Lots to address

Posted by The *Angriest* Pharmacist as Education, Hospital Pharmacy, Patient Education, True Story

Hello world! Buckle up, we’ve got a bunch of issues we’re going to cover today. The first relates back to a recent post about how to bust a fraudulent prescription. Watch this video about the prescription drug problem in Michigan. Turns out, they have an awesome system tracking prescriptions. They can view in real time all the patients that are doctor shopping, track the number of pills they’ve received, and even access all of their information. This is, of course, not a public database. Yet, the agency charged with tracking this data and generating the reports has no ground to stand on — as it’s not illegal in Michigan to “doctor shop,” and the state prosecutor doesn’t want to waste his time on these cases — he just wants the big dogs…for the glory of the big bust and getting his face on the evening news…What a crock of shit.

The funniest thing about the video is the very last sentence the reporter speaks. The lady they had all but busted doctor shopping refused an interview and said she was merely seeing all those doctors because she was going out of town and she needed to make sure she had enough Vicodin to last her. I just fucking wonder who paid for those prescriptions — it sure as shit wasn’t her, and I’d bet anything she made a good amount of money selling them on the skreeet. It’s a dollar a milligram in my area for hydrocodone and oxycodone (yes, they are considered the same per street rules). Xanax usually runs 10 bucks for 2 milligrams. Anyway…

If one breaks the law, regardless of how big of an issue it may be, it is the job of the prosecutors to see the case to fruition whether it be court, plea, or otherwise. Hopefully, you guys can get this changed! I’d really like to hear from some of our Michigan pharmacists — you guys have access to this program, Michigan Automated Prescription Service (MAPS), do you use it? Is it accurate and trustworthy? Do you use it to check sketchy patients and subsequently use it to deny them service?

-=+=-

I’m sure most of you have noticed that my number of posts has recently gone from 5/wk to 0/wk. I’ve gotten about 20 emails asking me where I’ve been! Have I gone on vacation? Did my dog die? Did my dox get dropped? Make no mistake - if I go on vacation or something happens to me, it’ll get on the website somehow. My last will and testament has direction for how to notify readers of my untimely, but all to expected, death…:-)

I feel awkward announcing this to the world. I’ve gained all my steam on this website because of my job. I am a community/retail pharmacist in Anytown, USA! Well, starting last Wednesday I’ve been working in a highly clinical role.

The clinical pharmacist at my local area hospital decided he wanted to get drunk in Hawaii for two weeks. Last year, they paid tons of cash to bring in a replacement for the two weeks. This year, the approached me about a month ago to see if I could do it. I’ve known the clinical guy there for quite some time. I spent the weekend prior to his vacation with him getting trained on my duties, their computer system (which is sweet), and pretty much everything a new employee would need. And yes, I had to watch that stupid fucking HIPAA video with the red headed lady that eavesdrops all over the hospital.

So, I arrive there at about 6am. There are three teams right now, and I am on two of them (the third team has a Pharm.D., MD on it…showoff!). Rounds for Team 1 start at 7:00am, and rounds for team 2 start at 8:30am. I do Vanc/Gent for the entire hospital. I also modify TPNs. Physicians set the initial TPN, and I modify them based on patient needs and expenditures (This was the HARDEST thing to remember for me because of the chemistry/equations I hadn’t touched in 5 years - at least Vanc/Gent is plug and chug)  I also narrow therapies based on C&S and patient needs. I’m also seeing that everyone gets normal health maintenance stuff while in house (stress ulcer prophylaxis, DVT prophylaxis, vitamins, vaccinations) - this was an initiative initiated by the normal clinical guy. I also do all discharge education (obviously).

I’m not a BCPS (Board Certified Pharmacotherapy Specialist) like he is, but I think I’m getting along just fine. Apparently, I’m eligible to take the exam — it’s 3 years after you graduate or immediately after you complete a residency…I’m not sure if that’s true or not. Anywho, the physicians all respected him immensely — and rightfully so. He is the smartest fucker I’ve ever met. I shit you not, I never asked him a question he didn’t know. He’s like a walking Koda-Kimble-Dipiro Database. That has been good and bad for me. Good in the sense that the physicians all believe in the importance of me being on the team because of the asset he is but bad because I don’t know everything he does, and I have to use the ole idiot-student-reply, “I’m not quite sure. I’ll research that and get back to you as soon as possible.” Needless to say, I look up quite a few things.

I’ve answered a lot of questions on rounds. I feel like I’m really an asset. They all appreciate and respect me, and it makes me feel all tingly inside. I was even asked to be the ‘leader’ of Grand Rounds this week. Essentially, I presented a current patient case then educated on a disease state. I chose my favorite because I already know a lot about it — Cirrhosis and associate complications. I talked about it all: portal hypertension, varices, acute management of variceal bleeds (including some preparation guidelines that I created for the hospital so that they had shit ready to go in case a cirrhosis patient pops a bleed - somatostatin, rapid infuser, plasma, platelets, blood typing/Rh factor early and blood stocked closely), hepatic encephalopathy, Child-Pugh classification….everything.

I got a good reception. I think it went very well, and I didn’t sound retarded.

And, of course, some dickhead doctor asked me a trick question — trying to throw me in front of the train, and I caught it and fired back.

“What are normal ammonia levels?”
“This institution considers 10-75 micrograms per deciliter within normal limits.”
“And, based on your clinical experience, at what level of hyperammonemia do you initiate treatment?” [Yeah...he was being a dick here. This was only like my 7th day there...ever...I have no clinical experience, but I knew the answer.]
“Actually, that’s a common misconception. You do not initiate treatment in cirrhosis based on ammonia levels. Ammonia levels alone do not dictate the presence of hepatic encephalopathy. Some patients could have a level of 80 and have severe symptoms, and another could have a level of 100 and be asymptomatic. Ideally, we would treat as symptoms emerge such as asterixis primarily, impaired cognition, confusion, agitation, euphoria, insomnia, and reversal of day-night sleeping pattern.” [I had them written down.]
“Oh. I see…” [He knew it. He just wanted me to fail.]

A few minutes later, he asked me about hepatorenal syndrome. I omitted it from my presentation because there really isn’t much to say, and we don’t have a hepatologist or a transplant team. I mean, there’s two types. In type one, you die within a month. In type two, you die within 6 months. He asked me what the cure was…

“The cure? Well, you can try an extensive fluid challenge to unlock the renal vasoconstriction — something like 2 liters with a rapid infuser. It won’t work, but you should try it. Most likely, your patients with this have advanced cirrhosis and will be on the liver transplant list if eligible. If they develop hepatorenal, you’d need to move their name up on the list quite a bit…”

Well, that’s about it.

I don’t really like the sound of, The Angriest Clinical Pharmacist. They’ve offered me the position on a semi permanent basis. Just a few days a week. Since winter is approaching they are going to expand to 4 teams. However, if I took it, I could no longer be the PIC at my pharmacy…so no deal…

Retail is what I am…I haven’t had my fill yet…:-)

Calling all hospital pharmacists

Posted by The *Angriest* Pharmacist as Hospital Pharmacy, Just a question

I’ve gotten several questions in the past asking me about Hospital Pharmacy — referring to someone in the central pharmacy that makes the IVs, fills med carts (or Pyxis, etc), maybe does a little bit of Gent/Vanc dosing, answers questions of nurses (is Drug 1 compatible with Drug 2 in a Y-site?), and potentially runs and outpatient pharmacy for the public or employees. My experience in that field is very, very minimal. I had one rotation in a hospital pharmacy — where I pretty much filled Pyxis and made IVs for 5 weeks. I didn’t learn much beyond that. These people are usually in Community/Retail pharmacy and want to know if I would ever consider switching. They also want to know about the job in general (why they think I would know — or would be able to help them is beyond me). Nonetheless, here is how I can help. I can solicit the advice/comments from my faithful readers!

Here’s what I want to know about this side of pharmacy:

- Pros and Cons
- Pay level, vacation time, benefits (Insurance, 401k, fringe) versus community pharmacy in the same area
- Role on the healthcare team (P&T — do they care what you think/say?)
- Level of staffing of Pharmacists and Technicians (Is it adequate?)
- Responsibilities of the technicians and the role they play in the pharmacy
- Amount of work expected to be completed with respect to hours in a shift
- Respect from physicians, nurses, administrators
- Opportunity for professional development and/or career advancement
- Anything else that would help someone asking the above question

Thanks in advance. Looking forward to the discussion.