Saturday, July 31, 2010

A Small Highlight From Friday's Pill Counting Action, But One That Made Me Kinda Happy.

Under the order for Lovenox it was written. It was written very clearly, and even though the prescription was faxed, it was still easy to read. That alone put the prescription in the upper 80th percentile of competence.

"Patient will be holding Coumadin." it said, and I stared at the prescription and smiled. I almost wanted to take a picture. I almost cried tears of joy. I almost wanted to find this doctor and wrap him in a big bear hug until I remembered I wasn't gay.

Those of you not in the professions probably don't know that Lovenox and Coumadin are both anti-coagulants. What this doctor was doing, you see, was going out of his way to let me know he knew the patient was on an anti-coagulant from another doctor and he was on top of the situation. Taking a few seconds to make sure everything would go smoothly for everyone involved.

"A simple step" those of you not in the professions might be saying to yourselves, and you would be right. You also probably don't know it's a simple step that never happens outside the theoretical fantasy world of pharmacy school. This is how drug interaction work usually goes my friends:

You drop off a prescription for drug X from Dr. Smith and I notice you're taking drug Y from Dr. Jones. There is a chance that drugs X and Y can be taken by an individual with your particular medical problems. There is also a one percent chance the combination of X and Y will set your liver on fire. Did Dr. Smith know what Dr. Jones was up to when he wrote the prescription and explain the risks to you before he sent you on your way? Or is your liver going to catch fire and your malpractice lawyer say I was negligent? Who knows? You are nowhere to be found, having left to go have your hair done. I call Dr. Smith's office and reach the 19 year old receptionist after navigating through the voicemail forest and spending five minutes on hold. I sense the fear in her voice as soon as I say I have a question about one of Dr. Smith's prescriptions.

I explain the situation and she confidently says "It says in the chart two times a day," which is an answer to a question I did not ask. I say I better talk to Dr. Smith directly about this and she says he's busy at the moment and she'll have him call me back. She goes to hang up and I ask if she has my number. She realizes she doesn't.

Ten prescriptions and two phone calls have backed up while I was doing this. The first caller asks if we carry the blue wart stuff  she saw on TV last night. You come back and I explain the liver incineration issue.

"So it's not ready?" is all you say. Your new hairdo looks terrible.

I catch a break and you agree to let me call you if and when Dr. Smith gets back to me. An hour passes and I hear nothing. I call Smith's office again and get the after hours answering service, who patches me through to Dr. Johnson, who is covering for Dr. Smith that evening.

"It's usually given twice a day, right?" is what Johnson has to say, and I wonder what part of "liver fire" sounds like "label directions." I try again.

"Ohhhhhhhhhh....says Johnson. You know, I never prescribe this........" Then 10 seconds of silence. Like the problem has been solved. When I refuse to go away it is agreed that maybe Smith himself should give me a call.

"Yes, I'm well aware of this!!!" Smith says half an hour later, extremely annoyed to be taken away from his dinner. "The thermoeosnophillic scan we did on the 5th indicated a low probability of liver fire and the alternative has a higher possibility of eyeball explosion." If I would have had access to your complete medical record I would have known this. But I don't. So I didn't. So a 5-second problem becomes an all-day affair. That's how these things usually go. And at the end of the day all you remember is that it took forever to fill your prescription and Wal-Mart never seems to take so long.

That's because the pharmacist at Wal-Mart decided to take a gamble and not check. Because he's only charging you $4 and has to keep the prescriptions moving if he's gonna keep his corporate bean counters happy.

Which is why those five words made me so goddamn happy. I kept repeating them to myself over and over as I filled the prescription, "patient will be holding Coumadin.......patient will be holding Coumadin...." I almost didn't want to let this prescription go.

The computer flagged the next one for Voltaren because the patient was taking methotrexate.

Two different doctors.



Anonymous said...

I decided rather than go to pharm school I would ask you instead. Most of the time I have an option for a generic I get it. I understand the whole equivalent concept. My eye guy demands on one prescription to never get the generic for pred forte. The eye dude is a mellow fam guy with multiplicitous kiddos and gets the whole this is costing me real money thing. But in the land of the bulgy, squint eyed gropers we absorb tons of the milky gold and the stories of generic is crap get validated alot. I have heard to compounder's tale of glass beads and seven days of spinning yada yada particle sizes shake alot. My question is rather than blindly accepting all generics how and when should I descrimnate?

one eyed king

Anonymous said...

Ah, a thing of beauty it was.

Did you know enoxaparin has 'gone generic'. Ecstasy.

Anonymous said...

What's the Pred-Forte for? Inflammation? IF the drug has an NDC, and it's FDA-approved as a generic equivalent as AB-rated to the proprietary product the chemical involved is pretty much the same.

Where the question of generic vs. brand might especially be a problem is it's a new drug as sole therapy for a chronic life-threatening condition, then a person probably want to see how the name brand does and get plasma levels at steady-state, before considering generics.

Some ethnic groups (heck--we can't know ALL our genetic make-up) are typified by differences in hereditary metabolic conditions e.g. enzyme components of the liver, sensitivities to different chemical receptors, etc., so the therapeutic 'window of difference' between a toxic level of a dose (or too low of a therapeutic dose) to the effective dose is 'narrower' than what a pharmacist/doctor wants to mess around with such as with digoxin, warfarin, and others that require careful 'tailoring'.

As DM points out, interactions sometimes push the drug levels above or sharply below the 'window' resulting in side-effects or ineffective levels of the therapeutic agent.

r0t said...

You know who gives a shit? Nobody.

Fucking noooooobody. I've come across only a few pharmacists which are concerned with anything regarding interactions which do not guarantee death. I can point them out because on the days they work, the bins are filled with DUR printouts.

Or concerned with accuracy? Fucking noooooobody.

I cannot count the number of times.

Have they written it for extended release, 4 times daily, when they've been on standard for as far as their profile displays? Just fill it for the XR.

Oh, you called the doctor to verify it's supposed to have changed? Who did you talk to? Why are you only telling me this now, when I've been holding onto the script since it was dropped off, and you made no documentation of it at all, until i asked? How come when I called them back to check your bullshit, they told me the complete opposite, and thanked me?

What's this.. this script I'm filing into the bin.. why is this lidocaine filled as the solution? It was written for the jelly. I typed it as the motherfucking jelly. Why did you change it? You've never heard of it as coming in a jelly? Why is it in the system, and why do we have it on the shelves?

This oxycontin is 3 weeks early, and from a different doctor. It's okay to fill, because they have a prescription and are paying cash? Didn't that office tell us to stop filling for them? That's an interesting way of doing things. You and that customer seem to be really friendly with each other.

$8 an hour is not enough money to have to double check somebody that makes six times as much as I do. I am very grateful for those of you that are careful and don't take the path of least resistance in all situations. My examples are a minority, but even the minority I've experienced must count with both hands..

Anonymous said...

Dear Disgruntled Tech,

Please, consider finding somewhere else to take it out on humanity. Not my pharmacy. I hear McDonald's starts out $7.25/hr and there are a limited choice of items on the menu to screw up, which might make for a happier life.

McDonald's what? A dead-end job? People always need to eat and it's honest work. There might not be such a plethora of material to potentially do damage to the rest of mankind.

What? It's not as exciting to say that one works fast food, rather than local pharmacy? A job is a job, puts food in the mouth and pays rent, and with less latent hostility, there's possibility of a better quality of life.

Seriously, think about it. There's probably a great recommendation from a pharmacist i.e. work ethic, attention to detail, etc.

An alternative? Get involved with your local techs/ association, catch up on C.E., document the issues you have e.g. check-mark graph, talk to your manager, etc.

I understand this particular blog post of DM was aimed toward the lack of cohesiveness among professional healthcare providers in a system wherein those without proper training or integrity serve as a barrier between access to patients and 'medicine'.

There may be few and far between pitiable rewards from knowing a life was saved that a diligent pharmacist feels in a typical chain drugstore.

C.L. RPh

r0t said...

C.L. RPh,

What the hell are you talking about? I can't connect anything you said in your comment with anything in the original blog post, or any of the comments.

Anonymous said...

All I'm saying is that $8/hr is not what the pharmacist, the person in charge, makes. The pharmacists' license is what brings validity to a drugstore. If there's no pharmacist on duty, technically the shop is not open.

If you have a question or find something wrong, ask the pharmacist about it. The tech doesn't sign off on anything a pharmacist does. If a patient's refill request is early, ask about it, but don't make a pharmacists' decision. If a patient is in cahoots with the pharmacist, note it or whatever your tech's association says to do, but sorry to say, it'd have to be an awfully cockily stupid pharmacist to engage in that kind of hanky-panky, although it's been done,

At $8/hr, it sounds as if you've not been working very long, so my advice is to open your ears and eyes to what's going on around you, and take some pharmacy technician classes so you can understand your role, and the repercussions be of better help to the pharmacy.

Try to understand why or why not jelly vs liquid is appropriate, and why the pharmacist doesn't willy-nilly change XR or SR to XL.

Why should you expect a pharmacist to tell you if there is a question on script on the phone, busy, or has the script in his hand, and if your attitude has been less than helpful in the past, don't expect anything. Do you think someone is going to want to spend 5 min. they dont' have trying to explain anything to someone who doesnt' care? Rather, the pharmacist might wish you were in bathroom on break and by some strange occurrence the ceiling fell and the shop had to hire someone else pronto.

Basically, techs are hired to do tech jobs. Some places require a technician to be trained and certified before hiring so that they understand what the job is.

The Fat Chick said...

$8 an hour huh? You must be working in one of those states that just hires techs off the street and requires no education whatsoever. The ones that wind up making techs in general look bad all over TV "news" magazines. You should probably find a different job. You make the rest of us look bad.

r0t said...

Again: what the FUCK are you talking about? It looks like you've entirely misinterpreted everything I said, somehow.

I never claimed the pharmacist makes 8/hour. I never said the tech signs off on what a pharmacist does. I never said the tech makes the decision for a pharmacist.

I work for a chain that doesn't pay their techs very well, obviously. Our raises are fixed and yearly. I've been doing this for more than four years. More than a quarter of my normal working time is spent training other people and pharmacists, not because that's my job, but because they go absolutely retarded when you put them in front of a computer, in the spotlight with an angry customer, or in any problem which is more complicated than "oh it's too soon."

If a pharmacist is filling narcotics 3 weeks early, from different doctors, there is something wrong. Something wrong that yes, I did spread word, and he suddenly left the company, the people he was filling the prescriptions for were arrested (I still have their mugshots saved on my phone), and an inventory of the narcotics gave the next pharmacist plenty of time trying to figure out where all of the roxicodone had gone.

There is no judgment whether jelly vs liquid was appropriate- the doctor had clearly written it for one, and the pharmacist changed it just because they had never heard of the other one existing. Even though it was typed and filled for it.

And, the pharmacist DID willy-nilly change XR/SL.

I should expect them to tell me because I'm at drop-off most of the time. This means all prescriptions go through me. I see everything, and am aware of all insurance problems.

The pharmacist claimed to call the office, when they were outright lying to my face. They didn't know the patient's name, the number to the office, or the medication, they merely told me to switch the medication. I told them I was going to call the doctor. I was standing there the entire time only a few feet from them, and only a short time later claimed to have called the MD and verified the change, which they DID NOT DO. They did not do this because I CALLED THE OFFICE AFTERWARD AND THEY SAID THEY HAD NEVER RECEIVED A CALL FROM US, AND GAVE THE OPPOSITE INSTRUCTIONS OF THE PHARMACIST.

I am trained, and certified. I understand my job. I understand my job to the point that I'm not a mindless peon that just rings people up all day and counts and calls insurance. I can smell bullshit, and when there's a problem, I know how to solve it. Many pharmacists sit and verify and do nothing else all day, take the path of least resistance to solve issues whether it's correct or not, and are constantly consulting me with the most mundane questions.

The great majority of pharmacists are not like this, I am only giving you examples of a very small sample of them. However, when that small sample works at your store, then you're exposed to it frequently.

r0t said...

The fat chick.. no comment on your username. How do I make anybody look bad? At all?

Did you spend thousands of dollars taking pharmacy technician classes at your community college, before realizing you got ripped off and prefer to think of yourself as somehow above everyone else regardless of your actual level of competency in a pharmacy?

It doesn't matter whether a state requires certification or not. The certification is an absolute joke, and anybody that's gone through with it an attest to this. My company doesn't even offer a raise for being certified. How you associate compensation with competency in such a terribly corporate environment where the first place they cut costs is through the techs and front-store staff, is beyond me.

countingbyfives said...

Those really ARE 5 of the best words you could see on a script. One time I took down a voicemail where the doctor specifically stated "I am aware of the interaction with warfarin, the patient will be monitored for this". 2 seconds of his time saved 2 hours of work for everyone. :)

@r0t: dear lord, what kind of pharmacists are you working with?? 3 weeks early on Oxycontin?? I would've turned that crap down in a heartbeat...more pharmacies need observant techs like you (and you deserve to work with equally observant pharmacists, haha)

Hope said...

I agree, r-funny symbol I don't recognize-t. Techs like you make the job worth doing! You are awesome for paying attention. I wish my own techs were like you; it would make my job infinitely better instead of hanging out as the only one standing between my patients and trouble. In the military, the techs check the pharmacist's work. In the long run, it doesn't matter who looks last, what matters is two sets of eyes. I'd work with you in a heartbeat.

GirlieSoGroovie said...


...makes me want to print tear-off sheets to give to customers to read while I fax their doc to try to fix the problem...luckily we have the option here of pharmacist adaptation of a prescription when the solution is so obvious it's ridiculous...