Sunday, March 10, 2013

TING AND I, Home Care Medications and Nutrition

By our seventh year of home care, we were using the gastric tube to administer the following medications, vitamins, and foods the indicated number of times per day: morphine sulfate* (eight), Carafate (sucralfate)* (four), Baclofen* (three), balanced nutrition liquid* (five), protein supplement* (twice), Prozac* (once), vitamins B6, B12, C*, and MgO, K, Ca* (each once), Fe (twice), yogurt (twice), Benadryl* (twice), Proloprim* (once), Ativan* (once), cranberry juice (once), aspirin* (once).

None of these was given against doctor’s orders. Those with asterisks were prescribed; some were available over the counter. Keeping track of these was done by a matrix, a “chart,” with rows being the items and their timing and the columns being the dates, with the intersection initialed by the nurse giving the item. Each chart noted the four chemicals to which Tina is allergic. A similar chart was developed for the many treatments needed regularly.

We had doctors’ orders for another dozen medications on a PRN (as needed) basis. This way, we were not asking the nurses to give Tina something not medically authorized.

In feeding, there are two easy ways to go wrong: too much food or too little. For Tina, we started with five cans of a 250-calorie balanced-nutrition drink. With the yogurt and juice, the total was nearly 1,400 calories. After a year or so, my 125-pound love had gained definite chub. Creases had formed in the skin on her back, and they were getting irritated. We cut back by one can a day to four per day, about 1,200 calories in all. Two feedings with whole cans were replaced by two feedings with half cans plus water. Slowly, the former sylph returned. At roughly 4,000 calories per pound of weight gained or lost, losing ten pounds should have taken about

(10 lb) x (4,000 cal/lb) / (250 cal/day) = 160 days,

probably not too different from what transpired. Physicists love equations.

My mother represented the other way to go wrong. She ate like a bird, a fussy bird, at that. In three months she went from about 125 pounds to about 110, a loss of 5 pounds per month. A similar estimate indicated she was getting 5 x 4,000 / 30 = 700 too few calories a day. I summarized this for her: “Eat or die!” She started eating more. “Eat and live!” became the rallying cry.


Powerful medications rarely have only one effect on the body. The other effects, “side effects,” one hopes will be benign or mild. We have to be watchful for them, especially during the early applications of a given medicine.

Tina is allergic to a few meds, and these are prominently listed at the top of each medication scheduling chart. If a new drug being started is related to any of these, we watch with particular care.

From the various nursing and medical handbooks, one can read a listing of typical, unusual, and rare side effects, with some highlighted as serious. In home care, the prescribing physicians are relying on nurses and family to detect such adverse reactions.

Less obvious is the interaction of two or more drugs to aggravate the side effects of each. We noticed Tina was losing her hair, which would have been very upsetting for her. We spotted two of her drugs that had this as a rare side effect. Combined, apparently, they were more of a problem. Checking with the doctor, we dropped or found a substitute for one of the drugs, and this problem went away. Surprisingly, one or more of her medications has led to a lovely waviness of her hair.

Drug interactions are hard to detect and probably more common than most people think. The number of combinations goes up rapidly with the number of drugs. For drug A and drug B, there is only 1 combination, AB. For A and B and C, there are 3 combinations: AB, AC, BC. For A and B and C and D, there are AB, AC, AD, BC, BD, CD, six paired combinations. For N drugs, each new drug adds (N-1) more pairs. Note, too, that three or more drugs lead to sets of triadic combinations: A and B and C and D have: ABC, ABD, ACD, and BCD. No wonder surprises turn up! We traced Tina’s only seizure episode to such a three-drug combination.

Did I mention that physicists love equations?

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