A 74-year-old hospitalized man with no cognitive impairment complained of dysphagia after his lunch. He had been treated with cardiac transplantation years ago and had been receiving hemodialysis for a number of years and was taking 26 tablets each day. On the day concerned, the patient received his medications in a tablet container. With retrosternal pain, a globus sensation, and active saliva flow, he underwent emergency upper endoscopy. A blister pack fragment was found close to the lower esophageal sphincter (figure) and removed. Following this episode, the patient reported he had swallowed all his tablets in one go, as he “usually did at home,” without noticing that one was still in its blister packaging. Emergencies of this kind have been reported repeatedly, indicating how important it is to prepare medications carefully even for patients who are in full possession of their faculties. Not all of them devote any thought to how things might be done in the hospital and stick to their usual habits.
Figure.
Translated from the original German by David Roseveare.
Cite this as: Beige J, Wallstabe I, Schiefke I: All gone down? Emergency blister pack removal.
Footnotes
Conflict of interest statement:
The authors declare that no conflict of interest exists.