23 September 2013
In our lifetimes, each one of us will be either a caregiver or a care-receiver. 1. Brady
It's been a year and a half since my last whitepaper. Several of you have asked why I stopped writing. My husband Frank was diagnosed with cancer in late 2010 and my role in life quickly changed from author and business-woman to caregiver. He passed away in April 2012 as the immediate result of a shoddy medical device and a shift in business practices that uses poorly regulated specialty pharmacies as distributors.
Care-giving in the
An incredible burden is placed on family caregivers today. We are given a burden that goes far beyond basic assisted living duties of bathing, cooking, cleaning, shopping, changing diapers, and routine errands. Today the family caregiver is expected to operate sophisticated medical equipment, recognize the signs of disease progression, treatment failure, and make critical patient assessments, all without adequate training or skills or support. I believe the device industry must take proactive responsibility to ease this burden and protect its reputation.
The American Medical Association tells us that 16% of caregivers report their own health worsening since taking on the caregiver role (mine did); 40% incur financial expenses for (non tax-deductable) care related products, services, and activities (I did); and 20% spend up to 10% of their monthly income on caregiving activities. 4. AMA Some lose their jobs when long-term leave expires. Loss of health-care coverage can follow soon after. In my own situation I was forced to stop working for two years; I supported my family and paid insurance premiums with our life savings.
Division of Labor
Frank C Suarez, March 2012
After a work-up, the lump was diagnosed as an abscess caused by a Staph infection. Frank was started on an IV and oral antibiotics and began improving immediately. After a few days of treatment, we were ecstatic with hope and confidence.
And then, on March 28, he was sent home with a Curlin 4000 CMS IV pump and Curlin IV administration sets. He was to receive an additional six weeks of IV antibiotic therapy at home. We had every hope of a positive outcome and every expectation that the specialty pharmacies in charge of his health would provide quality drugs and devices to support our needs. His meds and tubings were provided by Walgreen's Infusion Therapy. The pump was dispensed from another firm called Greatland Home Health Services but had a Walgreens label on it. I never was clear about who the home health care nurse worked for. A 24/7 support line was provided by someone to answer any questions that might arise at home.
The Curlin 4000 IV Pump
At 10 PM the first night the pump started to beep incessantly. A mystery code was displayed on the screen. We couldn't shut the noise off, and there were no instructions for use. My husband was infected, feverish, tired, weak, unable to concentrate, focus, or remember the five minutes of 'training' someone had given him at the hospital. I was tired, worried, scared, untrained, and alone with someone's life in my hands.
After extended deliberation, we remembered the promised 24/7 support line for the device. When we called the 1-800-number we got an answering service. The individual said they didn't know anything about IV pumps, they were just an answering service, and they would have someone call us back. Try to imagine the urgency of the situation, the loud screeching and unending noise this machine was making late at night, and our frightened helplessness and vulnerability.
Several minutes later, a return caller translated the secret code as meaning we needed to change the battery. Wouldn't you expect a home medical device to be dispensed with a fresh battery?
To compound our desperation, a previous user had jammed the lid to the battery closet on so tightly that we could not get it off. My husband was weak and could barely open a can of Pepsi. I have a small frame and arthritis in my hands; I need a pair of pliers to open a bottle of Ensure. The woman on the phone said it didn't matter that we were promised 24/7 support, they were not going to send a technician out after hours to help us. Finally my husband used a hammer and screwdriver to pry off the battery lid. I said a silent prayer for revenge hoping the damned machine would be destroyed.
Wouldn't you expect a home medical device to go through a quality check before being dispensed?
Two or three times a day over the next few days we would get error messages called "down occlusions," accompanied by loud screeching beeps and a pump that didn't deliver life-saving medicine. Since there were no instructions for use, I had not been trained, and Frank was never educated about error codes, we called the 1-800-number again. The return caller told us that a down occlusion meant there was an air bubble somewhere between the pump and the bag.
The air bubble was always in the region of the pump rollers, where the tubing was placed inside the pump. The IV set was built from two lengths of PVC tubing, attached to each other by a short segment of soft silicone-like tubing—a common construction for peristaltic pumps. The soft tubing went inside the pump and over the rollers so the rollers could move the fluid forward. This seemed to be the source of the air leak. I learned to take the tubing out of the pump, massage the air bubbles backward into the bag, replace the tubing, and restart the pump cycle. I worried that if air could be drawn in from the atmosphere, what other contaminants could be drawn in?
A Final Failure
The primary family caregiver is expected to assess the patient and make the most important medical decision of the patient's life: should they be taken to the hospital or can they make it safely through another night? Although I asked the doctors on two separate occasions to educate me about what to watch for, all I was ever told was that if Frank was in trouble he would be 'disoriented' or 'unable to concentrate'. I had visions of a cousin with dementia who ran away from home one cold winter night.
To my eternal heartbreak, Frank forgot to turn the pump back on after mass.
We discovered the pump was off about noon the next day. The clue was that it hadn't screeched at us for twelve hours. There was an air bubble 18 inches long in the tubing. I didn't know how to disconnect the tubing from a PICC line and replace it so I had no choice but to start the task of massaging the air bubble backwards into the bag. I had to fight to get a health-care nurse come out that same day.
At 4 PM the nurse arrived and calmly suggested that Frank be taken to the ER. He simply said, "He is dehydrated." I had no understanding of the significance of those words.
Finally in the ICU, the doctors told me the dehydration had caused his liver to shut down and toxins had built up in Frank's body and brain. If he survived there would be brain damage. Frank was calling out "love out, love out" and I thought he was telling me he no longer loved me. Later I realized he meant "lights out", but he couldn't grab the right noun. The doctor and I had conversations about whether or not to "put the paddles" to him.
A few days later Frank came home to die. The next day the administration set fell off the PICC line and he started to bleed all over his clothing, blankets, and bed. The specialty pharmacy, who promised to deliver such specialized care, actually asked me to rebuild the PICC line following instructions from them over the phone!
My husband passed away on 20 April, exactly four weeks after being diagnosed with an infection. If he hadn't been sent home, if we had been given decent equipment, if we had been given picture-based instructions-for-use, if we had been given training, if the home care nurse had come daily, if the tubing hadn't failed regularly, if I had been told the signs and danger of dehydration, if, if, if... he might have lived a few weeks longer. I used to think that if you have lived for 70 years what difference can one more week make? Now I know that the last week of life may be the most intimate, the most loving, the most important that a couple can share.
Thirty-two days after his death, many models of CURLIN IV administration sets were recalled, including the model number dispensed to my husband. Conveniently, the specialty pharmacy did not keep records of which lot numbers Frank received.
The Blameless Middle-Man—Specialty
The statement is significant because it illustrates how specialty pharmacies are used as a screen behind which the device industry hides. Moog only makes the devices, what specialty pharmacies do with them is not Moog's problem.
In a bipartisan effort, the House introduced HR 3089, the Compounding Clarity Act, last week. The bill would subject large compounding (specialty) operations to regular inspections, fees and other requirements from the Food and Drug Administration, and would mandate FDA to write regulations for these operations. The Senate introduced similar legislation, S 959—the Pharmaceutical Compounding and Accountability Act—in May. 5. House & Senate.
FDA's Home Use Device
 Practitioner Survey on
Medical Device Labeling
Practitioners agreed that more pictures and diagrams; use of color, larger font size and more white space; a short and a long version of the labeling; the short version attached to the device; hardcopy and electronic copies; and better paper quality, all were improvements needed in medical device labeling.
The practitioners identified instructions for use, troubleshooting, warnings, precautions, contraindications, adverse events, manufacturer's contact information, and lot numbers/serial numbers as the most important items to be included in the labeling. Clinical trials and references were ranked as unimportant. 7. Practitioner Survey.
 Caregiver Survey on Medical
In 2012, a group of 127 caregivers were surveyed for FDA regarding their needs and perceived shortfalls regarding labeling for devices used in the home.
These people were caring for adult family members (95%), usually spouses or partners (44%), and the majority had been using their medical equipment for three or more years. The most common medical conditions were stroke, heart disease, diabetes, cancer, lung disease, Alzheimer's or dementia, post-surgery recovery, or simply old age. The most common items of medical equipment used were patient lifts, wheelchairs, blood glucose monitors, specialty hospital beds, nebulizers, respiratory equipment, and assistive equipment.
Caregivers indicated that more pictures and diagrams would be useful in the instructions, that most don't have instructions for their equipment, and that the information they need isn't always contained in the manufacturer's instructions; instead, information came from other sources such as friends. 8. Caregiver Survey
 FDA Accessible Medical Device
FDA proposed to develop a standard format and standard content for device labeling. And they proposed that a pdf copy of every version of a device's labeling be maintained in a labeling 'database' to be maintained by FDA. Care receivers often use the same device for many years, but manufacturers commonly replace older versions of labeling as new versions become available. Care receivers using older devices are unable to obtain replacement copies of labeling if the original is lost or unavailable. 9. Accessible Labeling.
 Draft Guidance on Design
Considerations for Home Use Devices
Delivery of training is key. People who are dealing with life and death scenarios cannot Google for instructions. The manufacturer must make certain the labeling is in front of the caregivers face, on top of the contract for service, and permanently affixed to the device.
Support is key. If a device fails at 10 PM it is unreasonable to tell the caregiver they'll just have to wait until morning for help.
Quality is key. Devices cannot fail in home. Period.