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'Seek medical help urgently' is possibly not an emergency? (LONG)

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  • 'Seek medical help urgently' is possibly not an emergency? (LONG)

    Sapphire Silk's comment about the ER doctor that didn't seem to know his medications triggered a memory for me from an instance several years ago when I ended up in hospital, where likewise the ER nurses/doctors seemed... less than knowledgable shall we say.

    I'll emphasize that this is purely a historical curiousity for me, I'm on a totally different class of drug now (which seems to be working really well). I'm mainly just posting as the incident just had such totally opposite attitudes from the different parties involved. And I'm a curious kitty about such things....

    I have treatment resistant depression, and on the journey of discovery on what medication to use, my pyschiatrist tried me on a class of drugs called Monoamine oxidase inhibitors (MAOIs). Prior to commencing them he strongly emphasised how dangerous they could be, how important it was for me to follow the dietry restrictions and check with a pharmasist on any (even OTC or herbal) medicines which might react (which seems to be most of them), and to check my blood pressure regularly. He gave me a letter which I was supposed to carry which basically said that I was on this class of medication and it is known to cause dangerously high blood pressure possibly leading to death, and I was instructed to show it to any medical professional that I interacted with. If my blood pressure was too high (and nobody really defined too high, just as higher than my normal), I was to seek medical assistance URGENTLY (with big emphasis of the urgently).

    Having been suitably scared out of my wits, I was very good about following the restrictions and monitoring my blood pressure and things went smoothly for probably about 6 months. Then one night I had chest pains, and when I went to read my blood pressure it was highish (170/110 I think or thereabouts, where my normal was 130/90).

    I completely freaked out, and after a bit of panicing and dithering rang 000 (911 for you Americans). I think it got up to about 190/120 when the ambulance arrived, (the panicing would have been pushing it higher) and when they asked I said I'd like to go to the hospital just to be safe (they were fairly unconcerned about it being a true emergency but didn't seem to think it was completely trivial or a waste of their time either). So off they took me to the hospital (at the time I was of the attitude better safe than sorry and since I was living on my own I was scared if it was a reaction to the medication I might die. In retrospect I think the ambulance and hospital was overkill). Neither the ambulance guys or the hospital ER people seemed overly concerned about my blood pressure (although it did stay, in their words 'fairly high', all night) so I've always felt a little bad for possibly overreacting.

    I had shown the letter to the ambulance guys, and to the nurse/doctor when I arrived at the hospital. The hospital people (actual nurses and doctors, not the admin people) basically said 'MAOI, whats that?' which seemed (to this day) such a bizzarely different attitude from my pdoc. I could understand not knowing specific drugs, but this was a entire class of (older) drugs, and one with a supposedly fairly easily occurring fatal side effect.

    To those in the field, is this a fairly understandable response? Are there so many drug classes that it's reasonable for ER staff to not be familiar with even those that have a common fatal side affect? Or is it that the pdoc and pharmasists were being overly cautious in so stridently emphasising the risks? And what are your thoughts about whether going to the hospital was overkill vs a not unreasonable response (was I a SC or drama queen)?

    Thanks for any responses.

  • #2
    Hey, BlackCat.

    I think I can explain the situation.

    It actually is not that common for people to be on MAOIs anymore. Because of the issues with dietary restrictions, poor interactions with other medications, and side effects, they are considered the last line drug for most uses. With one exception, I haven't seen patients on an MAOI in years.

    We still do teach students about them, but since so few patients take them, it's hard to conceptualize the issues when you have little to know practical experience with them. So we have a new generation of nurses and doctors with no practical experience working with these drugs.

    The only MAOI in common use right now is Isoniazid, or INH, which is used as a prophylactic treatment for people who test positive on a TB skin test.

    As for the reaction of the EMTs to your blood pressure: keeping calm keeps the patient calm. "Oh, shit that blood pressure is high" isn't any good for the patient. And honestly, a BP that high in a young person is serious but no reason to panic. You have time to get them to a hospital for evaluation and treatment.

    You did the right thing by calling 000. You had a high BP and you were symptomatic. You absolutely needed to be evaluated by a physician. I hope they did a full cardiac workup on you (you don't say what the ER doc did). You were not being a drama queen, and I see no evidence of SC behavior. Anxiety is not being a SC if the anxiety is justified . . . and yours was.

    I'm glad you carry that letter with you. The confusion of the ER staff is exactly why you should continue to do so! They have google, they can look it up if they're unfamiliar with the drug.

    No one can know every drug out there. My anger with the ER nurse (not the doctor) was that he didn't bother to familiarize himself with a drug he clearly did not know before he gave it to me. I give drugs I don't know all that well all the time. I look the fuckers up in a drug book before I give them! If I'm the least bit unsure, I call the pharmacist for clarification. I also listen to what the patient tells me about the meds they take. The patient often knows as much or more about their medical problems, meds, and needs than I do.
    They say that God only gives us what we can handle. Apparently, God thinks I'm a bad ass.

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    • #3
      Ah, that does make a lot more sense Sapphire Silk, thank you for explaining it to me. I knew it was an uncommon drug, but hadn't realised it was that rare.

      Yes, the incident occurred early evening, and they ran a lot of tests that night/into the next morning (most of which I don't remember but there was an ECG as well as keeping me connected to the monitor screen with the constant BP readings until the next morning when the BP went back to normal). I do remember the stress test because I was admitted to a ward in the morning and they kept me that day/night and into the next day as they were waiting to do the stress test before releasing me. (since apparently if they had discharged me, I would have been on a waiting list for a few months to get the test done as an outpatient vs it only took them 24 hours to find a space as an inpatient). They definitely did a thorough job making sure it was nothing untoward.

      And yes, I've always loved the fact that my psychatrist always looks up any uncommon new medication he puts me on, even if he has other patients taking it. It's worth checking that there isn't something there that would make it unsuitable for a particular patient.

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      • #4
        There are three non-selective MAOIs in use for depression: Nardil, Parnate, and Marplan.

        They aren't common, but at one time were the drugs of choice for atypical depression. They are the oldest class of antidepressants, having been invented by accident whilst looking for a more effective antituberculosis treatment. I do dispense Nardil and Parnate once in a while; haven't seen Marplan recently, but it's still on the market, and per my wholesaler it still has no generic despite being on the market since 1959, which kind of demonstrates how little demand for it there is.

        (I was considering using Parnate once, due to its non-sedating property, but decided I would rather not lose the ability to eat chocolate. Went with Wellbutrin instead, which worked OK for me; I've been able to live without antidepressants for nearly two years now, thank G_d, but still keep a vial in the house, Just In Case.)

        Isoniazid or INH, as Sapphire mentioned above, is the first line treatment for TB, usually in combination with one or two other drugs to prevent development of resistance. They came up with iproniazid, thinking it might work better than INH. They found that the patients weren't getting any better, but suddenly weren't depressed about it, and said Hmmm. Maybe we can use this.

        There are a few other MAOIs on the market, but not for depression. Zyvox is an antibiotic; selegiline is an antiparkinsonian; Matulane is an anti-cancer drug.

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        • #5
          yikes. I saw those BP numbers and immediately thought "stroke/heart attack territory". Pressures can get that high with strenuous exercise/workload, but as soon as the load drops, so does the pressure. Normally. If one has that kind of pressure as a constant, something will break sooner or later.

          yes, the ambulance people were right to remain calm (they ARE professionals, amongst other things) to keep YOU calm. Hospital/ER staff not picking up the Physicians Desk Reference? Someone smack 'em with a rolled-up newspaper. The information is THERE.

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