Thursday, December 25, 2014

Meds failure

One advantage of retaining a high degree of privacy is that I can write more freely about "sensitive" issues.  This short essay will be about one of those sensitive issues.

One of the members of the ERJ household is highly medicated.  Those medicines extract a price in terms of side effects.  Consequently, we are in a continuous dance of attempting to titer the dosages down while supporting and fine-tuning the non-med issues that either stress or improve the condition.

Holidays are particularly difficult time and I screwed up royally.

Titering down

Several of the meds are administered multiple times of day.  We found that some dosage times were more critical for performance than others.  All doses contributed to the side effects.  It was a no-brainer to dial down the dosages that were less efficacious as they minimally impacted performance.  The downside is that the dosage schedule is highly asymmetric.  That asymmetry makes it impossible to look at the dose as it sits in the bottom of the cup and discern whether errors were made.

Another contributing factor is that one must titer down in baby steps.  The steps become smaller and the validation period longer when one is close enough to the brink to hear the pebbles echoing as they bounce downward into the abyss.  We administer two of the meds in the smallest size available.  Titering down with these requires a pill splitter.

Titering down is a game for patient people.  We are continuously skating the raggedy edge.  Each move is small and validated for a long period of time.  Just as one warm, sunny day in March does not make it summer, a week or two of satisfactory performance does not validate a lower dose.

Stresses matter

I do not like holidays.  They stress us in too many ways.  Holidays take us out of the routines that armor us.  We eat strange foods.  We eat too much.  We rub elbows with people who often times exasperate us.  Our sleep schedules go whack.  Aunt Matilda insists that we try her new punch recipe (admittedly delicious beyond description).

The person coordinating the "titering down" must make some strategic decisions during the holidays.  Bump the meds up until the turbulence of the holidays are behind us?  Stay the course and see how solidly the supporting measures bear up?

And in the back of our minds looms the questions:  What happens if the patient gets sick and vomits out some or all of the meds?  What happens if the patient's friends tell them it is a matter of having a strong will and meds are for weaklings?  What happens when the meds do not act as if they were the potency labeled.  These are all good reasons to have some stress-tests.

I screwed up

We have a meds tray that we fill up every week.  It gets the standard "drop" plus any additional meds.  In the past additional meds included ibuprofen for sprains and headaches, antibiotics for ear and sinus infections, expectorants and decongestants for sinus issues.  The minimum weekly med drop is 112 pills.

The dosage for one of the most critical meds is 1-and-a-half-tablets in the morning and half-a-tablet in the evening med drop.  Sadly, this critical med also has the most undesirable side effects.  Splitting tablets is a pain.  They rarely split exactly in half.

My screw-up was that I got the half-tablet right but I missed the one-and-a-half part.  That is, I shorted the patient about 35% of the dose that carried them through the majority of their waking hours.  This is a change we will probably work our way up to....but not during a holiday and not before all of the other supporting measures have been fully demonstrated.

Things went OK for two days.  The third day, not so OK.

It was a train wreck but it was not our worst-ever train wreck. It was probably ranked number five or six if we bothered to rate them.

We discovered the error after Mrs ERJ and I discussed the possibility of bumping up some of the critical meds to get us through the holiday season.  While fortifying the meds tray, Mrs ERJ noticed a conspicuous absence of half tablets in the morning med drop.


We are walking about on tippy-toe feet.  I am 95% sure this crisis is behind us.

We (I) am much humbler about my ability to avoid errors.  Mrs ERJ will perform a secondary check when I fill the caddy and I will do the same for her when she does.  It will most likely be a parity check where we simply count the number of discrete pill-like objects in the caddy on a drop-by-drop basis.

Other Systemic Fragility

The patient's condition is not something that can be effectively treated with apple cider vinegar, lavender aroma therapy and Pachelbel's Canon.  Consequently I am continuously scanning the horizon for threats to the supply line.

I experienced a rare stone-wall when I googled "country of origin med-name".  The FDA actively suppresses country-of-origin information for pharmaceuticals.   I pay attention to geopolitical instabilities.  Part of that attention is due to the expectation that I might be able to pre-fill critical meds when political tensions might impact material flows.



  1. That is extremely stressing, thoughts and prayers for y'all in getting it 'right'...

  2. Thank-you for your prayers and kind words.

    It would be much easier to get it right if "right" did not keep moving all around.

    Best regards,