Have I lost my Mind? Or has Evidence based medicine failed itself?
Last night was a pretty ordinary night at the accident and urgent medical centre where I was doing an evening rostered shift. There was nothing extraordinary about Ted* (not his real name). In fact there was nothing extraordinary about his presentation either. Just another octogenarian. He could have been your dad or grandad, your brother or uncle. A person, an individual. Someone who is dear to you. Evidence based medicine has turned him into ‘just another octogenarian’. But he is Ted. He is a person, not a number. He is not actually quite the same as any other octogenarian even if they have the same clinical diagnoses. But evidence based medicine has turned everyone like Ted into generic Ted.
Let me tell you more. You can decide what to make of the story. You can decide what you would do.
Ted arrived at the after hours medical centre with his daughter. That’s what they had been told to do. “Arrive after 5 and someone will see you”. He was from out of town and staying with his daughter to recuperate from his foot infection. He had been staying with another daughter who lived a 45 minute drive from his usual place of residence. You see, Ted at the age of 81 was till living independently at his own house, near to his own GP. But he had an infected foot and was staying with his daughter. He then travelled here to stay with another daughter. She wasn’t sure how long it would be for. But he was going to run out of his medication. But the locum GP at his regular practice would not do a repeat prescription for him as he/she hadn’t seen him before. So now he was in my waiting room. He needed more pills and his foot was still painful. Oh, and he was constipated and just wanted a ‘good shit’. He didn’t need to be in an urgent care facility where there are 2 doctors and a full waiting room. He did need care. But this story is not about that kind of care (important nonetheless).
He had the requisite medipac of drugs. I right cocktail. At least he brought them along because he didn’t have a clue what the pills were or what they were for other than he’d had a ‘heart attack’ in January. Prior to this he had been on no medication at all. Nada. Nothing. And he had got to 81. Pretty good in my eyes.
The medicine list:
Aspirin 100mg daily
Metoprolol 23.5 mg daily
Enalipril 2.5 mg bd
Atorvastain 80mg daily (I kid you not!)
That’s exactly what happens when Evidence Based Guidelines are used for generic Teds. Except that Ted is Ted, not generic Ted.
But Ted came in also for review and dressings on his sore foot. It looked rather like a diabetic foot to me. He had a lovely macerated digital space between is 4th and 5th toes. But he is not diabetic. His finger prick glucose was 11. Pretty high considering he ate last at lunchtime.
The elephant in the room: are these drugs of any benefit at all for Ted? He has no idea of any benefits. He takes them because the doctor at the hospital discharged him on these because he ‘had a heart attack’. Because that’s everyone who has a heart attack gets. Ted is not everyone. Ted is Ted. What actual benefits will Ted get from this cornucopia of drugs.In all likelihood none at all. And about the side effects and drug interactions?
We know that there is a correlation between statin use and diabetes. And 80mg? Better than poison. We know that beta blockers aren’t that good if you have diabetes. And aspirin in the elderly – quite a high risk of bleeding. And ticagralor? Is there any safety data for use in the elderly? So here is Ted with his muscles very likely affected by his high dose statin, and a sore foot. That increases his risk of falling. So does blood pressure medication. Falls in the elderly have a high morbidity and mortality – broken hips, brain bleeds – and he is on two drugs that can make bleeding worse.
So is it possible then that drug side effects have contributed to his sore foot and increased his morbidity (and mortality) risk? If so, it means that the medicines he has been prescribed ‘because he had a heart attack’ may not be doing anything useful for Ted at all, but may indeed reduce his quality of life. Did anybody bother to ask Ted what he might want for himself. It’s called informed consent.
Ah, well at least Ted might not die from a heart attack. But will he live longer or better?