Not-so-magic swizzle: A cautionary tale

The Lown Institute Vignette Competition challenges medical students and trainees to shine a light on everyday overuse and underuse – common practices that either give patients unnecessary tests and procedures, or that fail to give patients necessary care. Sharing stories of the downstream consequences of overuse can be a powerful counterbalance to the ‘more is better’ culture and can help clinicians recognize and avoid overuse. 

This year, we received vignette submissions from students and trainees all over the country (and internationally!) on topics from avoiding polypharmacy to inappropriate stenting to navigating clinical guidelines.

We spoke with vignette competition winner, Dr. Ricardo Nieves, second-year resident at the University of Pittsburgh Medical Center. His co-authors, Dr. Tariq Salim and Dr. Casey McQuade, are also residents at UPMC. Their vignette, The Devil is in the Details: Combination Medications, Oversedation, and Unnecessary Testing in the Geriatric Population explores what can happen when a commonly used combination drug is not adjusted to an elderly patient’s existing medication regime. 

Lown Institute: Tell me about how this case played out.

Dr. Ricardo Nieves: Tariq [Salim] and I were the night team called to respond to a patient’s altered mental status. She was a 78-year-old with chronic chest pain and esophagitis (enflamed esophagus) and became unresponsive during the night. A stroke code was called and from there, one thing rolled into another. The condition team evaluated her, we got blood work, a CT, and MRI. 

From the tests we could tell she hadn’t had a stroke, so we were wondering why a patient like her would be altered all of a sudden. Then after looking at her chart we realized she was receiving a combination medication called “Magic Swizzle” multiple times over the course of a given day.

Lown: What is “Magic Swizzle”? It doesn’t sound like a serious medication…

Dr. Nieves: Magic Swizzle is a combination medication that helps relieve pain and helps patients swallow. The name sounds harmless but there are some pretty serious drugs in it, including the active ingredient in Benadryl. I had a course of influenza in medical school and I got prescribed magic swizzle, it works great but I never know what it had in it.

Usually we schedule Magic Swizzle a couple of times during the day. For this patient we had evidence of esophagitis, she asked for the medication, and we saw she improved so we just gave her more. We don’t associate a lot of risks with this medication, so we didn’t think it would hurt. But we lost track of the medications given. When we looked in her throat for an exam, we saw that the liquid was still in her throat, she was absorbing it very slowly and getting more and more of the Benadryl. This can cause delirium and confusion.

Lown: How do you think this situation could have been avoided? 

Dr. Nieves: After the fact we were thinking, where did we go wrong? It might have been prevented if we had a pharmacist on our team, which is the case with many teams at UPMC. We have to be much more alert to the fact of medications that are started should be scrutinized, especially with elderly patients. We can’t automatically consider medications safe, but think, what are we treating with it, what are potential side effects, what could we be using that’s better? 

This goes hand in hand with being vigilant about medication we start people on. For the rest of that month we were very cognizant of the different medications we were starting. 

Lown: Is this type of case common in hospitals?

Dr. Nieves: This is not an isolated incident. After looking at some of the research on contraindicted medications (medications that aren’t supposed to be taken together), we saw that it’s exceedingly common among older adults.

Part of the problem is fragmentation of care, which happens everywhere. It’s not like one particular person made a mistake, but no one is taking responsibility. That’s why at UPMC we try to have multidisciplinary teams – have a nurse, pharmacist, social workers, physical therapist – to try and see different aspects of the same case. It all boils down to communication and clear lines of communication, between the clinicians and patients, and between members of the care team.