When I was doing my fellowship, one of my attendings asked for my opinion on some abstracts that had been submitted for a conference. I gave him my thoughts on whether the abstracts he showed me should be accepted or rejected, but this was one where I really didn't know what to say:
It was a case of a patient who was having chemo with vincristine, which was mistakenly injected intrathecally (into the subarachnoid space) instead of intravenously on cycle #5. First, let's examine that sentence: Vincristine was mistakenly injected intrathecally instead of intravenously.
How is that POSSIBLE? If I went in for chemo and I was supposed to get a drug in my vein, and they accidentally injected it into my spinal fluid, I really think I'd notice. Especially if it was my fifth time. Is there something I'm missing?? There must be. Anyway, the patient got a spinal cord injury and ended up quadriplegic. Yikes.
The abstract wasn't reporting this interesting complication though, but rather, the challenges associated with rehab for a patient on chemo. However, instead of actually reporting anything specific to this patient, he just gave a little book report on general complications associated with chemo during rehab.
But my absolute favorite part is the random "results" section he threw in:
Results: Spinal cord injury after accidental administration of intrathecal vincristine with ongoing chemotherapy is very difficult to treat.
It sure is.
Papers like that are what make me think there is too much pressure to publish on people whose job really has nothing to do with publishing research.ReplyDelete
Some people are talented researchers and writers. Some people have no talent for the task, but can get it done passably with diligent effort, which takes away from the time they spend doing things they are better suited to. Some people cannot write useable research no matter how much time they spend, but this has no bearing on their ability as teachers or clinicians.
I could be mistaken, but I believe that a lot of chemo drugs are given intrathecally, and in tandem. This lecturer that told us about Vinca toxicity mentioned something about the size of the needle being similar to the intrathecal agents, and so the intrathecal administration of Vincas can be an easy, absent-minded mistake, albeit with horrible consequences. Apparently they're trying to cut down on this occurrence by color coordinating the labels.ReplyDelete
Still, could you imagine becoming quadriplegic because of a simple medical error?
Yes, but if you've gotten IV chemo five times, and then someone wanted to put the chemo in your spine suddenly, wouldn't you question that??Delete
I'm a medical student and even I know that you have to be terribly wrong in the head to "mistakenly" administer a drug intrathecally instead of IV. How did he manage that???
Here's a nursing blunder:ReplyDelete
"In our March 12, 1997, issue we wrote about a nurse who administered oral medications intravenously to an 86-year-old patient. The nurse crushed and mixed together PAXIL (PARoxetine), potassium chloride solution, and a multivitamin tablet, and then administered the medications intravenously, after the patient refused the oral medications. The patient died 30 minutes later."
Interesting - this last example is particularly awful, given that the patient had refused the po meds. Negligence aside, it was illegal to change the route of administration without a change in the order.Delete
Well, illegal, yes, but I really posted it because it is so mind-bogglingly stupid.Delete
Vincristine is many times given along with methotrexate. Methotrexate can be given intrathecally, so its not surprising that someone just didn't read and put the two together.ReplyDelete
Exactly, leukemia patients often get IT Methotrexate and IV Vincristine on the same day as part of their standard regimen. At my hospital, the chemo pharmacy will not even send the Vincristine up to the floor until they have conformation that the LP and IT Methotrexate administration has already happened, so that way the 2 meds can't get mixed up.Delete
I can't remember how many times I've heard a story of a patient or family member catching the practitioner about to make a mistake (nurse ready to administer a drug the patient is allergic to, a patient being prepped for the wrong study) and when they question something or say something, they are told "Your doctor ORDERED THIS!" in that intimidating, condescending, how-dare-you-ask questions way.ReplyDelete
I had it happen to me. A nurse was preparing to give me an IV drug. When I asked what it was, she sighed and started in on the "This is a drug your doctor has ORDERED..." and then finally condescended to tell me what it was. When I told her I was allergic to it and pointed out the orange sticker on my medical record noting this allergy, she actually rolled her eyes and acted annoyed. As though I had done something wrong in advocating for my own safety.
Well, in fairness, that may be because the physician determined that it was either not a real allergy or that the documented reaction was of less significance than the therapeutic effect of the drug to be given.Delete
Recently I had a patient with a "sulfa" allergy, and in particular an allergy to Lasix, which putatively caused peripheral edema.
My boyfriend discovered a sulfa drugs allergy and the doctors refused to even look at the rapidly growing rash on his skin or accept that he was having trouble breathing until he was almost dead. He's mistrusted doctors ever since and I can't say I blame him.Delete
My memory on this particular incident was that my allergic reaction (hives) was noted on the allergy label. And yes, I've gotten the ol' "You probably didn't have an actual allergy to (x) drug" from the doctor and when they inquire as to what the 'allergic' reaction is, they usually look a little pale when I mention I had head to toe hives or acute, severe allergic reaction necessitating an ER visit (hives plus throat swelling, not quite enough to merit the 'anaphylaxis' label.)Delete
In 2006-ish during residency we had an out-of-hospital ICU transfer for a patient who received intrathecal Vincristine by mistake. Sorry, not Oncology but only rotating ICU that month but, as I understand, part of a combo therapy the patient receives and intravenous and intrathecal combo. Anywho, said patient was getting an active CSF infusion of NS to try to dilute it down. Nonetheless, Vincristine is incredibly toxic to neural tissue (i.e. it basically dissolves it) so the patient died. I find the transfer to 'higher level care' happens all the time during f*ckups like this so the death count goes on the residency hospital and not the private one.
Was the abstract accepted?ReplyDelete
Didn't get much oncology training in pharmacy, but pretty sure every pharmacist should know that vincristine is (possibly)fatal if given intrathecally.ReplyDelete
Our vincristine comes in a box marked FATAL IF GIVEN INTRATHECALLY and sleeves to put the syringes in that are black and red and say FATAL IF GIVEN INTRATHECALLY and stickers to put on the label that read the same.
Pretty awful mistake, but definitely possible