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OVERVIEW
How could someone ever mistake an NSAID for an antibiotic? These medications are completely different from one another! Under what circumstances could something like this possibly happen?
The case below gives a great example of how silly misinterpretations can actually have serious consequences regarding the management of a patient.
WHAT HAPPENED?
The patient in question is a 57 year old male who has a complicated past medical history. For the purposes of this page it is not necessary to fully unpack his past medical history, but rather it is more advantageous to hone in on his most urgent medical problem. This man was admitted to the ICU because he was having bloody vomitus, bloody bowel movements, and had become so hemodynamically unstable (from blood loss) that he had been losing consciousness. An upper GI endoscopy confirmed large ulcers in his stomach and duodenum that were very clearly the source of his GI bleed.
While this patient was in the ICU, a surgical consult was called for the patient. The on call resident sent the medical student on the team to go perform the consult. The student went to see the patient and then returned to present to the resident. He began his presentation stating in the opening line that the patient has a history of chronic NSAID usage. The surgical resident interrupted the medical student and asked how long the patient has been taking NSAIDs and what his dosage of medication have been. When the med student is unable to provide the exact date and dosage of the NSAID medications, the resident became upset and walked away from the medical student before the presentation can go any further.
The surgical resident then went to see the patient in the ICU. He made a point to check every medication and every dosage on the patient’s extensive med list. This ended up taking 45 minutes due to the usage of an interpreter for a more uncommon language, and the fact that the patient in question did not know many of his medications/dosages (so family members had to be called and consulted to cross reference information). At the end of this ordeal, the resident chastized the medical student for not doing better job in reconciling the medication list, and went to talk with the ICU team about the patient.
During this conversation it becomes clear that a very important medication on the med list called Meloxicam is being overlooked by the surgical resident. When asked what it is, the resident explains that it is an obscure antibiotic. Meloxicam is actually an NSAID medication that is very strongly associated with causing upper GI bleeds (like the one the patient has presented to the ICU with).
In going back to the history collected by the medical student, had the presentation been completed it would have been very clear that this Meloxicam actually was very clearly the cause of this patient’s upper GI ulcers. Prior to the episodes of GI bleeding, the patient had hurt his knee and began to take this medication in very high doses. Given the role of NSAIDs in causing GI bleeds, this medication is contraindicated in the patient, and arguably the patient should avoid any type of NSAIDs to prevent further bleeding.
The team ends up holding the patient’s Meloxicam during his ICU admission and then upon discharging the patient, the Meloxicam is unfortunately started again. The patient is not educated on the role of NSAIDs in causing GI bleeds. Within two weeks the medical student sees that the patient has been re-admitted to the ICU for another severe case of upper GI bleeding.
AT WHAT POINT DID THE FOREST BECOME LOST IN THE TREES?
It seems that the resident’s emphasis on the details of the medication history completely overlooked the whole POINT of why we ask patients about their medications. The resident spent 45 minutes going through every medication and dosage with the patient, however at the end of all of this, if he does not know what Meloxicam is….what good were his efforts? In the realm of stomach/GI ulcers the patient’s usage of NSAID medications (even obscure ones like Meloxicam) must be characterized! Even if the dosage and start date of the medication are not known, understanding which medications on the med list are contributory to the patient’s current presentation is the most essential component of the medication history! Knowing the dose and start date of a medication, while not knowing what the medication ACTUALLY IS typifies losing sight of the forest from the trees.
WHY SHOULD WE NOT THINK ITS COMPLETELY “CRAZY” THAT THIS HAPPENED?
While the resident’s behavior to the medical student does seem to be unsavory, we must appreciate that the base motivation of the resident was not a terrible one. It is important to try and confirm the accuracy of the medication list (and medication start dates/dosages are important pieces of information). While the medical student was able to identify the cause of the patient’s GI bleeding, he must also acknowledge that whenever possible it is a good idea to verify these details for patient medications.
That being said, the resident does need to prioritize his time investment a bit better. There are many more efficient ways of reconciling the patient’s medication list (instead of working through interpreters and family members at the bedside), and the residents usage of 45 minutes to do this task is questionable given the fact that at the end of it, he failed to identify the one medication that actually most likely was responsible for the patient’s GI bleed.
WHO CARES? WHAT WAS THE HARM IN WHAT HAPPENED?
This is one of the cases where the patient’s life was very clearly at risk due to his over-usage of the NSAID Meloxicam. While fortunately the patient did not lose his life, his second ICU admission could arguably have been avoided had he been informed that taking any NSAIDs (ESPECIALLY Meloxicam, one of the most dangerous for GI bleeds) would be contraindicated for him given his ulcers. It is of course true that the patient had chronic knee pain that needed to be managed, however there are of course other pain managment options that will not cause GI bleeding.
WHAT IS THE TEACHING POINT HERE? HOW DO WE AVOID THIS IN THE FUTURE?
There are a few important teaching points to take away from this case.
Don’t just do things to “do them”: In this case a medication list should not just be confirmed “just because”. The purpose of doing such an act is to contextualize the patient’s current presentation (and understand how the patient’s current medications could be contributing to their hospitalization). Going through the motions without being intentional is never a good idea in medicine!
Don’t be rigid in your thinking: because the medical student did not know details that the resident felt were important, he walked away from the medical student IN THE MIDDLE OF HIS PRESENTATION. While this was quite unpleasant for the medical student, it actually resulted in the resident missing arguably one of the most important pieces of medical history: the patient’s over usage of Meloxicam (as well as WHAT exactly this medication was).
Put your knowledge into action: the fact that this patient was allowed to take Meloxicam again after his discharge begs many questions. What is the point of understanding what is going on with a patient’s medications if you do not put that knowledge into action? This patient should have been educated properly on the role of Meloxicam/NSAIDs in causing his GI bleeding, so that after his discharge from the hospital he could avoid using any medications that would land him back in the ICU.
Page Updated: 09.28.2016