[lynn85]

I hope that I would have noticed this if I had been involved in this pt's care. Isn't lithium kind of a red flag drug, like digoxin? Either way, I'm glad the problem was finally corrected.





http://www.washingtonpost.com/wp-dyn...050203399.html

[EricEnfermero]

Good lord! Can you imagine if this woman would have had neurosurgery before this got sorted out?

[dld]

Yes, my dad died from this several years ago. My dad had went on a bus trip to Reno and when he came back he couldn't talk. Given his history of CVA, we all assumed it was a mild stroke, which it was, but the lithium level was mildly elevated in the ER, a fact that was not passed on to us. Since he couldn't talk we didn't know that he was not taking the lithium as prescribed, but had cut it down on his own without telling the doctor. He continued to receive lithium at the prescribed dose and get worse over the next week until he was comatose. He finally died of an IV line septacemia. It took me years to get over the anger. I still won't go to that hospital.

[bollweevil]

Scary. Glad it got corrected.

[earle58]

wow.
i am blown away.
even we nurses would have likely and immediately, wanted her lithium levels drawn.
dang...
what is wrong with this picture?

leslie

[talaxandra]

It does seem like something that would be included in the work up, but it's always easy in hindsight to spot the mistake. It's interesting how often, once there's a diagnosis, investigations into other causes etc gets overlooked - there's a fascinating book by Jerome Groopman called How Doctors Think that's just fantastic. Part of what he looks at is this phenomenon. Although I'm on a budget it was so great I had to buy a copy for myself.