Thank You Michael Crichton

First, I would like to point out that whoever scheduled a total of ten different examinations over the course of a three-week period needs to be informed that cruel and unusual punishment is prohibited by the Bill of Rights. I suspect that by the end of this week I will have lost what little sanity I have left.

But that's not what I'm posting to say--complaining about examinations may be part of student life, but there are more entertaining remarks that I can make. So here are a couple funny highlights from recent work shifts.

A girl calling me for a refill on her oral contraceptive pills expressed sincere belief when I told her that we didn't have the item in stock and that it would not come in until Thursday. The particular product recently went generic and there are still a few holdovers (despite the fact that they're made by the same company), but either way supplies of the brand name are not as numerous as they once were on our shelves.

I believe her exact phrasing was "wow, you guys can run out of drugs?" No, silly me, let me go open up the extradimensional pharmaceutical holding chamber where we keep the infinite supply.

But why reference Michael Crichton?

Those of you who have seen the movie Jurassic Park may recall a particular scene in which the power is out and most of the main cast is sealed in one of the bunkers, hiding from the rampaging dinosaurs. Attempting to formulate a plan, game warden Robert Muldoon brings up "the lysine contingency," a totally ridiculous safeguard thereafter explained by Samuel L. Jackson's computer programmer character:

"The lysine contingency - it's intended to prevent the spread of the animals is case they ever got off the island. Dr. Wu inserted a gene that makes a single faulty enzyme in protein metabolism. The animals can't manufacture the amino acid lysine. Unless they're continually supplied with lysine by us, they'll slip into a coma and die."

Of course, this makes absolutely no sense. Lysine is an essential amino acid, meaning that it cannot be synthesized by the human body--it must be consumed in the diet. In fact, no animals "manufacture" lysine. And as it is common enough--contained in many plants and all meat products--the "lysine contingency" isn't much of a plan at all.

I mostly mention this because I had trouble refraining from laughing the other day when a woman was desperately searching for L-lysine supplements. I should've asked her if she needed it to keep her pet dinosaur alive.

Selected Conversation of the Evening

From tonight's work shift. This phone call left me thinking.

"Hello, thank you for calling CorpoPharmacy, this is N.B., how can I help you?"

[shrill old woman's voice] "What's the name of that disease that's going around, it's killing lots of people and everyone is getting it?"

"Um...I'm...what?"

"You know! It's that disease, everyone has it..."

"Do you...er..."

"Why can't you just tell me what it is!?"

"Ma'am, you're being very vague. I don't actually know what you're asking."

"Everyone's getting it!"

"...do you have some idea as to what causes it?"

"NO! Nobody knows what causes it!"

"Er, no, I meant...how does it spread? Animal bites..."

[she cuts me off] "NO! You get it, it's spreading, it affects your brain, and you forget things!"

"...Alzheimer's?"

"YES!" *click*

I Thoroughly Apologize

A good deal of scotch and Sapporo later, I've come to the conclusion that it may, in fact, be time to post another work rant, because today officially made absolutely no sense whatsoever. As I've noted before, I don't typically post work rants, just because so many other pharmbloggers do it better than I do, but my egregious lack of content of late has me digging for things to post. I could honestly throw out some words of praise for the Purdue Pharmaceuticals rep I talked to today, or go into a long monologue about antibiotics, but I'll save that for a time when my blood-alcohol content is considerably lower.

The short story is that I dealt with the biggest jerk in the universe today.

The slightly longer story is that today I was "greeted" by a middle-aged man with salt-and-pepper hair, probably in his 50's or early 60's, presenting a prescription for prednisone. Sure. Easy. Prednisone. When do you want to pick this up?

"Right away," he says. "Also, I filled a script here two weeks ago for two weeks' worth of medication. I want it back."

"You want the prescription?" I was somewhat confused. "I want you to transfer it." "That's easy, just have the pharmacy call us." "Great," he said. "Transfer them to Canada."

Yes. Canada. The whole country.

"Er." As you may or may not know, once you fill a prescription, it is no longer yours. It is a legal document retained by the pharmacy, a contract between you, your doctor, and the pharmacist that you have been issued a specific medication for a specific purpose. You cannot get it back. It must be kept, filed, stamped, and otherwise notarized, presumably kept in a box somewhere in someone's pharmacy basement for at least seven years. Furthermore, there is no logical reason to want it back. Any other pharmacy can call for a copy and take your script. Canada, however, is apparently one big pharmacy and it can do whatever it damn well pleases.

At this point, the pharmacist noted that it was a matter of federal law that we had to retain his prescription. He was not happy about this, and the pharmacist suggested that he write his congressman.

There was a lot of shouting. I believe I was called a crook. I was told that I should be ashamed of myself for being part of the American pharmaceutical company's great scam, the price-gouging mafia of American drug stores, and all sorts of other general nastiness. I, apparently, am a terrible human being for charging this guy less than $20 for medications intended to prevent his blood pressure from skyrocketing and causing him to stroke out. Maybe we can blame the prednisone for his mental instability. Other customers joked about how nuts this guy was. The customer threatened to contact a lawyer unless we returned his prescriptions. We later noted, somewhat nervously, that it would have surprised none of us if he had jumped the counter or pulled a gun.

I quipped that should he have done so, a lawyer would've been provided for him, should he have been unable to afford one.

"Do you want THIS prescription filled here--and now? Not in Canada?" I wanted to make damn sure that he wanted his prednisone from an American pharmacy. He did.

The customer left the store, fuming. He came back five minutes later. "It's your lucky day!" he said, handing the pharmacist a slip of paper, a receipt from a Canadian mail-order pharmacy with a phone number and information for him. "Call this pharmacy and transfer my stuff there," he said. So the pharmacist called the number later. He was told to call a different number. He called that number and someone hung up on him. It was then that he noticed a number listed for a "United States Canada Mail-Order Service" at the bottom of the label. He called that number.

He got the patient. Apparently, the patient owns a company that imports and ships medications from Canada. GO FIGURE.

In any event, Canada wound up getting his prescriptions. Some specific Canadian pharmacy, that is, which is apparently legal albeit suspect, in the sense that the FDA has officially ruled that importing medications from Canada is "illegal." The Canadian pharmacy claims they do no billing, so none of us have any idea what the meds cost when imported. No one where I work plans to touch the situation with a ten-foot pole.

As an aside, physicians who read my blog? Don't sign your prescriptions "dispense as written." Just don't. Your patients want the cheaper generic. Your pharmacists want to dispense the cheaper generic. And don't refuse to permit substitution when we call you and tell you the patient wants generic, it's $10 versus $70. And for the love of all that is holy, don't sign antibiotics brand-name only. Do you really think there's that much variation between brand and generic Omnicef?

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.

Methylxanthines

News flash to a patient who chewed me out at work the other day because we didn't have the dosage of theophylline in stock that her pet dog had been prescribed (100 mg capsules, to be precise):

No one is on theophylline. Yes, I know theophylline is an asthma drug and that in theory that means it is an important, life-saving medication. There might be two people in this whole state on theophylline. Your suggestion that we should stock theophylline because it is a life-saving drug is analogous to being upset that we don't have a huge supply of thalidomide on hand. Thalidomide is used for renal cell carcinoma. We don't stock it because we might get one prescription for it by the end of this century.

You should train your dog to use an albuterol inhaler. We have one patient whose cat uses one. I don't know how she managed that, but she deserves some sort of award.