Saturday, March 31, 2012

The Seven Minute Itch

I'm home now, and home is where the heart is. It is also a favored hangout of the pancreas.

Meanwhile, I had an adventure in medical error. The other day, in the hospital, I noticed my head was itching. At first it was mild. I looked for flakes of dandruff. Soon, it was maddening. Then, my whole body began to itch. "Aha!" I thought, "I remember this!" I had a very mild form of red man syndrome. The same thing had happened to me 6 years ago.

Contrary to what you might think, red man syndrome does not involve a bunch of white people showing up with pox-laden blankets and taking all of your land. It's a drug reaction to the antibiotic  vancomycin. In severe cases, the patient turns bright red, and the skin starts to blister. It's quite unflattering. It's also painful.

I get the mild form of red man syndrome, which is merely annoying. The treatment (or prevention) is easy. You slow down the drip of vancomycin and/or take an first-generation antihistamine like diphenhydramine (aka Benadryl). Somehow, my adverse drug reaction had not entered the medical record, even though it had happened before at the same hospital. I called my nurse and asked her to give me some diphenhydramine and slow down the drip, and my itch went away. The rest of the doses were changed accordingly.

Yesterday, as I prepared to leave, the visiting nurse company representative came by. K and I made sure she knew about my reaction to vancomycin so that my home regimen could be adjusted. However, last night, when the nurse came by our house, we discovered that the vancomycin was to be given over 1 hour (the usual speed) instead of longer. Neither she, nor the pharmacy that had packaged the vancomycin, had been told about my red man syndrome. Luckily, as we discovered, I can tolerate the stuff at regular speed as long as I take my diphenhydramine in advance, and the diphenhydramine does not make me sleepy anymore.

It's a little frightening that a potentially serious adverse drug reaction could escape notice in such a top-flight hospital.

My take-away from this, though, is that it does not matter whether you are at the best hospital with the best doctors and nurses, etc. Information falls through the cracks. The visiting nurse rep may have forgotten what we told her because she slipped on a banana peel as she walked out the door. The nurse who knew about my adverse drug reaction never told the doctor, perhaps, because she may have been distracted by acute flatulence. I'm speculating here, but the bottom line is that no one in the medical system has as much time or attention to spend on your case as you and your family do. You are the last defense against medical error.


  1. A sobering reminder. Fortunately you and your family are spectacularly well suited to the task.

  2. Yes. The whole Medical Mafia on your side! Nurse Visi and company had better look out and get things right! " a la famiglia....and the rules that hold us together....."