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The Importance of having a Medical Quarterback who is reliable and available

Let’s start with three really important questions for this era of specialization and specialists.
1. Who actually takes care of the whole patient?
2. Who checks for interactions between medications and between diseases and medications?
3. Who notifies whom? When?

And now the story of Aunt E, who was the aunt of my lawyer.
This pleasant 82 year old spinster lived alone, and was capable of managing her investments and finances. She drank 3-4 martinis every evening and took Xanax® for sleep. She was admitted to hospital for pneumonia. On Day 3, she developed alcohol withdrawal (hallucinations). She was heavily sedated with Ativan® and Haldol®. Her serum sodium dropped, so doctors pumped salt water into her veins and started salt tablets by mouth. They also gave her Declomycin® to help restore her serum sodium. She developed wet lungs and went into heart failure. She was given a potent diuretic (Lasix®). Her serum sodium dropped further, and now her serum potassium dropped. She cannot be easily aroused. Four consultants were called in: cardiologist, neurologist, nephrologist (kidney), pulmonologist (lung). But who is taking care of Aunt E? She also developed a bladder infection from the catheter that was placed in her bladder. That was treated with Cipro® and ampicillin. She developed a vaginal yeast infection. Because of the stress, she also developed shingles.
On Day 5, her nephew called Dr. Lazar. Upon hearing the story, our Advocate in Chief gave the nephew a clear explanation about what to ask, whom to ask, and made recommendations about stopping medications in a specific order. On Day 8, Aunt E went home.
However, that’s not the end of the story. She went home one a variety of medications – as follows: Cymbalta® for shingles pain; Declomycin® for her low serum sodium; Lasix® for heart failure; Cipro® and ampicillin® for her urinary tract infection; Risperdal® (an antipsychotic because she was combative in the hospital); Aricept® (for Alzheimer’s disease, because she was combative in the hospital); Nexium (reason unknown); Percocet® for pain from the shingles; Probiotic capsules for her vaginal yeast infection; Albuterol and Spiriva® inhaler for her wheezing. If we look at this list, here’s what a medical quarterback sees. The shingles pain should receive a trial of the very safe lidocaine patch. No need to expose the patient to the side effects of Cymbalta and, especially, Percocet. Her heart failure was caused by questionable care – so let’s discontinue the Lasix, the Declomycin and the salt pills and put her on a low-salt diet instead. The Risperdal and Aricept can be discontinued safely. Albuterol is not a good drug for older folks because it causes, as predictable side effects, nervousness, jitters, and heart palpitations. Finally, the Xanax probably should be resumed, for this is a class of drugs that should not be stopped abruptly.

Aunt E lived for several more years before dying in her sleep one night.

What do we learn from this?
1. There must be a medical quarterback (either a primary care provider or a reliable advocate).
2. Too many cooks (specialists) indeed do spoil the broth (patient). Each is focused only on his particular organ and his particular problem.
3. Too many medications – some of which were wholly inappropriate, and others were prescribed to treat side effects of medications previously prescribed. This can become a vicious cycle.
4. In caring for, especially, the elderly
a. Ask about each and every new medication
b. Ask about drug-drug interactions (whether the drugs play nicely with each other)
c. Ask about drug-disease interactions (might this new drug make an old condition worse)
d. Ask, ask, and then ask some more!