Something I Forgot To Mention From My Crappy Day

I had the pleasure of being lectured by a physician about a drug interaction. It was regarding Zithromax and Coumadin.

Basically it started out with the doctor calling in a prescription for a Zpak for a patient who is taking Coumadin. This comes up as a major interaction in our computer system and seeing that the patient had never taken the two of them together and the Zpak was from a different prescriber than the Coumadin, I wanted to call the office to make sure if the doctor calling in the antibiotic was aware.

I must have hit a nerve with this doctor because, amazingly, I ended up speaking to him directly. "Name one antibiotic that doesn't potentially raise the INR. Azithromycin is not like the other macrolides. It's not like Biaxin or Erythromycin. Those drugs I would absolutely avoid in a Coumadin patient as well as any patient taking statins such as Zocor. I've never had a single problem with Zithromax."

He wouldn't allow me to get in a word. All I could say was "Yes, I agree," and I repeated it over and over again.

You see... The doctor is correct. Zithromax (azithromycin) isn't like the other macrolides. It doesn't have the same cytochrome P450 interactions, and it generally is much safer to use in patients taking Coumadin than the other macrolides. However, there are a number of case reports where the INR was elevated following a course of azithromycin. The mechanism is unclear (azithromycin may inhibit p-glycoprotein), and a good pattern could not be established. These case reports do show that there is some risk. Moreover, I actually worked for a little bit in a Coumadin clinic, and I've seen a patient's INR increase after getting a ZPak. It may be the safer choice, and in general, I don't mind seeing azithromycin used in Coumadin patients as long as the patient's INR is checked shortly after, and the patient is advised to monitor for signs and symptoms of bleeding. However, if it's possible to treat someone just as effectively with a different antibiotic, I'd rather see that.

And that was the case in this situation. Before calling the doctor, I asked the patient what he was getting the antibiotic for, and he said he had a cold. What do we know about colds? The common cold is caused by a virus. In fact, well over 90% of all upper respiratory tract infections are viral. Therefore, an antibiotic really isn't appropriate, especially in this case where the chosen antibiotic has the potential to increase the patients risk for bleeding.

Unfortunately, I'm not assertive enough and the doctor was too pushy to allow me to explain my reasoning for calling him about the interaction. All I could say was that I understood and agreed with what he was saying, but their still was some risk. If he wanted to stay with the Zpak, I wouldn't have much of a protest. I just wanted to make sure that he was aware of the situation.

After he was done lecturing me, he changed the patient to Amoxicillin. He and I both knew that he was simply giving out an antibiotic to make the patient think he was doing something to treat his cold. It didn't really matter which antibiotic he chose because the patient was going to get better in a couple days anyway. A ZPak is just so easy to write for, and with its once daily dosing, it's easy for patients to take.

That could lead to another point about overusing antibiotics, especially broad spectrum ones like azithromycin, but I'll save that for perhaps another day.

As Predicted, It All Evened Out

Wednesday was a great day at work for me. I predicted that my next day would probably be pretty shitty to balance things out. Yup.

I knew things were going to be bad even before I left my apartment this morning. When I pulled the laces tight to tie my shoes, they broke right off. No big deal I thought. I'll just take the laces down a loop and tie them from there. Once again, they broke. I was running a little late and had no time to tear apart my apartment looking for new shoelaces, so I brought them down one more loop, knotted both ends and went to work with my left shoe functioning basically as a slipper. Great start.

Within 5 minutes of walking into the pharmacy, everything started to go wrong. I spent an inordinate amount of time on the phone today trying to clarify poorly or incorrectly written prescriptions. I got a whole bunch of weird insurance rejections that I had never seen before, and I had to call to get those clarified. One customer had Lumenos insurance, and it literally took me 30 minutes to get 3 claims through due to a seemingly never ending string of "host processing errors."

A little later in the day, I had to apologize to a customer for one of Betty's prescription errors. It wasn't major (we gave her the wrong box of syringes), but I felt bad about it because I don't like it when the pharmacy makes any kind of error. Betty laughed about it. I still don't quite understand the humor in the situation.

Later, one of our other stores called to ask if we had any Fragmin in stock. Luckily, we had just ordered a box a day before to fill a Fragmin script for someone else, so we did have a few syringes. I let the other pharmacist know this, and she said she'd send the customer over with the prescription. About an hour later, a new customer to our pharmacy showed up with a prescription for Fragmin. As I was told over the phone, it was for more than we had in stock, but we had enough to get the customer through the weekend. Therefore, we dispensed what we had and ordered another box for Monday. The customer was happy.

About an hour later, another new customer showed up with... you guessed it... a Fragmin prescription. We had already given out all our Fragmin, but when we relayed this information to the customer, she told us that another pharmacist called and checked to see if we had it in stock before she came. Yup... The first Fragmin customer wasn't the one I was alerted to on the phone. The other pharmacist had been talking about this second customer.

Now, we're a pretty busy pharmacy by our company's standards. We fill about 2,300 scripts per week (which is down 20% from a couple years ago). Therefore, we see a wide variety of prescriptions. Do you know how many Fragmin prescriptions we received in this calendar year? Three! All three were presented to our pharmacy within the last 3 days. I never thought in a million years that two customers would come to our pharmacy looking for Fragmin on the same day. To further illustrate how rare Fragmin is, the customer had checked half a dozen pharmacies and came up empty on all of them. It's just not a popular drug, and most pharmacies don't stock it due to its very high price.

We ended up calling an on-call doctor to get the prescription changed to Lovenox, which we still didn't have the entire quantity on. The whole situation was frustrating to all parties involved (the patient, the doctor, and us).

Our clerks spent most of the day acting like they never worked in a pharmacy before. I have a lot of patience when it comes to helping them figure out a tricky insurance or helping them handle difficult, hard to understand customers. However, when they scream out "I NEED A PHARMACIST UP HERE!!!", and I go running to the front expecting to handle some kind of emergency only to find that they accidentally clicked onto a different window than the one our pharmacy software is on, I get quite annoyed. If you've been working in the pharmacy for a year and still mess up 50% of the time at taking a prescription number and putting in a refill, perhaps you should find a different department to work in.

In addition, when someone approaches the counter and says, "I have a question," please don't immediately scream for the pharmacist. Seventy-five percent of the time the customer simply wants to know something as trivial as which aisle the vitamins are located or where the restrooms are. You don't need a pharmacist license to point your finger to the desired section of the store.

At the end of the day, I knew alcohol would be in order for tonight. As I finish this post, I'm halfway through a 6-pack of Killian's. No, it's not healthy (or classy like scotch), but it suits me tonight.

Follow Up on Basketball and a Little Bit About My Good Day At Work

I didn't end up playing. Not because I didn't want to play, but rather the team had picked up a few extra players to replace me. Therefore, while I have a spot on the roster, there's kind of too many players showing up for the games. In short, they don't need me, and my presence would just serve to thin out everyone's minutes.

Like I said, it was my decision, and I'll have to live with it. It will probably end up saving me a lot of stress in the long run. I won't have to worry about getting all pissed off at myself after missing a few jumpshots.


On another note...

Have you ever had one of those days where you just knew that you did a really good job? I mean, I'm sure that most people feel like they do a good job at work, but we all have those days where we just really feel more on our game than usual. That's how I felt today. For every problem, I had the best solution. I was quick and efficient. I helped a number of customers. I even had the best one liners when joking around with my coworkers. It just felt like everyhing went right all day long.

Of course... That means my next day at work will probably be pretty shitty to balance out this one. However, I have a day to relish the feeling of this good day.

The Urge to Look Back

Several months ago I made a decision: The only way I could move forward with my life was to let go of most of the people and things that held me back. I stopped talking to most of my old friends. I made it a point to stop going to places and doing things that were out of character and against my own values. I figured that I had lived a lie for most of my life. I spent so much energy trying to conform to what I thought others wanted me to be.

So far, this approach hasn't brought me a great deal of happiness. In the absence of most of my friends, I pretty much just sit around my apartment on my days off. To say I'm bored is an understatement. However, I don't find myself feeling miserable any more. I don't hate myself for failing to live up to others' expectations. Moreover, I know that I now have the opportunity of forming new friendships and new relationships with people that are truly compatible with me. I'm nothing like most of my old friends. I'm an intellectual. I like to think and learn. I have a great interest in current events. I'm also, admittedly, a dork. I like sitting around playing video games. I don't like bars and clubs. I'm not big on parties. I don't have the same taste in women as my friends do (meaning that I don't go after a girl just because she's hot).

It's not that I think my friends are bad people. Not at all actually. Most of them are really good people. They're just not like me. I really never should have been friends with them in the first place. We have nothing in common... except I was very good basketball player. I'm a reserved, video game playing, straight A, science geek who just happens to be a really good athlete. Basketball was my ticket into the cool guy clique. It was my identity in middle school and high school. Hell, it was the one area where I stood out. It was an area that people recognized my strength. Even at college, I'd go to the gym and despite all the tall, athletic looking guys that were around, I was the one that people wanted to play with. I was the one that they tried to figure out how to shut down. I was the kid with the deadly jumpshot. All 5'9" 160 pounds of me. It made me feel good... One of the only things that did.

Earlier this year, I wrote about how I had played really poorly in my summer basketball league. I wrote about how I no longer had my quick first step. I no longer was able to explode to the hoop and finish strong. Even my jumpshot was failing me. I was completely miserable. I knew the reason my game had declined. I knew that standing on my feet for 10 and 12 hour days was ruining my athleticism. I didn't have the time or energy to keep in shape, so my game suffered because of it. In most people, that's just a part of growing up. To me, it was heart breaking. I felt like I lost my identity. There were so few things that I did really well, and losing my basketball ability was a big blow to my self esteem.

That's when I decided I had to give it up. I had to step away from the game I loved because it wasn't just a game to me anymore. I was letting it define me, and it wasn't healthy. I didn't give it up entirely. After all, basketball is still pretty good exercise. I'd still go down to a local park and shoot hoops several days per week during the summer. If some other people happened to show up, I'd gladly play some pick up games with them. However, I vowed I wouldn't play in any more leagues.

This brings me to my point... My former team's first game in the winter basketball league is tomorrow night. I told them that they could put my name on the roster, but I'd only play if they were short players. Now, I'm fighting the urge to go play tomorrow night. I really want to. I love basketball. However, it brings out the worst in me. If I play poorly, I'll go right back to hating myself. However, if I play well, I'll be incredibly happy, but I'll hate myself for being that happy over a stupid game.

I'm 26 years old. I basically have no true friends. I don't have a girlfriend or any prospects. I get very little happiness out of my existence, and the thing that makes me most happy is knocking down 3-pointers in a meaningless basketball game. It's sad.

This was my decision though. I have to live with it. It's not easy though, especially since both college and NBA basketball are starting up. Watching basketball gives me the urge to play. This is part of the whole moving on process though, so I'm going to try not to give in to that urge. I have a feeling I'm not going to be successful.

Pseudoephedrine

No, this post will not be about the federal law which keeps pseudoephedrine products behind the pharmacy counter. For the record, I honestly couldn't care less about the methamphetamine problem in this or any other country. If someone wants to take the initiative to buy 100 boxes of sudafed and cook up some meth in their basement, it doesn't bother me in the least bit. After all, I'm not the one that's developing a life threatening addiction for the sake of getting high. I'm not the one throwing my life away. Moreover, alcohol is a far bigger problem in this country than methamphetamine ever could be, but no one is trying to make alcohol illegal. If you want to fight a war on drugs, then I propose throwing alcohol in there for the sake of consistency.

Anyway...

When a customer comes to the counter with nasal congestion and wants some advice about which product to take, we always ask one question: "Do you have high blood pressure or take medication to treat high blood pressure?" If the patient answers yes, we automatically rule out the only OTC option that's effective for nasal congestion. In fact, it's one of the only OTC drugs that actually is effective at all.

With every new study that comes out, dextromethorphan looks less and less effective at suppressing cough. Guaifenesin has never really been proven to break up chest congestion. Ask allergy sufferers how well loratidine (Claritin) works for them, and you'll meet some pretty disappointed people. Pseudoephedrine really does work to relieve nasal congestion though, which is more than we can say about its replacement, phenylephrine.

If it's effective, then why are we so quick to rule it out for people taking antihypertensives? The answer we're taught to give is that pseudoephedrine can raise your blood pressure, which would be bad for a person that already has high blood pressure. However, I contend that a short, as needed course of pseudoephedrine probably isn't any more harmful than a stressful day at work. Moreover, someone who's blood pressure is well controlled by antihypertensive medication is at as much risk as someone who doesn't have high blood pressure and doesn't take any medication.

If you really look at the data, pseudoephedrine's effect on blood pressure isn't all that alarming. This patient counseling point is pounded into us from the very beginning of pharmacy school as if taking pseudoephedrine could send someone into a hypertensive crisis. In reality, it raises blood pressure by a few points on average, and its effect certainly isn't powerful enough to offset someone taking one or several antihypertensive medications.

If you really want to get serious about all these OTC interactions, we can include some we usually don't talk about. For example, someone taking beta blockers such as metoprolol or carvedilol for high blood pressure or chronic heart failure probably shouldn't be taking antihistamines either. Both metoprolol and carvedilol are metabolized by cytochrome P450 2D6, and most over the counter first generation antihistamines (i.e. diphenhydramine) inhibit 2D6, which would raise the levels of those drugs in their systems and put them at risk for a bradycardic episode. That never seems to stop us from recommending these products to people taking metoprolol or carvedilol, and rightfully so because the risk just isn't that great.

It's the same with pseudoephedrine. For the vast majority of cold sufferers the risk of a short, as needed course of pseudoephedrine causing an adverse event is very small. Therefore, when these situations come up, I usually ask patients if their high blood pressure is being well-controlled by their medication. If they say yes, I ask them if they check their blood pressure regularly and ask what the results tend to be. If they say that every time they go to their doctor's office, their blood pressure comes out 120/80 (or close to it), then I tell them that while pseudoephedrine can possibly raise blood pressure a small amount, using it for a few days on an as needed basis is generally safe. However, if the nasal congestion lasts more than 3 days, and/or you're not getting any relief from the pseudoephedrine, contact your doctor.

Of course, if the person has high, uncontrolled blood pressure, CHF, or poorly controlled diabetes, I wouldn't recommend pseudoephedrine products. However, in the other cases I mentioned, I feel like pharmacists are too quick to rule out one of the few effective OTC cold medications.

"He's been much better lately"

That's what my manager said in reference to the "improved" behavior of one the biggest assholes that fills prescriptions at our pharmacy. For the purpose of this post, the asshole's name is Sal. I wrote about Sal in the past when he decided to report us to the state board of pharmacy because we refused to fill his Lantus prescription when he had no refills left and still had enough insulin to last him for several more days.

That incident was with the previous manager of our store. Our new manager has decided to avoid the possibility of any future episodes by bending over backwards and giving Sal pretty much anything he wants. If it's a weekend and Sal has run out of test strips and doesn't have refills, we'll give him a box and get the refill authorization later. If we don't have enough medication to fill Sal's entire prescription at one time, we'll take some away from another customer (who called well in advance of when they'd run out of medication) so that we could give it to Sal. If Sal is too busy to wait 10 minutes, we'll push Sal's prescription to the top of the pile and get them done right away. Basically, the pharmacy staff is Sal's bitch.

Let me say that I don't necessarily disagree with my manager in his approach to handling Sal. He's just one customer, but he can cause a lot of problems. Therefore, getting him in and out of the pharmacy as quickly as possible while minimizing the chance of him having an outburst is generally a good strategy.

However... When my manager had the nerve to proclaim that Sal has been pretty pleasant recently, I had to call him out on it:

"Of course he's been pleasant lately. I'd be pretty nice too if everyone bent over and kissed my ass all the time. He's not too bad when he gets everything he wants whenever he wants it. However, the second he doesn't get his way, he throws a temper tantrum. The guy is an asshole and any attempt to say otherwise is just wrong."

It's sad and unfortunate that in many cases we act nicer and do more for our worst customers than for our best customers. However, when those asshole customers fill 10 or more prescriptions per month at your store, the threat of them taking their business elsewhere carries some weight. Therefore, we'll put up with more shit and bend over just a little further backwards to keep them happy. It sucks, but it's a reality of the retail world. I accept this reality.

I just refuse to think any more favorably of those assholes when they start acting just a little bit nicer after months of being waited on hand and foot. They're still bottom of the barrel scumbags to me.

Diabetic Testing Supplies

I think it's wonderful that Medicare covers test strips and lancets for diabetics. My only complaint is why do they have to have such strict prescription requirements. I fully understand the need to have specific directions, quantities, and a diagnosis code as to whether the patient requires insulin or not. I don't understand why pharmacists can't take that information over the phone.

Why can pharmacists accept a phoned in prescription for Vicodin or Lortab, but we need a hard copy (faxed or brought into us) in order to bill Medicare for test strips and lancets? Why are there no requirements like this for Medicaid? What makes Medicare different than Medicaid in this regard?

It's really just a giant pain in the ass, and it inconveniences both patients and doctors. What often happens is that the patient will call the pharmacy and use the telefill to ask for a refill on their test strips. Our, and many other pharmacies', telefill system will automatically fax the doctor a renewal request if the patient is out of refills. The doctor's office will get the request, and in a day or so, they'll fax the approval back to us.

This creates a problem because when we go to process the approved refill, we'll realize that the patient has Medicare. Therefore, we need to contact the doctor's office again for a new script that has all those wonderful Medicare requirements (specific product, quantity, directions, diagnosis code). Getting verbal confirmation over the phone simply isn't good enough, so we have to wait for the doctor to send the Medicare compliant prescription to us before we can fill it.

I just don't understand why all of this can't be accomplished with a phone call and the pharmacist documenting on the script the proper directions, quantity, and diagnosis code. Why does it have to be directly from the prescriber? Like I said, if we can get verbal confirmation of a Vicodin script, what's the harm in allowing it on a Medicare prescription? It's just a waste of time, in my opinion.

What did she say?

Conversation with our lead tech:

Me: I'm going to this party, and they're having a Secret Santa. I ended up drawing this guy. I have to figure out what to get now.

Tech: That shouldn't be too hard. Just get him a gift certificate to Dick's. What guy doesn't like Dicks?

All I had to do was look at her to make her turn bright red.

If I won the lottery

For whatever reason, I was thinking about what I'd do if I won the lottery. Of course, I've never bought a lotto ticket in my life, and I don't really have any plans on doing so in the near future. Despite this, that hypothetical, nearly impossible situation has been on my mind.

Honestly, I think my life would pretty much be the same. I'd take care of a few things of course. I'd pay off my car and college loans. Then, I'd probably buy a house or nice condo. Nothing extravagant. I don't need 12 bedrooms and a 10,000 square foot bathroom. I just want a nice, comfortable place.

Other than that, I don't think I'd do anything different. I'm pretty certain I'd still work, not out of love for my job, but because it's pretty much the only thing I do that makes me feel useful to society. I wouldn't take vacations to exotic locales. I wouldn't buy an Italian sports car. I wouldn't update my wardrobe with expensive, designer clothes. I wouldn't hit the clubs or fancy restaurants every night. In essence, it wouldn't change who I am or how I act in the least.

The only things I truly desire in life right now are things that money can't buy. Winning the lottery wouldn't bring me love and enable me to start a family. Those are things I'll have to figure out on my own, regardless of my financial situation. Otherwise, I hae pretty much everything I've always wanted from a maetrial sense. There was a short list of things I always wanted that I said I was going to get myself once I graduated from pharmacy school. I wanted a particular, near-luxury car. I wanted a big, flat screen TV with surround sound, and I wanted to get my own place. That was it. Those were my only desires.

I type this today while sitting at my comfortable desk chair in my modest one bedroom apartment. I have a Samsung LCD television in my living room. I have an entertainment system that includes surround sound speakers and all the newest videogame systems. My near-luxury sports sedan is parked outside. If I'm hungry, I can buy food. If I want new clothes, I can get them. If my computer breaks, I can replace it. I'm comfortable, more comfortable than most. From a materialistic standpoint, I have everything I could ever desire, and more than I probably deserve.

Maybe it's anti-American for me not to want more. After all, the backbone of our country and capitalism in general is that you constantly work to aquire and create more wealth. It's almost sad to think that our economy would break down if people who are in similar fiancial situations to my own decide they don't need anything else. If all these people just decided to stop spending money on extravagances, companies would go bankrupt and jobs would be lost.

There are a lot of statements I could make about modern society, but I'll hold off. I just find it amazing how if a couple things fell into place, I'd basically be living my ideal life. I'm fortunate.

Where this country fails...

She approached the counter nervously and asked to speak to a pharmacist. Her hands were shaking and voice quivering as she explained that her hours had been cut at her job, and she was dropped from the company's insurance plan. However, since she still maintained part time status, she made just a little too much money to qualify for Medicaid. She had various panic and mood disorders, and without insurance, she would have to pay about $1,000 per month for her medication.

She started to cry as she pleaded for us to help her in any way we can. There was just no way she could afford $1,000 per month for medication. However, going without them meant putting her mental stability and ultimately her life in jeopardy.

Not knowing what else to do, my pharmacy manager (a great guy) called social services on her behalf. Nine times out of ten, this causes you to wait on hold for 30 minutes until you finally speak to someone who tells you there's nothing they can do. This time, he got lucky. He still waited for 30 minutes, but when someone finally picked up, they were actually able to help him. He was able to get her set up with an appointment with a Medicaid "triage specialist" first thing the next morning.

We explained what she needed to bring to the appointment and gave her 3 days worth of her medication at no charge. Our efforts to help calmed her down as she was no longer crying. She was still shaking a bit, but she was very grateful. As she walked away, all I could think about is that she'll most likely be denied coverage...

This highlights a major flaw in this country. Health care, in our current system, is a privilege instead of a right. If you are lucky enough to get insurance through your job, or if you make enough money that you can afford the $12,000 per year for the average insurance policy, you get access to health care. Everyone else is fucked.

What kind of society do we live in when we have to choose between being able to pay a mortgage or pay for health care? How can we live with ourselves when we have to look at patients struggling to get by and tell them, "Sorry, you can't have the medication that keeps you healthy unless you can afford to pay for it." Or, "I'm sorry it's too expensive for you to see a doctor."

Just about every other industrialized nation in the world has some form of national health care. We stubbornly resist. Just like we stubbornly resist to join into agreements to cut carbon emissions. Just like we stubbornly resist to adopt the metric system. Just like we stubbornly resist accepting the scientific consensus that climate change and evolution are real. As much as we love to make fun of France in this country, France's system of national health care far exceeds our own. France is ranked #1 in the world in health care by the World Health Organization. The United States is ranked 37. Perhaps it just might be a good idea for us to stop insulting France just long enough to look at what they're doing with health care and try to incorporate that into our own system.

The only 2 arguments I hear against it are wait times and that it will increase our taxes. As for wait times, do you think that person who currently has no coverage at all right now cares about the wait times? Canada, with all its supposed wait times is also ranked higher than the United States in overall health care. The cost of Canada's health care plan is also less per citizen than the average cost of $12,000 per year for the average health care policy in the U.S. In fact, the United States pays the second most in the world for health care as a percentage of GDP. We're ranked first in per capita health care spending. For spending all that money, you'd think we'd be better than 37th in the world.

And don't give me the socialism argument. Socialistic institutions seem to be just fine when it comes to the police, fire departments, education, public works, etc. In the name of the free market, why don't we privatize all of those? Yeah, stupid idea, right? About as stupid an idea as privatizing health care insurance.

There's no good reason for people to be denied health care simply because they can't afford to pay for it. I dream of a day when the United States stops dragging its feet and finally adopts a superior model that is more in line with the rest of the industrialized world. Maybe then we can actually have something to back up our persistent claims of being the greatest country in the world.