Dough-mama

I clearly remember my great-grandmother. She passed away at the age of 90, when I was 19. She had been completely independent since her husband had died 20 years earlier. She still lived in the same apartment that they had shared; it was a regular apartment building, not an assisted living or a senior community or anything like that. She wasn't particularly intellectual, but she told the BEST stories; she told me about growing up during the Depression, why she never learned to drive, and all the gossip about the residents in the building. I remember sitting on her lap when I was little and marveling at just how soft and squishy she was. She was probably at least 75 pounds overweight, and didn't seem to care much at all.

If my great-grandmother were alive now, she would most likely have moved in to an assisted living facility. Well, she would be well over 100 years old now, so I suppose I mean if the Grandma of my memories were alive in the present day. I would see her orders come across my desk. Carb-controlled diet for the diabetes. NAS diet due to the hypertension. Encourage exercise. I actually saw an order for Alli for a resident last month. I know obesity is an epidemic in this country, but if someone gets to the age of 90, will it really hurt to let her have dessert?

I was reviewing a new admission to one of my rehab facilities this morning and noted her weight to be 305 pounds. She's 5'3". Fifty-three years old and having her second knee replacement surgery. Out of sheer curiousity, I calculated her BMI. Fifty-four. Her BMI is greater than her age. Makes me wonder how my grandmother would have compared. In this area, at least, she wouldn't have quite measured up.

What about Bob?

I found a rather interesting item in the Federal Register for April 29th, 2009 while searching for recent DEA actions. I didn't realize that revocations of DEA registrations were published there, and it makes for some interesting reading.

Bob's Pharmacy was investigated for dispensing controlled substances not pursuant to a valid order. Between April 15th and June 28th 2007, Bob's Pharmacy purchased more than 767,000 dosage units of hydrocodone! In just over two months, they purchased three quarters of a million dosage units. Unbelievable. The report goes on to detail various other problems, such as dispensing more than 6,000 prescription written by a physician who not longer had a valid DEA registration, and was only licensed in Louisiana (the pharmacy was in Florida). The prescriptions were being shipped all over the country, and weren't just limited to local Florida junkies.

If there are places like this that literally hand out vicodin like candy, why do the junkies bother the rest of us? Much easier to get it from Bob (or whomever has now taken his place).

Ready Fire Aim

I am on call all holiday weekend. Even though the paging service is supposed to be for EMERGENCIES, my definition of emergency is clearly different than that of the staff at my facilities. I had five pages yesterday, and then had one just before seven o'clock this morning. The message was that they needed a refill on a resident's clonidine patches. First, refills are not emergencies, that's bad planning on the part of the facility. Second, I know for a fact that those patches were sent as a special delivery on Tuesday because the facility manager called me freaking out and I checked the stupid things myself. Third, the patient had phoned the managing pharmacist on Thursday evening to officially terminate services with us and go with a corpo-pharmacy, because he disliked "how much" we charged him...set by his insurance copays, but he couldn't understand that because he has more than a touch of Alzheimer's.

The person who called me insisted that they did not have the patches, and absolutely must get them right away. I didn't think they even needed to change the patch today, but maybe it fell off. I have a lot of other patients at that facility, and I didn't want to get in a pissing match with a staff member. I told him that the patient had terminated services, and that I *knew* the patches had just been sent, but if he couldn't find them I would certainly bring a replacement box, instead of making him contact the new pharmacy, because it's good for relationship building (even though it's a huge cost to the pharmacy). He swore that he had looked everywhere...everywhere!...and they were not there. I go to work, fill the script, head to the facility, and as soon as I walk in the door he says to me, "I owe you a huge apology. I found them. They had gotten shoved to the back of the medication drawer."

There were a lot of choice words that I wanted to say to him, but I just said that if he needed anything else, he knew how to get in touch with me.

Black box warning: Do they mean anything anymore?

I remember first hearing about a black box warning being placed on a drug when I was in pharmacy school. It sounded like such a scary thing--"Black box warning! Stay away!" Now, it seems like everything has a black box warning. Everything has a medication guide. Does a black box warning have any meaning when practically every drug has one?

Warfarin has a black box warning for life-threatening bleeding. Seriously? Warfarin? Of course it can cause life-threatening bleeding! Why does it need to be given a black box warning? I decided to search google for references to black box warnings, to see just how large of a list I could make up. (I'm a nerd. Deal with it.)

Nevermind. I stopped counting when I got to 100. I did find some interesting new drugs (new to me, at least). What on earth is Edluar? Turns out that it is sublingual zolpidem tartrate. I don't know if it has officially been launched yet, but I bet there will be plenty of advertisements about it. Who comes up with these drug names though? Edluar?

Thank you for wasting my time

I am on call this weekend. The after-hours emergency line is supposed to only be available to our facility staff, and not individual patients in their homes. The owner of the company decided to make the number available publicly on our answering machine, just in case a facility misplaces it and needs to get in touch with the on call pharmacist. I just got paged by an ambulatory patient. The message from the answering service was that she had left the ER and didn't get a prescription for compazine, and she is throwing up. I debated whether to do it or not, because the paging service is not for our ambulatory patients. I decided to call her back and get more info. I got her voicemail.

You page me at HOME, like the answering machine at the pharmacy clearly states, and when I call you back within FIVE MINUTES, you let it go to voicemail? I was going to help you, but now you're on your own. YOU can call the hospital and have them call in a prescription to Target or Walmart or wherever, and you can deal with getting it. I am not going to make a special trip in to the pharmacy when it is CLOSED, because you don't want to handle your meds yourself. If you had picked up your phone right away, you would have saved yourself some aggravation.

Update: I called my paging service back and told them that if/when she calls again, to please tell her that I tried to call her back and got voicemail. If she wants to talk to me, she has to actually pick up the phone. She paged me again about 20 minutes later, and this time did pick up her phone. She was sounding plenty pathetic, describing how she had to go to the hospital for dehydration and diarrhea and various other complaints, then told me that the reason she called me was because the pharmacy at the hospital told her that her insurance wasn't working. She wanted me to call that pharmacy, transfer the prescription, fill it, and bring it to her. I told her that if the insurance didn't work at the other pharmacy, it wouldn't work for me either. She insisted that it magically would. "Just call them!" she begged. I told her that if she wanted me to transfer the prescription, she would have to give me the name and phone number of the pharmacy. She didn't know it. "Don't YOU have that information??" she asked me. No. I have no idea what other pharmacy YOU took YOUR prescription to.

This particular patient is state aid, and gets extra services though a local care agency. I told her to call her care agency's on call nurse, and maybe they could do something about the insurance issue (since they are also the insurance provider), or at least could get the on call nurse practitioner to call an order in to me. It's been three hours now, and I haven't heard anything else from her. I imagine the situation is taken care of.

Seriously though, stupid person, why on earth would the on call pharmacist at one pharmacy know why the insurance isn't working for a prescription you are filling at another pharmacy? How can you possibly rationalize to yourself that it is okay to call someone at home and ask them to open up the pharmacy, chase down your prescription, fill the prescription, and deliver it to your home...for FREE?? I'm sorry that you are so nauseated that you felt the need to go to the ER, but your insurance problem is not my issue to fix.

(Oh, by the way, the ER pharmacist called me to verify your current doses of narcotics. Nice job lying to him about how much oxycontin you take. It's not going to get you a new prescription.)

Anticipate the question

Yesterday, I called one of the NP's in the area to discuss a therapy change on an arrhythmia medication for one of my patients, Miss J. I can no longer get the medication from my distributor; Miss J has been on the same very low dose for at least eleven years, and she is my only patient currently on the medication. I anticipated that the NP would agree to discontinue the medication without much discussion, or would have an idea of what she would want to use instead. I neglected to investigate any similar alternatives.

The very first thing the NP asked me when I explained the situation with obtaining the med? "What would be the most similar thing? What would have the same therapeutic effect?" Shit. She admitted that she wasn't very familiar with the med; I quickly admitted my own ignorance and asked her to hold while I grabbed a reference book and looked up which other medication would be in the same class. DiPiro was the first thing I grabbed, and luckily I could find an answer fairly quickly. It was NOT a quality answer. After a short discussion the NP decided that she will probably discontinue the medication, but she needs to speak with Miss J's daughter, who is the POA and makes her health care decisions.

I felt like such a jerk. Of COURSE she would ask what else I would recommend! I made the assumption that there was no longer a need for the med, that Miss J has probably been on it for 50 years and nobody ever bothered to discontinue it because if it wasn't a problem, why stop it? If she's having decent rate control, the med is either working or doing nothing, but either way, she's fine. I just assumed that since Miss J is 97 years old, one fewer medication would probably be a good thing for her.

After I completely blundered through the phone call, one of my technicians (who used to work on an inpatient cardiology unit) volunteered some very helpful information that would have made a much better recommendation. Miss J is on a beta blocker, which has some antiarrhythmic properties. She is also on digoxin. Her recommendation was to stop the class Ia that she is currently taking and monitor the patient; if necessary, increase the beta-blocker.

Note to self: recognize when I have no idea what I am talking about, and read about the subject before trying to answer a question, especially cardiology.

Missing adderall tablets

I would like a show of hands...has anyone ever opened up a sealed, brand new stock bottle of a controlled substance (any controlled substance) to find that there were not one hundred tablets in the bottle as there should have been? On Tuesday, there were two tablets of adderall missing from a bottle of one hundred. On Thursday, there was one tablet missing. I was not the one who opened the bottle and filled prescriptions out of it. It was reported to me by another staff member. The entire work area was searched, but the tablets were not located. Could the bottle have been short, or is there another issue going on? I cannot remember ever having a stock bottle be short from the manufacturer on a controlled substance.

Pharmacy conferences

When I was in pharmacy school, we were highly encouraged to attend pharmacy conferences. The school had chapters of ASHP and the state pharmacy society, so those were popular, as was APhA. I only went to local meetings when I was in school, because the large meetings were too expensive for me at the time. Since I graduated, I've made a commitment to attend at least one conference each year, whether it is in-state or something I have to travel for. This year, I decided to go to a senior care conference sponsored by ASCP. It's being held this week, and I'm looking forward to traveling and meeting other pharmacists who specialize in geriatrics.

When I attend a good conference, I find myself more motivated to go back to work. I get some good practice ideas, and I love networking with other people. My coworkers think I'm a little strange because I like doing CE, and love going to meetings. Attending the meetings keeps me motivated to keep expanding my knowledge, and helps me identify the areas in which I need improvement.

Which conferences are worth looking in to? I usually blow off APhA's magazine (because I think the writing is not very good), but is the annual meeting a worthwhile experience?

Birth control!

The receptionist paged me this morning. "Jane, pick up line 3. This girl is insisting that I need to sell her Plan B and I have no idea what she's talking about!" The pharmacy's receptionist is about 55 years old, and has somehow managed to evade the media coverage of OTC Plan B. For reference, I work at a closed door, long term care pharmacy. I do not stock Plan B, because my patients don't NEED Plan B. I answered the phone and hear, "But I NEED Plan B!! Why won't she sell it to me?? Why is she telling me NO??"

I try to explain to this woman that we do not stock Plan B, but she kept interrupting me, accusing me of being one of those crazy pharmacists who want to limit reproductive rights for women. For the record, I think Plan B, when used appropriately, is a great thing. I tried suggesting that she call the retail pharmacy we are affiliated with, and she stops short. "Wait, you're not XYZ pharmacy? On Jackson Street?" No, I tell her, we're XYZ Senior Care, on Main Street. "Why didn't you tell me that right away, instead of wasting my time??" Slam. It should have been a clue when the receptionist answered the phone "Thank you for calling XYZ Senior Care Pharmacy..." but evidently not.

A nurse case manager for one of the psychiatric support groups called a few days ago. Her patients aren't elderly, but require special packaging and medication boxes that I provide. I draw the line at blister-packing birth control; it already comes that way. She was calling regarding a patient who happened to throw up a few hours after taking her pills, including her daily birth control. The nurse wanted me to dispense a replacement tablet to her patient, so she could take another dose today. I told her it would be fine, enough time passed between taking the dose and throwing up that the patient should be fine, and if the patient was really concerned, she could use a backup method for the next week.

Turns out, one of the patient's issues is an intense, paralyzing fear of pregnancy. She was freaking out that she could get pregnant from one missed pill. I told the nurse to just take the last pill from the pack if she *really* wants to take an extra. The patient also obsesses over patterns. She cannot take a tablet that is not meant for that day. The nurse was insisting that I need to provide a replacement tablet. She can't seem to understand when I explain that birth control pills are dispensed in whole packages. If I break a pack up for her, the rest goes to waste. The patient's insurance wouldn't pay for another pack, because it had just been filled less than 2 weeks ago. I told her that she could purchase a pack and be a little ahead. That idea was shot down as well.

My suggestions were:
1. Just skip the missed pill
2. Take the last pill from the pack if she really wanted to double up and refill a day earlier next time.
3. Buy an extra pack and just have extra on hand

The nurse case manager did not like any of these idea. "Just give her one replacement tablet," she kept repeating. She was not understand that I would be out $35 of drug cost if I did as she asked. Finally, after 5 minutes, I repeated the options and told her to pick of those, because I was not going to just waste a pack. She called me uncaring and hung up.

Almost makes me miss retail pharmacy.

Giving feedback to technicians

I have an issue with two technicians at work. One is in her late-50's, and one is in her early 20's. The older tech wants to argue about EVERYTHING. Today I signed off on an order for a nursing home resident for 10 days of antibiotic, but instructed her to only send 8 days worth, because the nursing home has a first-dose supply at the facility, and they had already started giving the antibiotic; thus, they did not need to receive a 10 day supply. She wanted to argue with me about why I wrote "for 10 days" on the label and told her to only send 8 days. She stated that I should have written "for 8 days" on the label, because that is what we were sending. When I explained to her my reasoning (because she was insistent that I was wrong), she just blew me off. I have tried to be nice to her, and now I just try to be matter of fact, and she doesn't seem to like either method of delivery. She just wants to argue with me.

The younger tech doesn't seem to care whether her work is correct or not. There is one particular point (how to properly enter prn refills on an order) that she refuses to do correctly. Today she said to me, "I'm just going to keep doing it how I'm doing it, and you can just keep changing it." Um, NO. I am trying to teach you how to do something properly, and you are being insubordinate? There are many other examples on both of these technicians.

I have spoken with the technician supervisor. He just agrees that the older tech is a pain in the ass and says I should ignore her as much as possible. She makes several errors each day, and I have to correct her, because my other option is to make all the corrections myself. She takes any corrections as a confrontation and has to make it a huge deal. In regards to the younger technician, he just acknowledges that she has an attitude, and that I should, again, "just ignore her".

I have also spoken with my boss, who owns the pharmacy. He is fond of saying that the technicians should not be disputing anything with the pharmacist, they should make any changes I ask and apologize for making the error, etc. I do not believe he actually tells the technicians that info, however. He just keeps telling me to be professional and polite and keep correcting them.

I am getting really sick of being polite to the staff when they are being so horrid to me. If I am polite, I get attitude thrown at me and they whisper amongst themselves that I am being condescending towards them. For example, if they fail to discontinue an order properly, or something else they overlook, I say, "Maybe the computer didn't save your work, but I need XYZ fixed." If I just say, "You didn't discontinue Mrs. Jones's order, please do it," I hear "I did TOO do it" and the younger one (most often) gets sullen and makes more errors, quite possibly on purpose to waste my time.

When I try to just be straightforward ("this order is for 10mg twice daily, it was entered as 20mg twice daily, please fix it"), I get the eye-roll, the "I didn't enter the order!" shriek, or the order slammed on the desk.

How should I deal with these two techs? Their supervisor has been made aware of the situation and does nothing; the owner of the pharmacy has been made aware of the situation and says that the supervisor should be dealing with it. I am so sick of being treated rudely by certain members of my staff when I am trying to do my job by making sure their work is correct. I am trying really hard not to just snap at them and say "because I'm the pharmacist, that's why!" How can I deal with them?