Tis a Tale Told by Many

Full of Sound and Fury

Signifying Nothing!

William Shakespeare

This is the final of Part 6. which is the calendar date of the 4th!

It is so long and protracted simply because of the Colossal amount of Drugs which were given to my mum on that one day, after the Huge amounts of 2G Ceftriaxone the previous day!

~Act Twenty Two~

  • FY2 also mentioned to me at our ‘talk’ on 4th at 13.00pm that she was going to send mum for a Doppler to check for clots!
  • FY2 Did Not write about this in her notes.
  • In fact it was the Consultant who ordered this Doppler the next day on the 5th?
  • Why? if FY2 suggested it on the 4th, did she delay?
  • N.B. Mum was Not sent for the Doppler until the 7th when this entire episode plus another, became a major factor in her death!
  • FY2 Did Not write in her notes that I asked her if mum had blood clots and her reply was  ‘No, I don’t think so, it’s just a precaution!’
  • If it was just a precaution then Why was the Clexane stopped at all on the 2nd?
  • N.B. The prescription for Clexane was already written and dispensed at 12-2pm.
  • This meant that FY2 had already written this prescription Before 13.00 when she spoke to me as though she was including me in permission to give this?
  • Not only that, but this was also Before ‘Discussing the case with Dr. …….. whether to give Dalteparin (Clexane had been written on her notes and scored through)?
  • N.B. FY2 wrote No Notes whatsoever stating that Heparin was stopped on the 2nd, therefore any other doctor reading these notes would be completely unaware of this.

This must have been another verbal instruction to a nurse not to give these, while failing to sign off the prescription sheet?

  • Wow – That’s some amount of verbalism in that ward!

Plus it must have been verbalised to the ‘disgruntled’ nurse on the 2nd as she gave the last dose at 10-12pm when FY2 went off duty that night!

  • Perhaps they have Super Memories for All their patients!

~SIXTH OVERDOSE~

Paracetamol:

  • N.B. Mum was given 1G Paracetamol at 7-9am, plus 1G Paracetamol at *11am, plus 1G Paracetamol at *12-2pm.
  • This was 2G in less than 3 hours!

A further 1G was given at 4-6pm, plus 1G at 10-12pm.

  • This would Total 5 Grams of Paracetamol within 14-16 hours, or 3 G’s within 6 hours!

Paracetamol is metabolised primarily in the liver.

In a normal dose of 1G four times a day, one-third of patients may have an increase in their liver function tests to *Three Times the normal value.

Here is a Preview Below of mum’s Liver Test Results on the 5th!

Normal AST <40.                Mum’s *296.

Normal ALT <50.                Mum’s  *313.

Normal Gamma-GT. <55.  Mum’s *373.

Normal Bilirubin 3-22.       Mum’s *5.

Normal Alk. Phos. 40-150. Mum’s *310.

Normal Protein 60-80.        Mum’s *52.

Normal Albumin 32-45.      Mum’s *19.

Normal Globulins 23-38.     Mum’s *33.

Toxicity can occur even with chronic ingestion of doses as low as 4G a day, and DEATH WITH AS LITTLE AS 6G A DAY!

Concomitant use of other drugs that induce CYP enzymes such as Carbamazepine have also been reported as risk factors!

OVERDOSE SYMPTOMS:  Nausea, upset stomach, Diaorrhea, convulsions, Coma, appetite loss, vomiting, Confusion, General Malaise, Jaundice, Coagulation Defects, cardiomyopathy, Sweating.

*Mum would have every single one of these in Red before she died!

Evidence of liver toxicity may develop in one to four days.

  • Spot On!   She Died Four Days Later!

In severe cases it may be evident in 12 hours.  Laboratory studies may show evidence of massive hepatic necrosis (that is the Liver dying!) with elevated large potential for overdose and toxicity.

Individuals that have overdosed on Paracetamol in general, have not specific symptoms for the first 24 hours although nausea, vomiting and diaphoresis may occur initially, these symptoms, in general resolve after several hours.

After resolution of these symptoms, *Individuals tend to feel better, and may believe that the worst is over.

*Patient has No complaints.  Still feels O.K.  (From FY2 Notes above.)

  • Did this not match perfectly?

If a toxic overdose was absorbed, after this brief feeling of relative wellness, the individual develops overt Liver Failure.  In massive overdoses, coma and metabolic acidosis may occur prior to hepatic failure.

Without timely treatment, overdose can lead to Liver Failure and Death within days!

Intravenous acetylcysteine (Parvolex/Acetadote) is used as a continuous intravenous infusion over 20 hours (total 300mg/kg).  Recommended administration involves infusion of a 150mg/kg loading dose over 15 mins. followed by a 50mg/kg infusion over 4 hours, the last 100mg/kg are infused over the remaining 16 hours of the protocol.

Once it has been determined that a potentially-toxic overdose has occurred, acetylcysteine is continued for the entire regimen, even after the Paracetamol level becomes undetectable in the blood.

If hepatic failure develops, acetylcysteine should be continued beyond the standard doses until hepatic function improves or until the patient has a liver transplant.

Acetylcysteine was Never given!

  • Can you guess Why?

PROGNOSIS:  The mortality rate from Paracetamol Overdose increases two days after ingestion, reaches a maximum on day Four!

  • Strange how FY2 was Off Duty two days later, And her appearance coincided again on day Four!
  • On day Four mum’s Jaundice appeared immediately when she died!
  • N.B. On 5th (Next Day when the results of the above Liver Function Tests arrived) the Department of Haematology Started Daily Requests:
  • FBC: No clinical details provided.
  • PLEASE SUPPLY CLINICAL DETAILS!
  • This request would be repeated on the 6th, the 7th and once again on the 7th after 8pm!
  • Clearly the Laboratory Technician knew something was amiss!
  • No Clinical Details were ever provided to the Haematology Department!
  • No further nurses or doctors notes for B.P., Oxygen Saturation, Respiratory, or Pulse were recorded from the Chart which were:

Next, along came lunch and mum and the other ladies were hungry, but this is no magician’s feat.  The aluminium lids were removed to reveal roast beef.

  • Mum looked constantly at her plate as I cut this up into small pieces to feed her.  Her hand was shaking.
  • Can you begin to imagine how torturous this was for her, and for me feeling helpless to help?

All the other ladies complained that it was cold. 

  • Mum was eating it without a murmur and I had no idea it was cold until then!

The nurse/assistant who brought these told everyone quite casually ‘This often happens.  It takes the food 15 minutes to get here’!

  • I gave mum some potatoes and rice pudding which she ate starvingly.

The roast beef was returned by all ladies.

  • Mum was still hungry!

By the afternoon visiting time mum looked absolutely exhausted and I asked the nurse about moving her about when they washed her as I felt this was sapping any energy she had.

  • Remember I had No idea about this chemical cosh she was receiving!

The nurse whom I had spoken to then wrote copious notes abut me in reference to my appeal above.  She also wrote that I had told FY2 that mum had not been cleaned properly.

I can see how Shit-stirring happens in this ward, as I was not referring to anyone but the one nurse who had abandoned mum in the toilet, previously, then went home. (The one with the mud on her trainers!)

The pity of it was that this particular nurse had done an excellent job of caring with mum!

  • At 13.15pm written by the nurse/assistant:

‘Daughter asked who was …..floor manager.  I told her…..advised her that it was…..and gave her his address.  I enquired was there anything the ward manager could help with tomorrow, but she said she wanted to complain ‘fire alarm being noisy and had gone on too long’.  She thinks it should be changed to a light system.’

Now for The Truth Once More!

The fire alarm went off around 12.30 and this was in the corridor facing mum’s ward door.  I said ‘That’s terrible, what a racket’!  She said it was up to the hospital and I asked who the manager responsible was.  She gave me his name, and still speaking casually I suggested it would be better if the alarm was cut shorter, maybe intermittent with flashing intermittent lights.

It finally stopped about three quarters of an hour later and by then I had a headache, never mind about the elderly patients who were unwell.

Deepak Prasher of UCL on BBC2 9.4.8 quoted ‘Noise Causes Stress’!

The staff appeared resigned to this along with the fact that only one plumber was available in the hospital and the sink required fixing for three weeks.

I used this sink to clean mum’s teeth in running water!

  • The other nurse on duty, who had written about my complaining, wrote:

‘Patient’s daughter called me and stated she wanted a saline drip put up on her mother as she was *sweating. I explained to her that this was not beneficial to her mother as she was overloaded and needed IV Furosemide earlier in the day.’

‘She was not happy with my explanation.’

  • Oh my, another opportunity to make the relative out to be a baddie!
  • Having told the facts so far, and picturing what I had to contend with on behalf of my mother, do you see the real picture emerging?

Ask yourself one question.

  • Whose benefits are these copious notes written about relatives for?
  • N.B. *Sweating is one of the symptoms of Paracetamol Overdose!

Ask yourself.   

Was I the Only person who saw this?

Mum Never, Ever sweated!  She was one of those people who generally find it difficult to break sweat-   a Redhead.

N.B. Methyl/Prednisolone:

Serum levels may be increased by Clarithromycin – Monitor!

Carbamazepine:

Serum levels may be increased by Clarithromycin – Monitor!

CYP3A4 Inducers Carbamazepine may decrease the level/effect of Clarithromycin.

Furosemide may enhance the nephrotoxicity (kidneys) of Cephalosporins – Ceftriaxone.

*Comcomitant administration of single doses of Clarithromycin + Carbamazepine are shown to result in increased plasma concentrations of Carbamazepine.

*Mum was given both of these on the 30th, 31st, 1st, 2nd, 3rd, 4th, 5th, 6th and 7th!

  • At 14.00 her B.P. was 135/82, pulse 102, Sats. 87% on 6L O2, resp., 24.

These were Not written on any nurse’s notes.

These were Not written on FY2’s notes.

  • At 2.20pm mum was given:

40mg Furosemide IV.

  • At 4-6pm mum was given:

1G Paracetamol Calpol

5mg Salbutamol Neb.

0.5mg Atrovent Neb.

  • At 22.00 her B.P. was 154/90, pulse 101, Sats., 98% on 2L O2, resp., 18.

These were Not written on any nursing notes.

These were Not written on FY2’s notes.

  • At 10-12pm mum was given:

1G Paracetamol Calpol

500mg Clarithromycin IV

5mls Carbamazepine Oral

5mg Salbutamol Neb.

0.5mg Atrovent Neb.

1 Drop ea. eye Latanoprost

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