Downey V.A. Hospital Was The Home of Polypharmacy and Megadoses

 

Desperate situations often produce less than optimum results. The patient population at Downey V.A. Hospital was an intractable bunch, tortured by some of the most severe psychopathology known to man. My first time passing medications was a real shocker as one pour soul was ordered 2000mg. of the potent major tranquilizer, Thorazine. Nursing school pharmacology taught me that a usual dose was 75-200mg of Thorazine. A ten fold dosage of 2 gms. was out of the ball park.

Another disturbing trend involved patients dosed with more than one major tranquilizer with some dispensed as many as four. When the V.A. administration discouraged megadoses, polyharmacy was haphazardly substituted. I don't know which practice was worse in fueling disabling side effects like tardive dyskinesia, polypharmacy or megadoses.

When I brought this up to our ward physician, Elihu Howland MD, he agreed that it was a less than desirable situation  and suggested that I do a study enumerating the problem and he would see what he could do. Good luck were his parting words which were uttered in a less than sincere manner.

I eagerly went to work and came up with the following.

There are a significant number of patients at Downey receiving  more than one antipsychotic drug or a witch's brew combination of these neuroleptics. Here on Building 66AB I found a patient receiving three different antipsychotic drugs with a PRN order for a fourth neuroleptic agent. This much chemical restraint could be as disabling as the underlying illness.

Many studies evaluating  polypharmacy under controlled conditions demonstrate that there is no effectiveness over monotherapy. There really is no basis in fact for the existence of polypharmacy as a treatment method nor empirical evidence for its continued use as an effective treatment modality. Additionally, polypharmacy creates an added risk, even a fatal outcome, from a combination of drugs with mutually additive effects. With polypharmacy it is nearly impossible to delineate which specific drug is the culprit inducing untoward side  effects.  Many articles conclude that single drugs are the treatment of choice over polypharmacy.

Furthurmore, a recent review clearly shows that  we have a number of patients on extremely high dosages of antipsychotics. Megadoses   seem related to poly pharmacy in that one poor option is often substituted for the other. When megadoses are discouraged, polypharmacy soon fills the void.

Megadoses indicate  we have a large group of chronic patients who have been receiving a very high dose for a long period of time and whose mental status has stabilized, yet no attempt has been made to reduce their dosage to the lowest effective maintenance level. This maintenance dosage should be as low as suitable for retaining therapeutic progress. Dosage should be gradually titrated down to avoid a sudden emergence of symptoms.

The notion of lowering doses is especially important when megadoses or high doses are ordered. The patient's symptoms , drug history, and general physical condition should be considered when the risk of megadoses is evaluated. The occurrence of side effects must be balanced the benefits in the chronic patient who continues to present psychotic symptoms endangering himself or nursing personnel.

Once control of target symptoms has achieved, the dosage must be be adjusted downward as most all patients could be maintained on a lower dosage level.

Perhaps we should start by eliminating polypharmacy and then carefully titrating down on some of the megadoses.

I submitted this report to Dr. Howland with a listing of the patients receiving polypharmacy and megadoses. While there was some success with reducing polypharmacy, there was much resistance to decreasing megadoses. The main argument was the patient was on these doses for a very long time so there was no rationale to decrease doses.

My frustrations working at Downey reached a boiling point a few months later when my head nurse recommended me for a grade promotion, but  it was rejected by the personnel office because I was 4 days shy of the time required in grade for promotion, but never fear, I could apply again next year.

I resigned from Downey V.A. on May 21, 1976 after working there 1 year, 5 months, and 28 days. It was a very long year and a half and made working in the OR seem like a walk in the park. I happily returned to my favorite stomping grounds in the O.R

WHAT IS A NARCOTIC PRESS?

 There are many vintage nursing terms that are unheard of in these modern times: Johnnies for hospital gowns, snaps for hemostats, monkey bars for orthopedic framed beds or hypo for any drug administered by a needle, regardless of route. Some of these names, at least, made sense in that their origin was pretty easy to figure out. One term that really through me for a loop, even in my younger days , was "narcotic press." I tried to learn what was behind these obscure terms in a foolish attempt to appear smart or wise, but, like they say, you can't make a silk purse out of a sow's stomach.

A narcotic press was not a newspaper about the perils of addiction or a device for squeezing the exudate from the papaver somniferum  poppy. Narcotics were secured in a double doored locked  metal box prominently located smack dab in the middle of the nursing station and frequently referred to as the narcotics press.

I used to love the way Filipino nurses called it a nar-koe-tiks press in their lovely melodic way of speaking, so different than the harsh, Chicago midwestern dialect that sounded like a Stryker saw hacking through bone in the morgue. Native nurses had rather inelegant terms for this storage  device like locker, cabinet, or box. Narcotics press had a nice ring to it.

Since most Filipino  nurses used the lovely narcotic press term so freely, I wondered if it came from their native Tagalog language. After learning the term had no roots in their native language, I set off on a mission to learn where the narcotic  press term originated.

Old nurses, having seen it all and done it all, were not very tolerant of nursing terminology cognoscenti like myself. Well seasoned nurses were intolerant of foolishness regardless of source, patients, colleagues, or whatever, it didn't much matter. It was a tough battle liberating information from these hard core characters, unless it was a direct matter concerning patient care, but young fools can be highly motivated when the quest for esoteric information is on the line.

I got quite a few answers regarding the narcotic press nomenclature inquiries. One aging bat thought it had something to do with triggering a red warning light located above the medication room door. Regulations required a visual indication whenever the narcotics press was open. Newer narcotics storage areas had a switch automatically linked to the outside door that triggered the warning light, older boxes required manually PRESSING a button and thus the term narcotic press was born. This explanation seemed a bit far fetched, but I guess anything is possible.

And finally, the best answer, verified by more than one aged nurse is the following revelation. The narcotic press nomenclature is a coinage born of frustration with securing the double doors of the contraption. Rules from the grand nursing poobah upon high specified that  narcotizing drugs must be stored behind two locked doors. closing the first, inside door was easy, but to get the outside door securely latched, you really had to press on the margins to get it shut. A narcotics press was born!

Zomax Was an Anguished Analgesic

 "Now I know how Zomax works. My stomach aches so bad 

I don't even notice my fractured femur!" (GI  distress was a 

common side effect of Zomax.)

Pharmaceutical representatives also known as drug salesmen had free run of the hospital in the early 1980s and offered endless supplies of assorted trinkets and free lunches to all who would listen to their huckstering. A revolution in pain relief by an innovative new analgesic supposedly as strong as a narcotic, but non-addicting , Zomax, manufactured by McNeil labs was the hot new product in 1980 and the sales folks were chomping on the bit. Alas, a non addicting drug as strong as morphine was too good to be true.

Zomax  marketing was unique in that ordinary nurses were targeted by the vulture like drug salesmen. I suspect McNeil was emboldened by their success in marketing the anesthetic, Sublimaze, to nurse anesthetists. The American Association of Nurse Anesthetists even increased their case load requirement for anesthesia  students using Sublimaze after McNeil greased the skids for their product. 

Like Pavlov's dogs, every nurse was conditioned to always have a pen, scissors, and a watch. There was even an organization to recruit unsuspecting, innocent youngsters to the brutal field of  nursing known as Penwaciez which was named for the 3 things a nurse must always have in her possession: a watch, pen, and scissors.

 McNeil had this holy nursing equipment  triumvirate covered with a cheap Chinese made nurse's watch with a huge Zomax insignia on the dial. It did work well until the non-replaceable batteries bought the farm and  even had a nice white band. Most nurses were easily suckered into the corporate marketing gamesmanship because it was rare for anyone to give nurses  much of anything. Physicians were the traditional recipients of pharmaceutical company swag. Fancy golf club cover ups and writing instruments were popular. 

Zomax pens were  soon ubiquitous at every nurses station and were really nice upgrade  from the  cheap Bic stick pens we were raised on. Zomax emblazoned scissors were functional and were one of the first bandage scissors with blue plastic covered handles. We liked them a lot even though "Zomax" was emblazoned on any place available..

With nurses being the boots on the ground for Zomax marketing, McNeil came up with a battleground themed sales campaign code  named "Operation 111." The  notation represented the 111 million dollars the pharmaceutical company planned to gain in sales when the drug was introduced. A salesman summed the scheme nicely, "We're calling it operation 111. Now if that sounds like a war, well in our world of sales that's what it is." Sales memos were complete with a crossed rifle insignia as well as tanks and fighter planes. Fighting and battle themed analogies are all to common in health care, but the human body was never meant to be a battleground.

Nurses were bombarded with the mantra that 100mg. of Zomax was the analgesic equal to 10mg of morphine and there was no risk of addiction or tolerance. The centerpiece of a sales meeting with medical folks frequently featured  a small ornate punch bowl filled with single Zomax pills wrapped in colorful foil which glowed incandescent in the room light as a beacon in the fight (oops another war analogy) against the formidable foe of pain. We were invited to help ourselves to experience this breakthrough analgesic. I took one for low back pain and my stomach felt like a threshing machine left out in the pasture way too long. One dose was more than enough for me and I had a tough time figuring out which was worse my stomach distress or my back ache. 

Zomax pills were manufactured in the shape of a cute little house or cottage. The soothing green tint and image of a happy pain free home, sweet home were definitely alluring. As the big name pharmaceutical  houses began to loose patents to generic manufacturers  on their lucrative name brand  drugs the age of distinctive pill making was hatched. The most unusual of the bunch was a molded hollow scripted Valium pill. Roche had really out done itself with this design. The hollow fancy scripted "V" appeared to float in the center of the pill.

Despite the fact that most nurses were unimpressed with Zomax's efficacy, it did produce 15 million prescriptions in the first 2 years on the market. Trouble was on the horizon. In March 1983, McNeil announced the drug was being pulled from the market as a result of 5 deaths following Zomax ingestion.

It was discovered that one of the metabolites of Zomax caused an anaphylactic reaction in a small subset of users. Over time, especially with intermittent use, antibodies  accumulated  and caused the adverse reaction. For the time being the dream of a non-addicting analgesic was dead.

When and Why Glass IV Bottles Disappeared

Glass IV bottles were all fun and games until you dropped one.

Up until the early 1970s you could receive your IV dispensed from any container as long as it was a gleaming glass bottle. These time tested and trusted  vessels had been the workhorse of infusion therapy for decades and possessed a sense of inertia that suggested  they would be around almost forever.

Having been raised  with glass IV bottles, older  nurses had a special reverence  for them. It was easy to view the level of remaining fluid and  glass was inert to allay any worries of interactions with the fluid contents. A strip of ordinary adhesive  tape could be easily applied to the side of the bottle with the time marked for the fluid levels. Pumps and controllers were nonexistent so we counted gtts/minute (gtts is a Latin abreviation for "gutta" meaning drops.) It  always amused me how health care folks  used  Latin to obfuscate the issue, but alas, that's a post  for another day.

KCl  and B&C vitamin supplements could be added to bottles without even using a needle, just plug that naked syringe into the air vent and inject away. I used to relish the visual treat of the deep yellow vitamin solution as it merged and mixed with the clear IV fluid in the bottle. Inject the colorful solution rapidly and a model of a spinning water spout could be replicated. I've heard the term "lightening in a bottle," but a miniature water spout was even more impressive.

 Nurses mixed all  IV fluids  on the patient care  floors, no need to involve the pharmacy with all those superfluous phone calls or redundant paper work. The air vent had another feature nurse's came to know and love. As the air bubble gurgled it's way through the fluid in the resonant glass botle to equalize  pressure, the soothing noise  was an auditory cue that all was right with the infusion. Infiltrated IV sites never produced the  gurgle. Glass IV bottles had a special place in every nurse's heart. We never gave a thought to their disappearance. What could possibly replace such a dependable and familiar piece of equipment?

The beginning of the end for glass IV bottles occurred in July of 1970. Outbreaks of hospital acquired sepsis by the bacteria  Entrobacter cloacae  were linked to Abbott Labs newly designed glass IV bottles with screw caps. The decades old bottle cap was pealed off to open the bottle similar to a pop tab on a can. Occasionally the metal would peal off unevenly resulting in a problem opening the bottle. A new screw on cap was designed to eliminate the opening problems. There were also problems with spiking the old design caps. Sometimes a tiny portion of the black stopper would break free and float freely in the IV solution. We were always told not to worry about it, but foreign bodies like little black flecks of stopper made every nurse nervous. Who in the world would want something like that coursing through their veins?

The newly designed threaded cap was easy to use and the problematic  black stopper was retired. We all liked the new design, but problems were waiting in the wings that would spell the end for glass bottles.

Viable bacteria gained access to the IV fluid while it cooled following the autoclave procedure which created a vacuum drawing bacteria in through the threaded interstices of the newly designed  screw- on cap. The end result was 412 known infections among hospitalized patients and 50 deaths. All of Abbott Lab's intravenous solutions in glass bottles  were withdrawn from the market in March, 1971.

On May 29, 1973 a Federal grand jury indicted 5 corporate officers from Abbott Laboratories. Investigation revealed the Abbott IV plant in Rocky Mount, N.C. was contaminated with a variety of pathogenic bacteria. The proliferation of bacteria was exacerbated by glass bottles of D5W falling from the assembly line and breaking ( a problem nurses knew all too well)  which provided the bacteria with an ample supply of growth media. This was one of the initial cases of health care officials facing criminal charges.

Hospitals were desperate for a supply of IV fluids and Baxter Labs had just introduced a novel product - IV fluids in a flexible rectangular configuration featuring a plastic container that collapsed as fluids infused. The flexible IV bags were tagged with the clever  name "Viaflex" and the revolution had begun. These bags could be stored in any position and touted a completely closed system-the bags collapsed as the fluid exited. No venting required. With the old bottle system it was risky to piggyback antibiotics into a primary line because drugs like Keflin came in 2 gm. bottles requiring a vent and connecting a vented secondary bottle to a vented primary line could allow for air embolism. Small plastic bags of piggyback medication eliminated the air embolism risk. Baxter acquired a pharmaceutical company and began selling premixed drugs in small 100cc plastic bags. The IV piggy back was off to a running start with the closed system mini-bags.  Soon many drugs administered by IM injection were being given IV and fancy new fangled notions of determining peak and trough levels of drugs evolved.

For a brief time period (1976-1980) Viaflex bags and glass IV bottles assumed  a tenuous coexistence. Vented IV sets were bicultural so to speak and could be used with either Viaflex IV bags or glass bottles. Using  nonvented  Viaflex IV tubing set up on a glass bottle was strictly taboo. Hapless practitioners that pulled this stunt found that without a means to relieve intrabottle pressure the drip chamber collapsed like a lung in a punctured pleural cavity. If the problem was not promptly corrected the negative pressure could begin to draw venous blood through the angiocath producing a tell tale red streak of blood in the IV tubing. Spooky indeed and guaranteed the nurse a prominent position on the wall of shame and vulnerable to endless gossip..."You would not believe what Suzy did with her IV last night...yada..yada," nurses only made this mistake once.

By 1980 the intravenous therapy world was ruled by Vialflex like flexible bags and glass bottles were gone for good. Abbott even began producing their own IV bag that had an unusual feature that nurses disliked. The port for adding medications was a blue bull's eye  target about 3 inches up from the bottom of the bag. When adding drugs to an IV, nurses were used to holding the port in one hand to steady it while injecting with the other hand. There was nothing to grasp on that blue bull's eye and nurses in a hurry were known to poke a hole through the opposite wall of the bag resulting in much cursing and  general unpleasantness.

This transition from glass to plastic  was difficult for seasoned old nurses who by  nature of their basic constitution were resistant to change. Glass bottles had prominent labels and were easy to identify; bags were produced with an over wrap that obscured the label. Drip chambers on glass bottles hung perfectly vertical; on bags the drip chamber was often hanging at an angle. Patient transfers with a bottle always required the careful use of a pole to maintain the positioning of the bottle. Nurses were appalled at the occasional  practice of tossing the IV bag on the patient's lap or chest during brief transfers.  Bottles would roll off and break if this crude trick was attempted. It was easier to thread a solid object like a bottle through an opening for an arm when changing patient gowns. Those IV bags were like getting a grip on a handful of Jello.  Finally, hanging those flimsy bags could be difficult. It was necessary to free up the folded vinyl hanger and thread the small opening over the hook on an IV pole.

I am truly impressed by the variety of realistic sounds produced by electronic devices like that camera shutter clicking noise on cell phones or that  "whoosh" noise when sending an email. The Oldfoolrn  medical equipment design institute has come up with another innovation. How about an electronic IV pump or controller that emits a skeumorphic noise replicating that gurgling noise as a bubble coursing through a vented  glass IV bottle. Lots of old nurses would  truly love hearing  that reassuring noise again.

Thorazine - An Old Fashioned Cure-All

Thorazine was thought of as a revolutionary breakthrough medication similar to Penicillin when the FDA approved it's use in the early 1950's. It was the very first psychiatric medication useful in the treatment of schizophrenia. Before Thorazine,  institutions used leather restraints, alternating cold and hot body packs and of course crude psychosurgery such as lobotomy.

In a bizzare side note Freud never received the Nobel prize for his work, but the fellow with that ice pick brain surgery  got the call from Sweeden to come pick up his Nobel prize for lobotomy. Efforts to recall this Nobel have been unsuccessful.

Thorazine was discovered while searching for a cure for malaria and worked by blocking dopamine receptors  in the brain - a chemical lobotomy. After Thorazine disables the dopamine receptors all sorts of bad things happen. Blocking dopamine does blunt the psychosis, but fooling around with neurotransmitters never has a happy ending. Akathesia (constant uncontrolled restlessness,) sustained muscle sasms leading to a debilitating constant muscle activity called tardive dyskinesia. I always thought of Thorazine as the equivalent of weeding a garden with a hand grenade. Sure the psychosis was blunted, but so was everything else that made the person an individual. These people were mere shells of human beings. The reeks and wrecks found on the backward of any long term psych hospital were not there only for their psychosis. The institutionalization and side effects of long term phenothiazine therapy were at fault too.

Thorazine was supplied in a wide range of dosage forms including;  syrup,  concentrate, injectable vials and even suppositories.  On my first medication passing adventure at Downey VA I had a med card that indicated the patient was to receive 2000mg of Thorazine concentrate. I was taught the maximum dose was around 200 mg. How could a patient receive 2 grams of this potent tranquilizer and survive? I was told this was the correct dose and the patient acquired a tolerance over the decades and to go ahead and give it. The patient shuffled up to the med room, gulped it down and went about his business. Simply amazing.

Some of the long term Thorazine concentrate consumers requested the nasty tasting substance "straight."  This meant giving the drug in a small medicine cup diluted with just a splash of tap water. The concentrate turned a brilliant shade of pink when the water was added and this was long before the color was associated with cancer survivors. Thorazine concentrate was just plain nasty smelling. Cracking that big brown tinted bottle unleashed a scent not unlike the Testors glue that I used as a youngster to assemble plastic model kits. We usually diluted it in a thick sugary substance called simply "citric." I doubted this tactic made it any more palatable, but at least it knocked some of the unpleasant smell down.

There is ample truth to the old adage that when there are 3 or more treatments for the same condition, none of them are effective. The pharmacologic corollary- If one drug is used to treat multiple divergent illnesses; it's not an effective drug. Here is an interesting hodge-podge of ailments that Thorazine was purported to cure in 1950s ads. A foolish panacea if I do say so.

Hmm.. this might just work. Snow him on Thorazine and see if he makes it to the bar.

I wonder if her "serene detachment" persisted through the muscle spasms of tardive dyskinesia.

In my experience, Thorazine induced rapid, shallow respirations-not sure how well this would play out for asthmatics.

Thorazine was known for it's hypotensive actions. Throw in an old time general

anesthetic with a Thorazine pre-op and watch the B/P drop like a lead balloon.

Wow.. never realized Thorazine was such a miracle drug with an assortment of therapeutic applications. It did work well for nausea in small doses of 25mg, but patients never asked for a repeat dose. I always asked post-op patients if their nausea was relieved by the small dose of Thorazine and their reply was always something to the effect that it worked but made their mouth very dry and induced a profound malaise and general feeling of unwellness. "Don't give that to me again!" was a frequent request.

When drugs are touted as having so many uses I suspect it's because they don't work too well for anything. Of course this lesson has been well learned and would never happen today. HeHe.

Where Did Mercurochrome Disappear To?

I've seen plenty of treatment modalities go from widespread use to complete and total extinction. Things like scultetus  binders, Phisohex, French eye suture needles,  hypodermoclysis, and last but not least; Mercurochrome which was a local antiseptic nick named "monkey blood" because of it's unusual color. When applied to skin it dried to a lovely orangey-is that a word?- red color. Worryworts used to fret that the coloration obscured inflammation, but infection cleared so quickly (hopefully) that this was a moot point.

An add from 1952 touted the child friendly nature of this first aid miracle solution: "Mercurochrome is one of the best antiseptics for first aid as  children do not hesitate to report their injuries promptly when mercurochrome is the household antiseptic because they know it will not hurt."

Every kid's mother had a bottle of this stuff readily available in the home medicine cabinet as an over-the-counter antiseptic. In the hospital it was mixed with Maalox and applied to decubitus ulcers and in the OR,  the final step after a Phisohex and Zepharin  prep was to paint the surgical site with Mercurochrome. Everyone knew when it was time to start a case because the Mercurochrome painted skin would almost glow in a radiant reddish-orange hue beckoning the awaiting team. What a beautiful site that glowing orange belly rhythmically rising falling with the Airshields ventilator chugging away. Everything seemed right with the world...It was great to be alive. Like Dr. Slambow used to say, "IT's TIME TO HIT IT."

In 1998, sourpusses at the FDA declared that "Mercurochrome was not generally recognized as safe and effective as an over the counter antiseptic," and interstate sale of "monkey blood" was prohibited. Maybe the science was lacking, but anecdotally, Mercurochrome had been around forever and did not kill or injure an appreciable number of people.

The hysterics over the medical use of mercury finally caught up with and doomed the use of  mercurochrome. What the heck?? Mercury was everywhere back when I was a nurse. Amalgym dental fillings-I have a mouthful.- thermometers to insert in an assortment of orifices, Thimersol preservative in multi-dose vials, syphgmomanometers, and every floor had a big brown glass bottle filled with mercury to inflate Miller/Abbot intestinal  tubes. These 10 foot long python like hoses tubes were filled with 45cc of mercury after the tube was in a patient's stomach and used for gastric decompression. Peristalsis moved the mercury filled balloon and tube through the GI tract like a whippet chasing a jackrabbit. Where that mercury filled balloon went, the tube was sure to follow. I heard stories about how one parapetic Miller/Abbott  tube made the complete GI tract  journey exiting from the anus. Anyone up for a round trip?

When on call,we used to play with mercury on the same table we dined from.  Dumping a glob of that marvelous silver liquid out of the brown glass bottle  and then corralling all those little BB sized  silver spheres and getting them back in the bottle could while away the time. We also thought getting squirted by an errant arterial bleeder was a badge of honor. Ahh.. the ignorance of youth when thoughts of mercury toxicity or hepatitis were far away. Dumb, but happy!

We knew nothing of the facts that mercury in sufficient doses is indeed toxic to the brain and kidneys. Although the mercury in Mercurochrome was negligible, the FDA required manufacturers to prove the benefit of their product outweighed the risk. This was never accomplished and Mercurochrome has disappeared for good.

My original title for this post was going to be: "Mercurochrome: Malicously Maligned for Malevolent Mercurialism."  Something about this aging business has attracted me to alliteration and I'm even starting to think in alliterations. Perhaps a long nap will help with some of this nonsense.  Thanks for journeying into my bottomless pit of eternal foolishness. I still worry about all you folks reading my posts so late at night. Lots of unpleasant things used to happen when I worked nights and I hope you are getting along with more grace than I did back in the day.

Epinephrine Evils - A Trio of Heathers Straight From Hell

Allright, it's time for some fun and games. I am breaking a promise to myself to abstain from blogging about present day healthcare. I make it a practice to avoid watching the television, but while on one of my frequent MD visits, the fancy newfangled flat screen TV was showing the House Committee  interrogating  Mylan Pharmaceuticals  jet setting CEO Heather Bresch. It was a  fortuitous circumstance that medical care was close by because  she made me physically ill and even the legislators were disgusted and admonished her sickening greed by hiking the price of an Epipen over 500%.

Suddenly as Yogi Berra so aptly stated "It was deja vu all over again." Another Heather and her malicious use of epinephrine popped into my aging brain. Kristin Heather Gilbert was VA nurse serial killer that murdered patients with IV epinephrine. Those with strong stomachs can google her name for the unsavory details.  I figured if I could connect the dots with these Heathers from Hell, I could break my promise to myself about abstaining from current issues. My suspicions were right on, these Hellish Heathers do have some things in common.  My promise to avoid blogging about  personal health issues (don't get me started on that one,) politics and religion still stand

To play this game simply match the "Heather" pictured on the left to her favorite epinephrine delivery device. The correct matchups are revealed at the end of this post. How's that for a sneaky, underhanded trick to encourage your readership?  I better stop hanging around with these Heathers. They really do creep me out.

.

What does Heather Bresch, the greedy Mylan Pharmaceutical CEO and Kristin Heather Gilbert a VA nurse and serial killer have in common other than their names. The answer: they both used epinephrine for novel and unintended purposes. While Heather Bresch used a dirt cheap drug, epinephrine to get filthy rich, Kristin Heather Gilbert used it to impress her boyfriend with her cardiac resuscitation skills. Unfortunately the cardiac arrests were caused by Nurse Gilbert overdosing her patients with epinephrine. Two very twisted ladies using a "life saving" drug to fulfill their own personal goals without any consideration of what they were doing to vulnerable patients. Neither one of these Heathers  ever apologized for their actions.


 In 1989 Nurse Gilbert joined the staff of The North Hampton MA Veterans Affairs Hospital. In 1990 she was even featured in a VA publication, The Practitioner. Likewise, Heather Bresch was recognized in Esquire magazine as a 2011 "Patriot of the Year." It's a sad world when it's considered patriotic to accumulate wealth at the expense of vulnerable patients that require medications. Both of these ladies were apparently considered exemplary examples of humankind according to the articles published.
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The parallels of these two women are truly stunning. Nurse Gilbert was frequently described as a habitual liar for most of her twisted life. She falsely claimed to be related to Lizzie Borden, the infamous axe killer.  Heather Bresch falsely  claimed she obtained a MBA from West Virginia University  and officials at this school falsified transcripts to reflect classes she never attended. The lies and falsification resulted in the resignation of the university leader, but Ms. Bresch was promoted at Mylan. I imagine that pulling off this academic deception empowered her and set her on her current trajectory of promoting the Epipen and the subsequent crazy price inflation of her product.

Ms. Gilbert had a lover that worked at the same VA hospital on the security force and hospital policy mandated his presence at all cardiac resuscitations. He quickly became impressed with Nurse Gilbert's cardiac arrest skills. In the mid 1990s investigation revealed that the arrests were caused by iatrogenic injection of epinephrine administered by Mrs. Gilbert. At trial in 2001,  it was suggested her motive was to impress the boyfriend. She was convicted of 4 of the murders and is serving a life sentence in a Texas Federal prison. It was speculated that she was responsible for 80 - 100 murders, but this could be much higher as 300+ patients died while under her watch.

Ms Bresch's motives were far less lethal, but I am certain she was on a crusade to impress share holders and boost Mylan stock price. Both of these Heathers turned a blind eye to the vulnerable patients impacted by their nefarious actions to impress a third party that should have been completely out of the picture.

Both of these women had the ability to compartmentalize their lives. Nurse Gilbert had been married and had 2 children which gave outward appearances of normalcy. Ms. Bresch's father Senator Manchin said his daughter was a very kind person and would give anything to someone in need. I guess he was  never underinsured and try to purchase an Epipen for an allergic child.

Both these ladies misled people and put their needs above others. I guess the serial killer, Kristin Heather is the worst part of this very bad lot. When I think of innocent and vulnerable children being deprived of an important medical treatment, it makes me wonder. One thing is for sure, they both would have been publicly shamed in front of their classmates and given the boot from a diploma nursing school. Our behavior was very closely monitored and one false move and you were history.

According to our student handbook, we were never allowed to be in the dorm while possessing money with the exception of a small amount of change for the pay phone. The school emphasized that it provided everything we could ever need including: housing, uniforms, linens, books, lab supplies and 3 meals per day if you could arouse yourself for the 6AM breakfast. Although we did miss out on Heather Bresch's millions, we had every thing we needed to learn nursing and that was all that really mattered.

Overall, stories like these evil Heathers add fuel to an underlying felling of depression. When I was a youngster the best way to avoid dark moods was to immerse myself in the work of the OR. It was tough to feel bad after a long case that went perfectly with Dr. Slambow extolling my virtues and saying with gratitude that he could have never done it without me.  Those bright OR lights boosted a dreary mood . Now as  an oldster, it gives me a sense of pride and peaceful satisfaction to look down at my Bovie burned finger and arthritic knees knowing that I helped someone at their most vulnerable and critical time and never gave a thought to the $4.95 per hour that I earned. You can verify that with some of my old paystubs (Just search Fools Gold- It's Payday.)

 I doubt any of the above Heathers will ever find such peace. I suspect it is fun to jetset about on private aircraft or live in a fancy neighborhood, but when you are old, the good feelings come from memories of people you have helped along the way such as the trauma patient you worked on all night  in the OR and then watched him walk out of the hospital to his waiting  family. I'm not all  that religious, but I am certain there is a special place in Hell for people that use sick, vulnerable people for personal gain. These Heathers are a tsunami of evil, death, and greed.

I should probably stick with my foolishness and old school nursing stories, but seeing Ms. Bresch  so arrogantly testifying before that congressional committee got my old iron poor blood to boiling. Everything is so different today.

The puzzle at the beginning of the post is very simple. Top photo is Heather Bresch and her grossly inflated Epipen. Middle is Heather Snootphull, a notorious drug fiend that tried to get high by inhaling epinephrine nasal spray. Lastly on the bottom is serial killer Kristin Heather Gilbert and her ampules of epinephrine. I betcha she injected a billion dollars worth of that drug at Mylan's prices.

Epipen Foolishness and A Real Money Maker

In all my years of nursing practice I have witnessed a total of 3 anaphylactic reactions and none of them were life threatening. Anecdotal accounts are really worthless so I looked it up. The annual death rate from anaphylaxis is 0.63 per million. You really are more likely to be struck by lightening (1 per million.) The lifesaving merits of the Epipen have been grossly overhyped by Mylan Pharmaceuticals.

Heather Bresch  the disgusting Mylan CEO not only boosted the price of the Epipen, she used her mother ( a school board leader bigshot)  to peddle this "life saving" Epeipen to school districts. It would have  greater social value to peddle lightening rods.

I made my vast fortune with my scrub nurse skills, but everyone can always use more money. Here is my proposal direct from the Old Fool product development institute.

Cardiac arrest is very common. If you have one of those fancy new AEDs nearby you might survive, but with one caveat. All that time your heart stopped your body was anaerobically metabolizing glucose creating a Life threatening acidosis. Just ask Heather Bresch if you don't believe me

To the rescue from Oldfool pharmaceutials comes a breakthrough new product. Sodium bicarbonate in autoinjectable devices. Just find a handy vein and go to town. Sodium Bicarb will buffer that nasty acidosis in nothing flat.

Stop the Epipen Madness

This story has all the usual elements of a Big Pharma vs. patient drama but with a few twists. We have the usual villainous CEO but this time it's a female Martin Shkreli in the form of a person named Heather Bresch who runs Mylan. She boosted the price of an auto injector device for epinephrine to be used for treating anaphylaxis by a gazillion per cent.

Rather than piling on this greedy CEO it might be easier to cease using her overpriced product. There is a simple alternative called a needle and syringe. To make this novel device fool proof simply preload it with the correct dose. You can jab that needle into your thigh just as you would with that auto injector gizmo and save yourself big money.

You are only going to frustrate yourself by trying to reason with Big Pharma CEOs. Most of them are hard core, dyed in the wool sociopaths. Ms. Bresch even attempted to claim she possessed an MBA degree that she never earned. Stay away from people like this. They are nothing but heartache and trouble. Epinephrine is dirt cheap and syringes are easy to use. Problem solved. Next on the agenda those leaking Micro Cool Surgical gowns profiled on 60 Minutes. I've got a simple fix for that one too.

Sleeping Pills: A Hypnotics History From 1960-1990

Sleeping pills always reminded me of the organized crime situation in Chicago; widespread, old players withdrawn (or jailed), new players or pills on the scene every decade, claims to be safe and acceptable, but very dangerous, and often fatal with long term use.

In the 1960's the big time hypnotic players were barbiturates such as the alluring red/pink Seconal. These little capsules were like a knock out punch in a medicine cup. After witnessing their power, I used to get sleepy just looking at the potent pill. Give one of these little 100mg capsules to a patient and it was guaranteed that in 30 minutes they would be sawing logs. I used to speculate that in a pinch these gems could be used for light anesthesia in minor cases.  I discovered that notion was not far from the truth. Dr. Bustoff, our plastic surgeon, used to order Seconal prior to performing local cases with Lidocaine. I vividly recall one case involving the excision of multiple sebaceous cysts where Dr. Bustoff  underestimated the length of the procedure and the patient began to arouse. "Tell him to stop screaming and give him 100mg of seconal STAT," was the order from the good doctor. Sure enough, 5 minutes later the patient was sound asleep and business went on as usual in the OR. Maybe open heart surgery could be done with a double dose!

Seconal was a drug that was carefully accounted for even before the Controlled Substances Act of 1970. The drug was sold by Eli Lilly and was packaged in small numbered cellophane ( a plastics precursor) packets that were reverse  numbered and rolled into strips and packaged 25 in a memorable green box with the Lilly logo plastered all over it. The company must have really been proud of this product. Nurses had a tremendous amount of respect for this powerful drug and I was never aware of diversion or abuse issues with nurses, although I have heard stories about health care workers becoming addicted. This drug was like penicillin in that fancy marketing campaigns and drug salesmen were unnecessary. The end results speak for themselves and did not really require promotions.

Occasionally, I research google something before I write (if you could call it that) about it. It was shocking to me that a pharmaceutical company recently acquired the right to market Seconal and was currently selling it for $3,000 per 100 capsules because the drug had been found useful in physician assisted suicides. Kind of sad, but then I realized that I must have handled over a million dollars worth of this drug.  It seemed like almost every hospital patient was on Seconal. As a nurse it always seemed like big money was flowing right through me or around me, but I can't complain, I've always had everything I could want with the wealth accumulated from being a scrub nurse. Life is good and most mornings I couldn't wait to get going in the OR which was probably a lot more important than the money. All of my old colleagues who have gone onto their great reward ran out of health long before they ran out of money.

Around 1970 or so, Seconal began to fall out of favor as it's addictive potential was recognized. A patient experiencing symptoms of barbiturate withdraw was not pleasant and the only way to combat the problem was with reintroducing the drug and tapering off it. Sometimes old school detox treatments were probably not too smart. Abbott labs actually made a D5W solution containing ethyl alcohol to prevent DTs while alcoholics underwent medical treatment. As a young nurse, I noticed a disproportionate number of alcoholics coming from suburbs around Ohare airport. I figured the jet noise must have driven them to the bottle.

In 1970 the shift to "safe" alternatives to Seconal was in full swing. The two I remember best were Doriden and Pacidyl. The most popular of these at our hospital was by far Placidyl. It came in 3 memorable doses; big, green jelly bean 750 mg cartoonish looking gelatin capsules, red gelatin jelly bean capsules which were 500mg and round gelatin 200mg capsules. The 200mg strength was intended to induce sleep if a patient aroused (not likely) from the heavy duty jelly bean capsules. Placidyl was not counted and there were huge stock bottles of it in every med room. Some nurses claimed the 500mg capsules were an effective way to deal with working an occasional night as a daytime sleep aid, but I never really wanted to try it after seeing what it did to patients.

One of the perks of being a senior student nurse was a class bus trip to Abbott Labs in North Chicago, Illinois. This drug company treated us like royalty (so different from our instructors.) We were treated to a really good lunch and a tour of the facility. The Placidyl production line was very memorable with 1000's of those red  Placidyl capsules and gelatin waste everywhere from molding the capsules. The excess gelatin was not really wasted, the drug company reused it as backing for the little paper memo tablets they gave away to medical personnel to promote their products. One of the tag lines printed on the Placidyl gelatin bound notepads was; "PLACIDYL...and softly,gentle slumber comes. Rest assured." When I saw this clever slogan the first thing that came to mind was "take one Placidyl too many and rest in peace." How different from the pharmaceutical industry of today that just raises prices to whatever level they please. I don't think that any drug company of today would worry about wasting gelatin or taking the trouble to use it as paper tablet binding material. It was very clever to convert a waste product (gelatin) into a marketing promotion for the product that created the waste. A profit circle of sorts.

Despite an alluring, peaceful sounding name there were big time problems with Placidyl. There was a very narrow margin between therapeutic and toxic levels of the drug which resulted in overdose. I did not have much experience with Doriden, but I think it was so addictive that the FDA banned the manufacture of it. Both Placidyl and Doriden were on the way out in the late 1970's and the new decade ushered in the benzodiazepine era.

Dalmane was a biggie and widely used sleeping pill in the 1980's. Patients used to complain of a funny taste in their mouth in the morning after awakening from a Dalmane induced sleep. To me, it did not seem to have the potent knockout ability of Seconal or Placidyl. In the mid 1980's there was some discussion that perhaps Dalmane had too long of a half life and a short acting benzodiazepine, Halcion was used. From my observation, this did not seem to be effective and there was much patient dissatisfaction. Lots of patients complained from feeling hung over the day after taking Dalmane.

I don't really know what came next in the hypnotic arena, but judging from the direct to consumer advertising, this must be a fertile market. Direct consumer advertising of toxic prescription drugs is one of the dumbest things that I have ever witnessed, but that's a contemporary issue and beyond the scope of my old time foolishness.

Foolishness and science are about as dangerous of a combination as guns and alcohol so don't take anything here as being factually accurate. There is probably enough misinformation in some of my posts to launch a Donald Trump speech. Oopsie, I should not have said that, but at least I have a good excuse. These are old memories sifted through an ancient nervous system.

Derifil - Nose Plugs in a Bottle

Before the advent of air conditioning and ventilation systems, hospitals were a virtual cafeteria of disgusting olfactory stimulation. The various offensive smells would just hang in the halls of the hospitals. Often times you could tell which ward you were on just by the character of the different smells. I think the worst was probably the detox ward. Combine the pungent stink of paraldehyde with every effluent a body could expel and you get the picture.

I remember a job interview where the meticulously attired supervisor asked me what my priorities would be if hired. The response popped into my head and I spouted out without much thought, "The ward smells just terrible. I would do something to mitigate the stink." The boss looked somewhat bemused, but offered me the job.

Traditional odor control involved opening as many windows as possible, using fans, dumping soiled linen as quickly as possible, and cover-ups like Airwick sticks positioned on door transoms. These odor camouflaging sticks looked like large green candles and did manage to add another olfactory flavor to the mix. I hated the smell of these green monsters as much as the scent from expelled lactulose enemas. I know it sounds paradoxical but those Airwick sticks had the nastiest "clean" smell that I have ever inhaled.

There was a revolutionary pharmaceutical product that was introduced at our hospital in the early 1980's. It was called Derifil and the product insert with this drug made some spectacular claims that had nurses enthralled.

This stuff was a chlorophyll derived medication administered orally in a beautifully colored greenish/black pill. We were totally fascinated by this pills color. Some said that it was the greenest black color they had ever seen and others insisted that it was blackest green color. Anyhow, it was very unique.

The medication was touted as an internal deodorant that actually quashed odors within the patients body before the stink could be expelled. It was said to quench the odor of stool, emesis, and even wounds draining purulent goo. I never figured out how a patient with vomiting could retain an oral dose, but the product insert did indeed specify that Derifil would destink an emeisis. We thought the hospital should obtain candy dishes to dispense this miracle drug. Just fill the dish to the brim and pass out the green/black miracle pills to every patient in sight with double doses on the detox ward especially prior to administering Lactulose enemas.

The Derifil era at our hospital only lasted for a couple of years and was quickly forgotten. This stuff was definitely effective at mitigating the odor of stool and doctors would order it for some patients that were squeamish about their new  colostomies and were preoccupied with the odor.

Derifil was introduced before pharmaceutical companies were clever enough to medicalize and come up with a pathological sounding name for the disorder and physicians did not recognize odor control as a serious medical issue. Maybe if the drug companies marketed Derifil to combat OOD (offensive odor disorder) the odor control game could have been propelled to a new paradigm. Without clever marketing, Derifil came to be regarded as a lifestyle drug before anyone even heard of lifestyle drugs. Physicians and patients alike failed to see odor control as a significant medical problem.

I also think that lack of  compliance with the odor control regimen may have been an issue. Who wants to acknowledge that they stink so bad they have to take a pill? People have evolved through the years an ability to tolerate their own body smells no matter how bad. I have been in attendance at many code browns (a great new term I picked up from you whippersnapperrns) where the nurses and aides are gagging and resisting the urge to run away while the patient lies there without batting an eyelash. People are basically immune to their own bad smells and not keen on taking a drug like Derifil.

Derifil seemed like a good idea at the time, but it quickly fell out of favor. I wonder, with new pharmaceutical marketing techniques this medication could be resurrected and become a commercial success.