Diagnosed — A Case-Based Post

Posted by The *Angriest* Pharmacist as Doctors, Education, Patient Education, Results, True Story

Older lady (50-something) calls in today….really…today January 13, 2010.

“I have a pretty bad stomach ache. I’ve tried everything.”

After a lengthy discussion with a lady that was pretty sharp when it came to OTC meds and taking care of herself, here were the facts:

- Epigastric pain above the belly button, beneath the sternum.
- Rarely radiated. Sometimes pulsated. Sometimes had back pain, but figured it was due to her job as a cashier.
- Patient has (un)controlled hypertension. Her BP is high, but she is finally under treatment after years and years of uncontrolled HTN. It’s on the way down, but not to goal yet.
- Has tried the following meds: Rolaids, Gaviscon, Milk of Magnesia, Fibercon, Colace, Zantac/Pepcid, Omeprazole, Protonix, and Tylenol/Ibuprofen (after thinking it could be muscular).
- Worsened over time.

So, short list of facts. Very busy pharmacy. As a pharmacist, we’ve really gone as far as we can go with our expertise — as far as what we can suggest. What do you think the patient has? What do you tell her to do?

The answer is below.

I told the patient she had let this problem linger for far too long. She needed to go to the doctor and be seen. I told her to “mention the pharmacist wondering about a ‘triple A’ to her physician. Some doctor’s might call it an A-A-A.”

I told the lady at the time that this was a crazy idea, probably not even on the radar, and the doctor would probably laugh, but it was something to think about on the list of possibilities. I then explained it to her — what an abdominal aortic aneurysm was — and she was obviously scared which made me feel like a douche. I told her how rare they were and not to worry about it.

Later this evening I get a FAX from her primary care physician with her admission face sheet and the following handwritten:

HOW DOES A PHARMACIST DIAGNOSE AN A.A.A. OVER THE PHONE?

– If she survives the surgery, we can say you saved her life…(well, you and the vascular surgeon)

Lucky Guess…I know…because I didn’t even know her name when we spoke on the phone — I didn’t ask. We do fill her medicines, and I recognized her name when I saw the fax. I even know her face…I will update on her status tomorrow if I find out.

=========UPDATE=========

Liberal is too Liberal

Posted by The *Angriest* Pharmacist as Doctors, Drug Seekers, Just a question, Laws, Patient Education, True Story, Work Sucks

I’ve got a problem. There’s a physician in my town wreaking havoc on the livers of everyone in the entire area. Drug seekers rejoice! If your drug of choice is Fioricet (Butalbital/Acetaminophen/Caffeine), Soma (Carisoprodol), or Ultram (Tramadol) you are in luck.

I’m not joking when I say that he has put them in the ground — 6 feet under. He’s got more people addicted to more drugs than should be possible. I’ve been told by several of his “patients” that do their trading with me that they enter his “exam room,” state a problem that they have, and he begins writing. He doesn’t touch them. He doesn’t ask any questions. I couldn’t tell you the number of times folks have gotten to the counter and not known what X-drug was written for as they aren’t having that problem at all — for instance, Detrol LA for a 24-year old male.

He’s also a big fan of Nubain, Promethazine, and Syringes. I call it the SCUZ-BALL COCKTAIL! They give they Phenergan so you can inject more NUBAIN! It’s a GREAT idea!

But, TAestP, why on earth is he writing for Nubain and Fioricet when he could write for Demerol and PERCocet. That’s because this fuck wrote so many controls (and neglected to chart a single word) that they took his DEA license from him! So, he’s been reduced to writing drugs that SHOULD be controlled rather than drugs that ARE controlled.

What I hate about this situation is that I feel like I am an accessory to his negligence. I don’t fill things early. I don’t do cash prices after insurance rejects. I make notes about an (8 per day max) on Tramadol even though his 1-2t po q4-6h prn pain #240 clearly suggests 12 per day. [Seizure anyone?]I don’t fill anything above the Tylenol limit per day.

I’m doing everything by the book on my end. What type of liability falls to me (and every other pharmacist in my area filling these scripts)? I’ve got documentation outlining reports / complaints that I’ve made to the DEA and Medicaid Fraud and Waste Department. I’m trying to get this felon off the streets — or at least get his pad taken from him!

Pharmacists are fighting tooth and nail to get just PPIs or Statins as behind-the-counter / prescriptive-authority drug classes for RPhs and this jackass can’t get his taken away fast enough!

Expounding on Courtesy

Posted by The *Angriest* Pharmacist as Courtesy, Disgusting, Doctors, Laws, Lazy People, Me hating others, Politics, True Story, Work Sucks

Some may remember a post I wrote some time ago titled, “Common Courtesy.” Well, apparently, not everyone in the world has read that post yet.

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I know challenge all of you to read it again and ensure that every person you know reads it as well.

I’m currently working on a collaborative practice agreement between myself and a group of local physicians that prescribe about 30% of my business that would allow me to change and edit prescriptions per protocol to fit insurance/payment needs. Meaning — if one of them writes Lipitor and it’s for a cash-pay patient, I can immediately change it to an equivalent dose of Simvastatin. Each of these changes had to be hand written, researched and decided by me. Then, I had to talk it over with 1 of the doctor’s to make sure they would be cool with what I decided. член большой

Now we get to the next step. My company’s legal department. I’ve called 3 different people in the legal department 3 different times. That’s a total of 9 voicemails left since last Monday. I’m not calling with a request to sue someone, or that I’m in trouble, or that I raped a male technician in the bathroom. I just want a little direction when it comes to the formatting of the document as well as the requirements that they would like on both parts. Still, after that, it has to go through the doctor’s legal department — before I and the physicians can sign it. But, I can’t get past several steps ago — because my company’s legal department can’t take 10 minutes to call me back.

Fucking. Bogus.

Common Courtesy people…common courtesy…what if I had raped that technician? Hopefully they get the memo. Tomorrow, I’m going up the ladder…I’ve spent way too much of my own, so far unpaid, time on this issue to be dicked around.

This is more for the readers

Posted by The *Angriest* Pharmacist as Courtesy, Doctors, Drug Seekers, Education, Just a question, Lazy People, Me being a dick, PHARMACY SECRETS!, Rude, Stupid Nurses, Stupid People, True Story, Work Sucks

I got this from a reader recently. Let’s have a little bit of discussion on the double standard which applies to pharmacy (hereafter known as ‘gimme gimme gimme!’)

Friday night, a guy comes in. Wants a refill on omeprazole 40mg. Naturally, he didn’t call ahead or even have his bottle with him. He’s obnoxious and rude, balks that it will take TEN MINUTES to fill, and proceeds to stare at me thru the glass like I’m some sort of animal. The claim comes back prior auth, with the reject that the insurance will pay for X number capsules in 90 days, then they require prior auth.

I explain this to said jerk, who naturally flips out and calls me incompetent. Then he’s going to sue me because I won’t fill his medication and he NEEDS it. Riggggggght. I explain I’ll fill whatever he wants, but his insurance isn’t paying for it at this time, so he’ll have to.

Normally, I would’ve fronted someone 3 pills for the weekend. But I play by the golden rule, so this dude was paying, no favors from me. He pays for 5 capsules and leaves in a huff.

That’s all pretty typical, now we get to the good part..Monday morning I get a call from jerk’s doctor’s office. The nurse asks why I wouldn’t fill his prescription. Uhhh, I did fill it and he paid for 5 capsules. THEN SHE TELLS ME I SHOULD’VE JUST GIVEN HIM THE PILLS AT NO CHARGE. Ok. I don’t know about anyone else, but anytime I’ve EVER been to ANY doctor’s office they have about 6 million different signs posted stating, “PAYMENT IS DUE AT TIME SERVICES ARE RENDERED.” Last time I went I had to SIGN A FORM stating that I understood that I WOULD BE FINANCIALLY RESPONSIBLE for paying for any service that my insurance did not cover.

I told her it’s not my practice to give out medication for free. If the request is denied, then who is paying for those capsules? She really had no answer for that.

I’ve been thru the prior auth, front a-couple pills song and dance a million times..what gets me is the GROSS HYPOCROSISY and DOUBLE STANDARD here. This nurse scolded me for refusing to give medication away for free. As far as I know, no doctors are EVER giving their services away for free, they make sure they’re getting paid. Why should it be any different at the pharmacy?!

Any thoughts you might have on this particular incident/topic would be appreciated.

Thanks,

Frustr8ed Pharm

I’m sure we’re gonna all agree that we will give 3 days or so if it’s a maintenance meds, but is there more to the situation then that?