Not such a simple request after all (Christine Dixon)

As an independent prescriber, I am often asked by nurses to prescribe laxatives and antacids. These requests, which often seem simple on the surface, can be complex, and prompt clinical intervention is sometimes required.  

A few months ago I was on a ward that I don’t routinely visit and a nurse asked me to prescribe glycerol suppositories for a patient. I have often seen doctors do so on demand, but I prefer to check the situation first.

The patient had received a hip replacement two days before and was feeling uncomfortable with a distended abdomen. I believed that there was a possibility of intestinal obstruction or stasis and recommended that a doctor examine the patient’s abdomen. Realising that the patient had been sick several times that morning reinforced my opinion that a suppository was not the answer.

By the time the doctor arrived the patient had been sick again, this time producing “coffee grounds”. The doctor transferred the patient to our high dependency unit and started treatment for a gastric bleed.

This week on the ward round, a patient complained of several episodes of loose, dark stools. The doctor started omeprazole as a precaution. In the afternoon, a nurse bleeped me and asked if I would prescribe an antacid. I declined and said the patient needed to be re-examined by the doctor. The patient was subsequently transferred to the HDU with a gastric bleed.

I work in an elective orthopaedic centre where 70% of our hip and knee replacement patients are aged over 70 years. All are given a low molecular weight heparin after surgery and are therefore at risk of gastric bleeds; so far this year we have seen three (from about 2,500 procedures). It is interesting that, for two of these patients, nursing staff requested a simple remedy from the pharmacist prescriber rather than contacting the doctor.

I am asked to prescribe antacids several times a month and suppositories several times a week. I am always conscious of the silent myocardial infarction posing as indigestion, so am cautious when prescribing antacids. I consider the possibility of intestinal obstruction or stasis when assessing the need for suppositories — but had never seen a gastrointestinal bleed posing as obstruction, as in the first example.

We all need to tune our radar to spot the unusual among the routine.

Christine Dixon is principal pharmacist at the South West London Elective Orthopaedic Centre, Epsom and St Helier University Hospitals NHS Trust