I have four words for you: frustrating, confusing, scary, and stressful. That's what happens when the drugs you need aren’t available for your patients. And it’s been a big problem for the past few months as physicians and veterinarians struggle to make do without the crucial drugs that are used for anesthesia, seizure control, and pain management. 

According to The Wall Street Journal, the trouble poses more than a mere challenge for the clinicians involved. According to a recent study, patient safety is clearly being compromised:

Pharmacists and other health-care practitioners say ongoing drug shortages are accompanied by difficulties including a lack of available information, trouble finding alternative medications, and deadly errors, according to a survey conducted by the nonprofit Institute for Safe Medication Practices.

And here are some of their findings:

  • A variety of difficulties associated with drug shortages, including a lack of information about a shortage’s duration (85% of respondents said this was frequently or always a problem during the past year), a lack of advanced warning from manufacturers or the FDA (84%), difficulty finding a good alternative (80%), internal hoarding (58%), and physician anger towards pharmacists, nurses or hospital in response to a shortage (55%).
  • Some 64% of respondents reported there was a risk of adverse patient outcomes associated with a drug shortage, and one in three said their facility had a shortage-related "near miss." One in four reported errors, and one in five reported adverse patient outcomes.
  • Most of the drugs involved in the shortages are so-called "high alert medications," which have the highest risk of injury if misused. Those include the blood thinner heparin, chemotherapy drugs, morphine, epinephrine and the neuromuscular blocking agents used in surgery.

Troublesome, right? To say the least.

How scary is this? This scary: I believe it contributed to the death of one of my patients last week. Here’s the story …

Floreana, Flor, is a toad huntress. I’ve told her stories here many times before. That’s partly because she has been our worst serial offender (you know, some dogs will learn to stay away from the creatures that do them wrong, while others — typically terriers — will keep going back for more), but it’s also because she was my parents’ dog.

Last Thursday I received a call: Flor got another toad and this time it was very bad. The housekeeper had no car (my parents were out of the country), so I dropped everything and picked her up. She was seizuring on my lap as we drove to my place of work.

At this point it was already on my mind: We have no propofol! And the last time she received such a big dose of toad toxin (secreted onto the skin), the only medication that had any ability to quiet her seizure activity was propofol (yes, the same drug that killed Michael Jackson).

So when it became clear that the third dose of Valium and the second dose of phenobarbital were achieving a less-than-desired effect, I decided to wrap her up and take her to the specialty hospital for better drugs than I had on hand. By then it was too late. She vomited and subsequently suffered a respiratory arrest and profound bradycardia (very slow heart rate).

CPR. Drugs. Oxygen. Recovery. And then a mad dash to the specialty hospital ensued … only to discover that they also didn't have propofol on hand.

She continued to seizure through the night, developing aspiration  pneumonia (after all that vomiting I knew it was coming) and severe arrhythmias (toad toxin is a powerful cardiotoxin, too), so that she'd have to spend the night in an oxygen cage with a continuous EKG and constant attention.

Honestly, I considered euthanizing her at this point. My parents wouldn’t have blamed me, but the boyfriend urged me to give her a chance. And by the next morning she did look better. She even sat up when I tried to leave. But she was still horribly groggy from all the drugs.

So it was that I took her home that following night, wobbly and urpy as she was. Thinking she was out of the woods and would be more comfy with me, I set her to sleep in a crate next to Slumdog — only a few short inches from my bed.

At 3 a.m., Slumdog awoke me with his piteous whining. Flor’s breathing had become dangerously shallow. Though still curled into a comfy little ball, her pulses were imperceptible, her heart rate slow as a horse’s. She was dying. Right there and then I told her she would be OK, and that she was loved. And she went.

Sure, the lack of propofol, which had helped her so quickly in the past, may not have had anything to do with it. Yet the fact that neither hospital had the drug available may well have been the deciding factor. In light of her previous successful recovery with the drug, can you blame me for wondering?

Then there’s this less obvious, less personal issue to consider: Does the fact that physicians and veterinarians have to change their anesthetic and pain control protocols so suddenly factor into medical errors? Of course it does!

Imagine your place of work suddenly altering its basic practices from one week to the next. Wouldn't some errors be expected? It’s no different in medicine, only the stakes are changed.

Yet here’s the thing: Word of this problem has only recently started trickling down to patients and pet owners. Though it’s been frustrating for me, I haven’t thought about it in terms of my patients’ care until this episode.

But as with so many profoundly important issues, sometimes things have to hit you broadside — and hard — before they make their true impact known.

Dr. Patty Khuly

Pic of the day: "kitten pills" by Rakka