Saturday, February 23, 2008

Paging William Shatner

Normally, I don't post work rants, because I feel like that subject has been well-covered in the blogosphere. But today's "pill-counting action," to steal a phrase from the Drugmonkey, concluded with a jaw-dropping exchange that ties into some of the stuff I've been covering lately. Diabetes, that is.

I missed the initial exchange between the woman at the counter and the pharmacist. "Hey, N.B.," he said, "she needs some insulin and some syringes. Can you get her set up?" He went off to do something else. I confirmed the type of insulin in question (Humulin 70/30 mix, which is available without a prescription). I asked how many vials she wanted. "I dunno, how much are they? I'm getting tired of having to go to the pharmacy all the time, maybe I'll get a bunch." About $40. She decided she only wanted one.

"What kind of syringes do you need?" "I dunno," she said. Hmm. Perhaps her doctor sent her here with no patient counseling whatsoever, although he would've at least written her a script. "Alright, how many units do you use?"

She looked confused by this question. "I think 30. Three times a day."

This is an absolutely ridiculous amount of 70/30 for a newly-diagnosed diabetic to be using. I'd estimate she weighed less than 130 pounds; half that amount would've been reasonable. And Humulin 70/30 is an intermediate-acting insulin, so that many doses/day was outrageous. Also, the idea that she would be unsure as to how much insulin to use was mindblowing.

The pharmacist stepped over to me as I was digging around for syringes and suggested (quietly) that we go ahead and give her 40 syringes--no more--because he was convinced she was just going to pitch the insulin and use the syringes for something else. I have commented before on how I don't have a problem with providing syringes and needles to drug users because in my state I'm not liable for what they do when they leave the pharmacy as long as I follow proper sale protocols and the person has a valid photo ID. Alright. 40 syringes.

"Should I get one of these meters?" She was referring to the blood glucose meters, of course. "Yes," I said, "you should have one. How often does your doctor want you to test your blood sugar?"

"I don't know," she said, "this isn't really for me, it's for my boyfriend, he's never done this before." If she was just trying to get syringes, she could've come up with something less elaborate. There was certainly no need to buy a glucometer. I was pretty sure at this point she did, indeed, have a boyfriend with diabetes who needed insulin.

This is bad territory. Now I am not counseling my patient. I am counseling my patient's (slightly loopy) messenger.

"How often should he check his sugar?"

"Well," I told her, "it depends on what your physican wants you to do, but usually at least twice a day, more often if you're trying to monitor changes in blood sugar closely."

This is the part where we entered the Pharmacy Twilight Zone.

"So, how much insulin is he supposed to use?"

I refrained from falling over in shock. "Er. How much did your physician say to use?"

She seemingly ignored this question. "What if he takes his sugar, what should it be? What's high? What's normal?" "Depends on whether he's eaten recently, among other factors. Usually, if he hasn't eaten in a long time, it should be pretty low, like 80-120. Did the doctor tell him what his goals were?"

"So he should check his sugar and if it's above that he should take insulin?"

I was starting to get the impression at this point that this boyfriend of hers had never, in fact, seen a doctor about his diabetes. Or, perhaps, he had seen a doctor once, ignored everything he was told, went home and told his girlfriend that he had diabetes and needed insulin, and set off a bizarre chain reaction that somehow ended with "I can get a random pharmacist to sell me insulin, confirm the diganosis of diabetes, and prescribe an appropriate insulin regimen for a patient he will never see again."

Note to the reader. THIS IS WRONG.

"Yeah," she continued, "he doesn't pay attention to stuff, he can't do this himself, so I'm trying to take care of it. I'm goin' to go to nursing school, I gotta understand this stuff, I know about checking blood sugar. He can't do this stuff himself, you know how boys are."

I just blinked at her. "Uh."

"Well, some of em' anyway."

I'm not sure who to blame for this scenario. Opponents to universal health care? A careless physician? I don't think the blame belongs to a doctor. Her boyfriend came in a couple minutes later. He had no clear idea of what was going on. Apparently he knew he needed insulin--and that was it. He remarked that the insulin and glucometer were expensive. "It'd be cheaper to get the other medicine," he said. "Yeah, well," replied his girlfriend agitatedly, "you're too disorganized to do that, so we have to waste the money like this."

She produced a one-hundred dollar bill to pay her tab, at which point I requested a photo ID for the syringes. She didn't have one. He didn't either.

"We'll just use the syringes we've got at home," she said. They took the insulin and the glucometer and left the store. The pharmacist and I stood and stared at each other in total shock. We were both completely baffled by the exchange. I am moderately concerned that he's going to go home, overdose himself on insulin, and wind up in the ER, convulsing and in shock. If it had been my call, I wouldn't have sold them the insulin, but the pharmacist didn't have a problem with it. This was the most confusing exchange I'd ever had with a "patient." I had a distinct notion that both of these people were like cats without whiskers, perpetually caught behind the refridgerator, and I had just let them leave the store with a bottle of something that could easily result in an unintentional lethal overdose if used improperly.

I kind of hope these people never breed. The cynical part of me thinks that this problem will short itself out in short order when this guy removes himself from the gene pool.


PalMD said...

As someone who deals with drug-seekers every day, I can tell you that I would not be surprised if something untoward was going on. It could have been simple ignorance (which I also see every day), but not all drug addicts are smart, and sometimes they can't keep a good story going.

BTW, I wish we had needle-exchange programs everywhere.

Dharma said...

I'm an EMT. I see people who don't have insurance and who have, on the basis of a single urine stick that indicated the presence of sugar, gone ahead and treated themselves as if they were insulin dependent diabetics. I've lost count of the amount of people my colleagues and I have been called out for who have gone and bought insulin, needles and syringes and a glucometer over-the-counter and who have had nearly killed themselves by self-medicating. I think that the lack of insurance plays a HUGE part in all of this; people don't want to run up bills for ongoing treatment and/or can't afford the co-pay for the care OR the medications.....that, and they're generally ill-informed and uneducated about the different type of diabetes and think that 'diabetic' automatically means they have to take insulin shots. Either way, it's a dangerous game and I am disgusted that people can buy insulin without a prescription.