medication shortages

Monday, November 5, 2012

There is a fragile line between success and failure in sports. Often it comes down to what team can survive injuries to key players and the game plan is adjusted. The fan expects that there is always another player who can come in, but sometimes the bench is empty. It may not be the star player that cannot be replaced, but instead it may be the specialized skill of a long snapper or the place kicker who changes the complexion of the game. In medicine, the patient can be placed at a major disadvantage if a needed medication isn’t available. In this land of plenty, medication shortages are becoming routine and rationing medical care wasn’t supposed to refer to whether a hospital f=pharmacy was well stocked.

There is a pipeline that delivers medication from the pharmaceutical company’s manufacturing plant to the pharmacist in the hospital. Like building a care or a computer, there are many steps involved in delivering the components, but instead of motherboard sand steering wheels, there are chemicals and reagents that need to arrive in just in time to make the final drug. Sometimes, there are scheduled downtimes and hospitals can stockpile medications to meet their needs and sometimes, there just isn’t enough to go around and no idea when the next shipment will arrive.

The memo said that intravenous nitroglycerin is in very short supply and won’t be available for routine use. Nitro dilates blood vessels and is one of the staples for treating angina and other symptoms caused by narrowing of arteries to the heart muscle. By dilating those blood vessels, increase blood flow can restore oxygen supply and prevent muscle damage. It’s also a great drug for controlling very high blood pressure because it works quickly and if the blood pressure drops too low, turning off the IV infusion makes the effects of the drug go away. IV nitro is a great way to treat patients but a nat8oinawide shortage makes us go to the bench for alternatives. In the chest pain patient, it may be morphine, oxygen and nitroglycerin tablets dissolved under the tongue (but be wary; it’s a big dose of nitro and can the blood pressure can fall quickly). Still it’s an alternative standard of care that worked well before the intravenous nitro was introduced 30 years ago.

Propofol is a great anesthetic if used in a controlled setting, like the operating room or ER, but it’s running out as well. While it got a bad rap with the unfortunate death of Michael Jackson, the drug works wonders in sedating patients for short painful procedures, like reducing joint dislocations or shocking a heart rhythm back to normal. It works quickly and wears off quickly so that patients tend to wake up quickly. The alternatives are narcotics and sedatives that work well but the patient needs a longer time to wake up. That means more manpower planning because the time a nurse will be at the bedside may be measured in hours and not minutes.

There are dozens of other drugs that running into shortages and are on the FDA list. From cancer medications to antibiotics and medicines to treat seizures, doctors and pharmacists are planning ahead looking at second line alternatives to treat the variety of illnesses that can arrive at the hospital’s door. It may be an inconvenience like the shortage of sodium bicarbonate that is used to buffer lidocaine and make it burn less when used to anesthetize a cut before suturing, or it can be a big deal. Certain antibiotics used to treat very resistant bacteria are in short supply and the alternatives are less than attractive.

In an American hospital, the shelves have always been full. A medical team responds to losing a player, whether a role player or a star, will be very similar to the football coach looking down the bench and finding a replacement. It may not be the same and it may not be the best, but the game plan has to be adjusted to have the best chance of winning. Somehow, though, it seems that the medical stakes are a bit higher.

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