I’ll consult
my
sources…

15. I used the internet…reputable sources only!

16. Another
UTI?
What
the…!?

17. Serotonin Syndrome:
SSRI antidepressant (citalopram)
+
Tramadol (serotonergic pain
medication to replace Vioxx)
=
Unrecognized serotonin syndrome

18. 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

19. 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

20. 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

21. Fervid’s Prescribing Cascade
Unrecognized drug adverse effects,
symptoms of Serotonin Syndrome,
were treated with additional drugs
as if these symptoms were new
conditions.

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

23. 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.

24. ARICEPT!? But
this delirium
was caused by
the drugs...
What the…??

25. A picture is worth a thousand words…
Over-medicated After the “drugectomy”

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

27. Here we
go
again…

28. 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

29. 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

30. 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.”

31. 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

32. Let’s DO
SOMETHING
about
polypharmacy!

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

34. “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...”

35. Dedicated to Fervid Trimble 1917 - 2008
A picnic in the garden with Fervid

36. Contact:
johanna@daletrimble.com