Primum Non Nocere I

(part two) (part three) (part four) (part five) (part six) (part seven) (part eight)

Much ado has been quite prevalent of late, and of a detracting nature as far as my writing is to be considered. It hasn't been about nothing: my sister's health has been at the mercy of an industry that sucks pharmaceutical cock like an inner-city crack whore...it is beyond disgraceful...

A slightly detailed synopsis is presented here in letter form, from the afternoon that the most recent facts hit me (a rough draft, yes; and obviously penned for ventilation, not litigation):


Xxxxxxx X H---, MD
Axsx. Cxix. Pxoxexsxr, Xoxuxtxrx
Dxpx. ox Nxuxoxcxexcxs, XCXD
Xaxixix Cxnxex fxr Xexoxoxixax Dxsxaxe
X5X2X Pxmxrxdx Rxax, Sxixe xxx
Xxxxx, CA 9xxxx

Xxxxx P---, MD
Dxpxoxaxe, Xmxrxcxn Xoxrx ox Ixtxrxax Mxdxcxnx
Xextxe xox Hxaxtx Cxrx
X5X1X Pxmxrxdx Rxax
Xxxxx, CA 9xxxx


July 28, 2007


Dear Bastards:

Yesterday it was brought to our family's attention that the prescription for Depakote accompanying E--- upon her release from Pomerado Hospital this past May was incorrectly filled. Dangerously so. I believe the the word Dr. H---, her neurologist, chose to describe her current state was "toxic."

The visit to Dr H---'s office yesterday, July 27, brought this reprehensible oversight out in the open when it became apparent that E--- was sent from the hospital with one of her prescriptions being Depakote EC, but filled as Depakote ER.

From the Abbot Laboratories information regarding it's product (Depakote ER) under "Dosage and Administration":

"Depakote ER is an extended-release product intended for once-a-day oral administration."

Under sub-heading "Migraine":

"The recommended starting dose is 500mg once daily for one week, thereafter increasing to 1000 mg once daily."

E--- was directed to take this drug, a t 500mg a dose, three times a day.

The above information posted by Abbot for Depakote ER contrasts with the company's information regarding dosage for their similar product, Depakote, (again, under the same sub-heading "Migraine"):

"The recommended starting dose is 250 mg twice daily. Some patients may benefit from doses up to 1000mg/day. In the clinical trials, there was no evidence that higher doses led to greater efficacy."

In sum, she was directed to overdose on a drug she wasn't supposed to be on at all.

(The company does, however, list the exact same info regarding overdosage for either drug: "Overdosage with valproate may result in somnolence, heart block, and deep coma. Fatalities have been reported; however patients have recovered from valproate levels as high as 2120 micrograms/mL.")

-----------

E--- spent thirteen days at Pomerado in late April / early May and another eight days again in May, with one emergency room visit in between, obtaining treatment for a severe bout of a recurring condition known as hemiplegic migraine. These incidents have occurred roughly once a year for the past three years, and this last instance was her worst episode to date. Her condition was somewhat anomalous, to say the least; in fact, it took several days to have Dr H--- conclude that this is indeed a hemiplegic migraine at all, as it is a rarity in adults, particularly when it does not fall under the criteria described by "Adult Onset Familial Hemiplegic Migraine."

It is difficult to say if anything had been cured; only that the worst has been abated, and that was generally through a mixture of empiricism and deduction. The paralysis, severe and continuous headaches, occasional seizure and overall stroke-like symptoms appeared wholly unique to all but E--- and her family, for the latter had been through this before. The three most significant drugs administered to her through IV were the steroid prednisone, v arious narcotics for pain (primarily Diladud) and Depakote, used for prophylaxis of migraines.

She was released on May 19 with prescriptions for all three (with Oxycontin instead of Diladud), to be administered orally with the intention of tapering off as soon as favorable conditions would permit. She had a full and active life before this most recent event, and was expected to return to that life, though we knew there would be some recovery time involved.

Once the steroids were discontinued (about two weeks, tapered off with Dr. P---'s guidance) an immediate change became apparent. After a brief period of near-constant sleep coinciding with her body's decreased steroid use, E--- started to look and act like a zombie. Almost continuously. Alongside this there was constant aversion to light and sound, and anything sudden or abrupt, often to the point of terror being experienced by E---. This did not subside, and in fact acted against her in tandem with her other recent setbacks due to constant migraines, the side effects of large steroid doses for weeks at a time, and the overall atrophy occurring throughout her body from both the repercussions of her neurological disorder and weeks of near total bedrest. Dr. H--- was notified, whereupon he asked that bloodwork be done to test for liver function and Depakote levels. The bloodwork was carried out on June 6.

At this point the family, unable to condone the continued intake of the Depakote as directed, but with the knowledge that Depakote intake cannot be stopped immediately, decided to have E--- remove one of her three daily doses. The main factor in this decision by the family (aside from the inability to further countenance E--- turning into a vegetable before their eyes) was the knowledge that a like drug, Topamax, was once briefly administered to E--- by another neurologist, with the intention of staving off seizures and preventing migraines. The effects on E--- were almost identical, and she had to cease immediately.

While waiting to be informed of the results of the bloodwork, E--- saw her primary physician, Dr. P---, about once every week. The removal of the steroid and the tapering off of the Oxycontin were under the purview of Dr. P---; and in these respects things were going more or less as well as to be expected - E---'s overall condition was improving, although with considerable "peaks and valleys," and with the effect of the two remaining daily doses of Depakote to be determined. Some days she could leave the house for a couple hours of activity, others were spent indoors, primarily laying down. Overexertion by a physical activity lasting longer or requiring more than running a few errands would result in two to three days time needed for recuperation.

During this time occasional bouts of compromised mental agility came and went. E--- was sometimes foggy in her thoughts, sometimes lucid. A pronounced difference from the post-steroid thrice-daily doses of Depakote ER, but apparent nonetheless that there was something analogous to a governor on her brain now and then. The ability to absorb and process data was not always present; in fact, in the past, and aside from the all the physical discomfort and temporary setbacks, her inability to perform and comprehend normal associations were only present around the before, during or after period of a migraine. And she was seemingly exhibiting every possible side effect from Depakote / Depakote ER.

After a couple calls to Dr. H---'s office, the results were eventually transferred to Dr. P---'s office. A Depakote level of 18 was shown, and Dr. P--- was candid in his admission of not knowing what that meant. In recent weeks her joints and musculature have become extremely sore, the possibility of arthritus introduced, and that is understandably wherein lies the focus of Dr. P--- - that which is not neurological.

A further call was placed to Dr. H---'s on July 26, politely insisting that E--- be seen as soon as possible and not at the next scheduled visit in early September. A slot was found at noon yesterday, July 27.

-----------

Within E---'s discharge papers, both the one from May 2 and the one from May 19, the list of medications to be taken is clearly notated in print and initialed by the RN. The stay ending on May 2 was authorized by Dr. H---, and the stay ending on May 19 by Dr. P---, presumably with Dr. H---'s blessing. Analyzing these two pieces of paper, the possible breakdown in communication becomes apparent:

i) On May 2, Depakote, 500mg every twelve hours, is written out by the RN and is authorized to be filled along with the other prescriptions by Dr. H--- upon E---'s release.

ii) On May 19, Depakote EC, 500mg three times a day, is written out by the RN and is authorized to be filled along with the other prescriptions by Dr. Pre sant upon E---'s release.

iii) Both "Depakote" and "Depakote EC" mean the same thing, the "EC" standing for enteric coated. And it is a notably different medication from Depakote ER, where the "ER" stands for extended release and to be administered only once daily. Further complicating this is that the two drugs are generally listed as "Depakote" and "Depakote ER." The "EC" is often omitted when referencing the former.

iv) It is marketed as such (as Depakote and Depakote ER) by Abbot Laboratories, and the possibility is strong that it resides on the pharmacy shelf labeled as such.

v) Both doctors had to write out E---'s prescriptions personally upon her release, the same medications that were relayed to the RN that wrote them out clearly on the discharge papers. On May 2, the Depakote listed would have been filled as such. On May 19, the Depakote EC, handwritten on the prescription by Dr. P---, allows for the possibility for misinterpretation by adding two letters after the word "Depakote."

vi) This was clearly misread by the pharmacist, who filled the May 19 prescription as Depakote ER, 500mg, to be taken three times a day.

E--- took the pills as directed until circumstance prevented her family from allowing that dosage to continue. She took the pills twice daily until the July 27 office visit, whereupon Dr. H--- ceased the dosage immediately and switched her from Depakote ER to Depakote, and to a 250mg dose three times a day with bloodwork to be done on August 3, and an expected reduction in dosage thereafter once the results come back.

-----------

The following questions arise from this unfortunate lack of judgment and oversight, for which E--- has paid the price:

Dr. P--- wrote out the prescriptions upon E---'s May 19 release from Pomerado. The drug most affecting her neurology for the indefinite future, Depakote, was presumably added to list of other medications by Dr. H---. Dr. P--- admitted in the above-notated office visit that he wasn't familiar with certain aspects of Depakote. Given that one's handwriting is sometimes difficult to decipher by another, is he aware of the severity in difference between Depakote EC and Depakote ER?

Why was't the word "Depakote" used alone in this prescription? Or, if necessary, since two doctors were involved and E---'s primary physician was not her neurologist, why not an explicit communication to all concerned that Depakote ER is NOT to be used? If the family was made aware of this fact beforehand, and the potency of the drug in question should someone at the pharmacy make the exact mistake it appears has been made, it would have simply been added to the list of things to be hyper-vigilant about given the severity of E---'s condition.

Surely Dr. H--- would immediately notify E--- of the high Depakote levels after looking at the results of the bloodwork, as he alone would know that something must be gravely wrong with the dosage for her condition to be, quote, "toxic." He was notified expressly of the family's concerns, as that is what initiated the bloodwork done on June 6. Is it reasonable to assume that he wouldn't have seen a level of 18 without taking immediate action? Yesterday he took immediate action, while intimating that normal levels range between 4 and 12. Did he not look at those results until yesterday afternoon?

Finally, what accountability does the CVS pharmacy have for misreading the prescription from Dr. P--- The carelessness exhibited in that one transaction may have caused irrevocable damage to E---'s well-being.

The consequences of such negligence are still unclear: not only have E---'s mental faculties been handicapped by this overdose of medication, it has prevented her body from a reasonable recovery time toward normality by keeping her, and it, in a form of limbo. The long-term effects of this serious oversight remain to be seen.

For now, her family just expects you sorry motherfuckers to start kicking down some answers.

May a Hippo take a Greek oath with your hind quarters.

Sincerely,


Goff ack Ur-selbes
Consiglieri and Claims Adjuster, Esq.


Copyright 2007 Jexican Publishing. All Rights Reserved.