First Do More Harm

Hello strangers,

Last night was probably one of the more stressful nights at my job, and it really wasn't all that bad. Considering the amount of prescriptions we run, it's surprising that there aren't more problems than there are. If people would just hold out for a while, problems will take care of themselves. The check is in the mail, and your drugs are on their way. Trust me--I'm a doctor.

I got home, decompressed with a really fatty roast beef sandwich decked with melty cheese and mushrooms. So good and so bad and the perfect reward for a job well done. Afterwards, I enjoyed Dragonball Z on the CW. Yes, I still watch cartoons once in a while even though they're silly. Reminds me of simpler times.

Then around 10:30AM, I hear the door open and heard the scuffling of more than one person's shoes. So I peered around and saw my bro and this girl, whom I supposed was his girlfriend. Eh, whatever. He didn't say anything about bringing her home, and so I didn't feel obligated to cease making a nice mold of my butt-cheeks onto my favorite part of the couch. That is, I stayed seated enjoying my toons.

--

After introductions,

some girl: so your brother tells me you're a pharmacist

me: uh huh

some girl: where do you work?

me: in hospice at an independent

some girl: where at?

me: (gives locale)

annoying girl: (etc etc etc) why don't you work at a large hospital like MD Anderson or somewhere in the Med center? (etc etc etc) the benefits are better for when you retire.. (etc etc etc)

irritated me: (silently) who are you to tell me what I should do within 5 minutes of meeting me? (spokenly) I really like my job. They treat me well, and there's not much stress.

more annoying girl: (acknowledging and ignoring my comment) It's good you like your job. Not many can say that. (but wanting to reiterate her point) but you know, large hospitals generally have better benefits and such.

irritated me: umm, are you a pharmacist?

annoying girl reveals herself: oh, no, I'm a psychiatrist.

me: (silently) it figures, an MD and a shrink. (spokenly) oh okay. The benefits aren't really that much better. I worked for [large chain retail], and although pay is less, benefits are about on par.

shrink: (etc etc etc, reiterates point and acknowledges that there's politics when working at large facility, but still maintains her initial suggestion that I should try working for a large facility)

me: (maintain almost-rude indifference by watching TV and ignoring the girl in the room)

--

Thankfully my brother gets done doing whatever he needed to do and they left. I'm generally a very nice person when meeting new people, and I generally make a good impression, but not when I'm tired and not when your opening remarks criticize what I do for a living. 

Goodness, I thought shrinks where supposed to make you feel better about yourself. She made me want to ask her to write me a prescription for Paxil, take 1 as needed post mindf-cking.

But I wasn't so mean as to ask her, "Biological clock ticking much? You know you're dating a guy without a college degree, right?" No, no, my parents have messed with my head long enough for any shrink to make a dent in this impenetrable defense of perpetual self-doubt. It's like when virus-infected cells can't be infected by subsequent viruses.

--

much later,

me: you missed your future daughter-in-law by 30 minutes?

Mama: oh, really?

me: uh huh. Brother brought his girlfriend home. She's a psychiatrist. Do you know what that is?

Mama: Yes, 4 years medical school and then residency. (not impressed) She must be old, right?

me: (laughing) probably around brother's age.

Mama: (as if he had brought home a crackhead) Well, he can do want he wants. I can't stop him from doing anything. (her typical passive-aggressive way of disapproving)

--

Yep, in a battle of wits, I put money on Mama!

The CAGE Test

to alcoholics, again,

In school, they teach us about the treatment for alcoholism, which is (long story short) to stop drinking. Acute and chronic alcoholism can lead to liver failure, heart failure, and other things which I wish I had a pharmacist-intern to look up and do a report for me.

Once the liver is affected, there's not much treatment except to stop drinking, take some meds that may or may not work (pentoxifylline, steroids) and pray for the best. If the person has been clean long enough, they may qualify for a liver transplant, but I think most people feel shady for giving a liver to someone who lost the original of his/her own free will. Alcoholic cardiomyopathy mimics symptoms of traditional heart failure where the patients can feel like they're drowning when laying down. They're both crappy ways to go. If it was up to me, I'd want to OD on this new street drug called 'cheese'*.

So after a casual wondering and joking about my own drinking habits, I remembered there was a questionnaire to see if a person may have a problem. When I first learned about it in 1st or 2nd year of school, I answered 0 out of 4, but let's see how the hands of time has corrupted this once innocent soul:

C - Have you ever felt you should cut down on your drinking?

Sure, because it gets damn expensive. When you start your alcoholic career with the top shelf stuff that costs >$35/750mL, it adds up. And these single malt scotches, which are my new drugs of choice, are even more expensive with age. But the 18yrs are so smooth and leave the most delicious lingering vapors on the tongue long after the first dram.

A- Have people annoyed you by criticizing your drinking?

Not really, because I usually beat them to the punch by telling them jokingly that I'm an alcoholic. And alcoholics of a feather flock together, so there would be some serious pot-calling-the-kettle-black action going on if that were to happen.

G - Have you ever felt bad or guilty about your drinking?

Only the two times when I woke up still drunk from the night before. Oh, and the time I 'redecorated' my friend's digs...twice..

E - Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

I can honestly say never to this question. I believe in rehydration, bland carbs, and non-thought-provoking comedies like Scrubs or Chappelle's Show. And I never like having the same food or drink two days in a row, so I couldn't possibly imbibe the same vile poison the morning after.
--

So in short and honestly: yes, no, yes, no. But one must factor in the healthy dose of guilt that is cultured in every non-doctor** Asian male who is almost inevitably considered a failure in the eyes of his parents, myself not excluded.

But no, I don't truly consider of myself an alcoholic. I am a binge-drinker with a weak will, a hardy liver, and a short memory. And if I am to die anyway, I might as well die having a good time never feeling like I was deprived of anything again. [A higher power] knows I've long lived a life engineered for the joy of the progenitors and not the progeny.

--
*You must go to that link--I couldn't stop laughing the first time I heard it on This American Life!
**Only M.D. counts here. D.O. need not apply, so forget about my Pharm.D. meeting my parents' expectations!

Pre-Filled Flu Syr

Dear new techs,

The bad part about working at a brand new store is that you can hardly find a pharmacy technician with any experience. All those AIU, Remington, ITT tech places promising thorough training and career placement have fine print saying jobs aren't guaranteed. The reason being that employers want people with real-world understanding of the job. But when you open in a brand new market, those trade school grads are the ones you can find with some exposure, however minimal.

Though you can find a truly remarkable individual once in a while who ends up being really great but didn't have any experience initially, that is the exception. Experience matters, period.

But luckily for me, the techs at my store have a good attitude towards learning, which is really the most important characteristic in my opinion.

With new techs, you do see some pretty funny situations such as a tech saying that we were out of stock of albuterol MDI ('Dude, there's ProAir, Proventil, or Ventolin...pick one') or ordering Indocin suppositories because that's all that was pulled up in the computer when they typed 'Indocin' (brand for Indomethacin, which we had 10 bottles on the shelf).

But the one that took the cake, which I could see myself doing if I had a brain fart, was this:

I came in one night and noticed that we had low-dose heparin syringes, the kind that they used to clear out or push through medicines in IV lines in hospitals. It's pretty common in hospital pharmacies which usually carry several cases of them. But not in a retail pharmacy--if you have an IV line, you should probably be in a hospital or a long-term care facility. And IV drugs are probably not going to be covered under prescription insurance anyway.

Anyway, I laughed at it, chalking it up to ordering error, which happens a lot. The syringes came in white boxes with about 50 in each. In turn, the 4 white boxes fit inside a large cardboard box, which had the label: BD Pre-Filled Flush Syringes.

My goodness, so that's the reason! BD Pre-Filled Flush Syringes. I guess one of the techs thought that the 'BD Pre-Filled Flu Syr' in the wholesaler catalog was the pre-filled flu syringes that we've been using like warmcakes*.

And we can't return it because it's 'generic', but at least it's cheap. So if you need some flush syringes, get a prescription and then holla at yo boy.
--

*Flu shots haven't exactly been flying off the shelf. Maybe 10/week if that?

The Ambien Prior Authorization

Dear new RPh's and techs,

A post for my retail pharmacy people and those insomniacs whose insurance refuses to pay for sleep pills.

Just about the middle of last year, I started to notice that refills for zolpidem, generic Ambien, was being rejected for a prior authorization. This means that the insurance company wants to talk to the doctor to make sure that the patient really, really needs the medicine. What it really means is that insurance companies are the spawn of the devil and don't want to pay for anything.

A quick note about insurance companies: their business model is to take regular premiums from their customers and find ways to NOT pay out claims. One of the sneaky ways they do this is to send out brand new cards every year so that they can expire the old ones and hopefully not pay for a refill. In doing so, they make my job sucky for a few months out of the year, even more than usual with having to deal with insurance.

Most of the time though, their prior authorizations (PA) are well founded: rejecting an ADHD med for a kid who is 4 years old (my goodness, are we going to pump 1 year-olds with Ritalin next because they cry too much? wait a minute, we do! *sad face*), rejecting Cambia(R) because it's glorified ground-up diclofenac*, and rejecting Nexium(R) because it's basically rehashed omeprazole whose patent had run out**.

To these situations, I must say to the insurance co's, 'Nicely done. If I had more time to talk to the doctors to convince them to use medicines judiciously, I'd do the same. But since I'm here to dispense drugs pursuant to a prescription, I'd really wish that you'd make my life easier and just approve the medicine for a $200 copay so I can tell the patient to take it or leave it or take it up with their insurance/doctor. Because a PA makes it look like the pharmacy is being withholding, when it is in fact, you who are the angry wife (who is withholding of the marital obligation). Thank you.'

But I just don't understand when they reject meds which are comparatively dirt cheap (in the $40 range). Branded Lamisil tablets used to be prohibitively expensive, but the generic isn't too bad. Come on, guys! Let the old dude have it for his onychomycosis! Or when they rejected generic zolpidem when they had paid for it the first couple of months.

But then I remembered the lecture I gave on sleep disorders shortly after I graduated***: Ambien is FDA-approved for 'short-term treatment of insomnia characterized by difficulties with sleep initiation. Ambien has been shown to decrease sleep latency for up to 35 days in controlled clinical studies.'

Bingo! The resident medical 'expert' at the insurance department picked up on the little bit of important information (the package insert that accompanies the drug bottle), and found a great reason to reject refills of Ambien. 'Dear Dr. so-and-so: As you can see from the package insert, Ambien (Zolpidem) is not approved for treatment lasting longer than 35 days. Thank you.'

Anyone with any bit of reason (even insurance companies) knows that Ambien doesn't simply stop working after 35 days because the drug isn't approved for long-term treatment. It simply meant that Sanofi-Aventis didn't have the money to run the trial longer or were afraid that the sleep-inducing effects would wear off after 35 days and would lead to not-so-good-looking clinical results. As such, the drug is FDA-labeled for short-term treatment and now insurance companies have a perfectly valid reason to reject a claim using a prior authorization.

They could run longer trials now, but they won't because Ambien is generic, so they couldn't re-coop their expenses.
--

So why know all of this? Because it is always better to explain to customers how it really isn't your fault. When you pass the buck to other folks, preferably drug or insurance companies, customers can get angry at them instead of at you. By the way, don't pass the blame to their doctor, because they may really like their doctor or their doctor may call and chew you out.

'Why is my insurance not paying for my medicine?'

*Smile* 'Well, sir. Ambien is not approved for long-term treatment of insomnia. Though I realize that you've been using it for years now, the original studies approving the medicine was only for short-term treatment. I think the insurance company wants to run this by with your doctor and make sure that there isn't a better way to treat your insomnia.'

Congratulations! The customer is no longer angry at you, and thinks you're pretty swell for your insurance knowledge. He shakes your hand, happily pays the ~$40 for the cash price of Ambien, and will take it up himself with his doctor/insurance.

Based on a true story.

Incidentally, you could also recommend the customer to get a prescription for Temazepam (generic Restoril) which is only about $20 per month without insurance.
--

*I wanted to tell the patient to get a prescription for diclofenac 50 mg, buy a mortar and pestle, grind the pills up herself to put in water, and save $200 for 5 friggin packets!

**Please explain this to me: Omeprazole 20 mg and Nexium 40 mg are the most commonly dispensed strengths. We are made to believe that the S-enantiomer is supposedly the more active (or only active) component of the racemic mixture, and/or that it has less side effects. Therefore, if Omeprazole 20 mg contains 10 mg of the S-enantiomer (Nexium) and 10 mg of the R-enantiomer, wouldn't the equivalent strength of Omeprazole 20 mg be Nexium 10 mg?

So why does AstraZeneca market Nexium 40 mg which would be in essence, a four-fold increase in strength vs Omeprazole 20 mg (Prilosec, which they made)? Don't give me some BS about how there are fewer side effects so you could give a higher dose--show me a person who was taken off omeprazole for side effects and I'll show you a hypochondriac.

***Excuse the not-so-subtle reference to my genius :)

Practicing Scared Pharmacy

Dear poker degenerates,

About a month ago, I was playing 1-2 No Limit Hold Em at Winstar, a casino just a few miles north of the Texas-Oklahoma border. The Winstar poker room happens to be one of the few redeeming things about the Okie state*. The deck was hitting me in the mouth that night, meaning I was catching everything. On one hand, I flopped a boat, sixes over jacks, when my opponent flopped trips (6-6 vs J-9, flop J-J-6), and I proceeded to take the guy’s money. On another, I flopped top two-pair and made a really stupid all-in move out of turn, raising an additional $160 on a $100 bet ($260 total). Fortunately, the guy behind me folded a flopped straight because he respected my tight-aggressive play, and the initial raiser didn’t hit his draw. That sent the folder on tilt, and he berated me with stuff like, ‘I really hand it to you…not many people would have had the guts (sarcasm for ‘stupidity’) to raise all-in with two-pair.’

Then a few hands later, I completed a nut straight draw (Broadway) against the tilter’s flopped set and took the rest of his stack, sending him out the casino door. I had started the night losing my initial $200 buy-in, but scrambled up to $560 with my last bill. But with the cards I had that night, a better player would have made so much more. I was playing scared poker, and it cost me additional winnings.

This was the microcosm hand for the night: I was dealt J-9s on the button with two horrible players sitting to my left in the blinds. The first guy played loose-aggressive slop poker, pretty much continuation betting with any 2 cards after the flop. He bet and folded out of turn, insulted the dealers, and even folded a few hands when he could have checked his cards. The guy to his left was pretty much an open book: he bet his made hands, called his draws, and folded his mess. Easy pickings: I raised to $7 pretty much every time I had the button, and this time I had my favorite hand.

They both call as I lick my chops. The flop comes, and it takes all my power not to drool all over the cards: Q-10-8 rainbow. I flopped the nuts with my J-9, which is the best 5-card hand given the cards on the table. My brother calls it the hon bi, which is literally translated from Vietnamese as ‘the marbles’. They both check, and I make a sizeable value bet, about three-fourths of the pot, hoping that one of them would call. They both do, which made me a little anxious. I put the loose guy on a draw, and the tight guy on top pair, overpair, or a set. A 5 came on the turn. They check, I bet more this time, and they both call again. Now I’m thinking that one of them likely had a set on the flop. The river came. Another 5, a scare card for me. Again they check in front of me. Amateurs love to slowplay. They love to reveal the winning hand and rub it in your face. And I had a belief that at least one of them had turned his set into a boat with the river 5, and this was enough to make me check behind them.

I turn over my flopped straight, and they both muck their hands. Though I don’t know what they truly had, I’d probably say the loose guy had a busted draw (K-J) and was paying me off, and the tight guy had top pair, top kicker (A-Q). And somehow I didn’t make more money after flopping the nut straight. While I was replaying the hand in my head, reviewing all the action, the guy on my right, a solid 19-year old Asian (it’s an Indian casino with a lower gambling age) with a diamond stud in his left ear, needled me with, ‘Dude, why didn’t you bet the river? You had it!’

‘The 5 was a scare card. I thought at least one of them made a full house.’

He considers, agrees silently to himself, and then tries to set me on tilt, ‘So what? Are you playing scared poker?’

I shrugged and smiled. I was winning, and I didn’t care. Looking back, I realize that I had given them odds (at least one of them) to draw out on me. And the odds of them having the boat were slim since they both would have raised (or check-raised) me if they had flopped a set.

Scared poker is my current M.O., and I'm working hard to change that. To triple barrel your nothing against an opponent's something; that is mostly genius and sometimes gross stupidity.
--

Poker is simpler than life in that poker boils down to the chips in front of you. A correct decision nets more chips. A correct decision could also mean less lost chips, which is equally as important. Like life, it is a game of incomplete information; we have to make decisions based on what we know, however little that is. And if we consistently make good decisions, we will make more money in the long run. It is a game which rewards good play and punishes bad play. Therefore, it is a just game. People who complain about bad beats and others' poor play are just not applying themselves.

But life is far more difficult than poker, which is itself an extremely complex game. And it is fraught with injustice: how is playing professional sports worth 100x more than teaching kids how to read and write. Or how is rapping/singing about degrading acts which are performed with semen rewarded better than doing research which paves the way for the cure for HIV/AIDS?

And to set ‘justice’ even more off kilter, we have allowed frivolous lawsuits to dictate our lifestyles. It’s common sense that your coffee should be hot; do you need a warning saying that it could cause you injury if spilled?

What affect me personally are all these inane commercials with ambulance chasers asking people if they’ve suffered injury from medicines. If people read the warnings, there really shouldn’t be anything to complain about: there are risks inherent with any medicine. If Accutane(R) can cause DEATH (suicidal ideation), why are people suing about upset stomachs and diarrhea? As such, there is tremendous risk of not covering your backside as a healthcare professional.

And for myself at least, there is little upside to exposing yourself to liability. In the past 10 years or so, there was some study done in some pediatric journal which purported that common over-the-counter remedies were useless for kids under 6 years. Since then, most manufacturers have removed the dosing for kids under 6. Some pediatricians will swear at you up and down for recommending those medicines while other peds docs will call you an idiot for refusing to recommend them. PharmDs are technically doctors and self-proclaimed ‘medication experts’, and so I guess we do have authority to supersede drug manufacturer labeling. But it's not like I get paid any extra when I make a recommendation which might expose me to a lawsuit if something bad happens.

I know if I recommend common OTC remedies for kids outside of the packaging recommendations (which is ill-advised), most kids will probably end up fine. Their parents will have the placebo effect of giving their kids something to help with the sniffles even though those medicines may not have any effect at all (so the study says) and has absolutely no effect on the curing the true sickness. But heaven forbid if one of those kids decompensates and croaks. Then the parents, their lawyers, and the late local news will be on my ass for recommending the damn drug.

‘We have here ‘doctor’ Nguyen who had recommended a medicine which specifically said not to be used in children under 6. ‘Doctor’ Nguyen, what do you have to say for yourself now that this innocent child is irreparably injured?’

‘You are all absolute idiots. Thank you malpractice insurance for covering my behind. You asked for my professional opinion, and I gave it, and now you're suing me for it. Next time, go Google it, and then sue yourselves.’

No thanks! What do I say on a daily basis? ‘There is nothing labeled for kids under 6 (or 4 or 2 years, depending on the medicine). You can ask your physician about it, and if they recommend it, then I can show you where it is. But I cannot recommend anything outside the package recommendation as I could lose my license.’ If you’re not comfortable doing something, say that you could lose your license--that works pretty well.

One of my friends says that I’m being a coward, that he’d rather help 100 people in need while exposing himself to potential liability, than intentionally being unhelpful like myself. And that’s fine. To each his/her own. I personally like having a license. And it’s far less likely that I’d be sued for refusing to recommend something than for recommending something off-label.
--

In real poker played in casinos, you can only bet and lose what is in front of you. If some guy bets $1,000, and you only have $200 on the table, then you can go all-in to win the $200 part of his $1,000 bet. You don't have to fold or throw in your car keys as they do in the TV shows and movies. In the case of my flopped straight, it would have been the right move (in hindsight) to go all-in as those players had a history of calling with second best hands. In the unlikely case that one of them had the full house, I would have only lost a couple hundred.

In life you can lose so much more, your entire livelihood depending on the lawyer who's suing you. My friend can go ahead and bet all-in with his weak straight. Eventually, one of his opponents will have made a boat and take away all his money, the clothes off his back, and the food from his kids' mouths.

Me? I got bills to pay, and so I practice scared pharmacy.

--
*Why is it that neighbors are so mean to each other or are deemed ‘rivals’? Is proximity like when your bro/sis invade your personal space while in the backseat on long roadtrips?

[Buttocks] Out of You and Me

Dear cliche users,

If I ever hear someone say that stupid phrase, 'Don't assume: you make an ass out of you and me,' I'm going to advise them to put on their most expensive outfit, go to the bad side of town, and walk from liquor store to liquor store flashing $100 dollar bills. See how far that gets them. Or they just can assume that it would probably be a bad idea.

You have to assume, you have the right to assume, and you have to take things for granted. You don't wonder in the middle of the night whether the sun will come out tomorrow or if the sky will be blue; you naturally assume it to happen because it's always happened that way. For those philosophers out there, you're not going to question every damn little thing; you'd go absolutely insane! If you have to question whether each table exists in and of itself, you'd end up eating your lunch on your lap (or does that exist? or does your lunch? or do you?).

Okay, I'm reaching the point of hyperbole. Fine. But I do get tired of people saying I generalize too much or assume too many things. That, I would contend, is the essence of my efficient thought process, the source of my intelligence. I ignore things which I feel don't matter, and I assume things which I judge can be assumed to be true. Then I distill the facts, and make a decision which happens to be correct more often than not. If I ignore what shouldn't have been ignored or assume that which should not be assumed, then I factor it in the next go-around.

People go wrong when they assume things incorrectly, thus leading to false conclusions. Or they assume racist/prejudicial ideas and voice them and get in trouble, ie Michael Richards & Mel Gibson. Caution: link contains excessive use of the n-word.

Good assumption: If you must have racist ideas, it's generally not a good idea to say them in public where people are videotaping you to be put on Youtube.

The more things that can be assumed and the more things that can be ignored, the better and more efficient the decision will be (and the more decisions you can make). That does not necessarily mean that the decision will be more accurate, just more efficient. I don't strive to be perfect in my thought; my quest is to be right the vast majority of the time. I quit going for 100s on grades a while back because perfection hindered progress.

I don't bring this up because I'm irritated that someone attacked my mode of reasoning and logic (to be right a lot of the time rather than all of the time); I bring it up because my OCD has recently flared up rather unexpectedly, and it has been quite frustrating.

To explain, I don't touch light switches or wash my hands to an excessive amount. I do like my things to be clean, in right angles, undamaged, orderly, controlled, etc. But that makes sense to me because it's efficient; I don't have to search for things because I know where they are because they have a place. Moving my stuff or damaging it will certainly piss me off, but it won't be the end of my world.

The weirdest thing, until recently, was that if I was uncertain whether I had locked my car, I'd walk back to check even if it was an entire parking lot. This only happens once every few months. And it is really just paranoia from living in Houston rather than OCD.

The truly OCD thing that has come up deals with the verification of prescriptions. For non-pharmacy folks, pharmacists get paid primarily to verify that a prescription has been filled correctly and that there aren't any major/severe interactions. This is required by law, but the law does not dictate how you're supposed to do it. You can make some hand gestures or pray or chant or trust that your techs did everything correct, but ultimately if the prescription is wrong, you're liable.

Depending on the error, you can be fined, your license can be reprimanded, you can be put on probation, and in the most severe of cases, it can even be revoked, though I've only heard of revocations for unethical things like stealing narcotics or deliberate falsifications (insurance fraud), not for an error in good faith. It's not like in It's a Wonderful Life where the druggist* becomes a bum because he misfilled a prescription for the little kid; if you make an honest mistake, they're probably not going to take away your livelihood. Probably not (again with my assumptions).

But people are another thing. They will sue sue sue like there's no tomorrow. Lawyers find ways to sue for stupid stuff that is already on the drug information sheet. Reglan: 'May cause tardive dyskinesia'. Lawyers think, 'that sounds really bad, so I can probably sue for it!' Accutane: 'May cause death, among other things'. The ambulance chasers, after reviewing the 10 pages of side effects: 'Aha! You didn't say GI side effects! Gotcha!'

So don't misfill. Because it can be potentially bad for the patient as well as very bad for you.
--

Over the past year of being a pharmacist, I've developed my own process for verification. And fortunately, I have not misfilled of my own accord as far as I know. For me, the last step of verification is to make sure that what is in the vial is what it is supposed to be. This means opening the vial and comparing it to the picture on the computer screen or with the stock bottle it came from.

This usually isn't a problem because I fill most of the prescriptions I verify since I work alone at night. And so that last step of comparing pills is generally trivial for me since I trust in my work.

Until now. Nothing has happened; there hasn't been a misfill or even a close misfill. I have found that when I have too much time on my hands, I start to doubt in the certainty of my efficient process. In my thoughts and decision-making, I aim to be most efficient, not most accurate. But as a pharmacist, I aim to be most accurate first, since they don't take your license away for being too slow. When there are several prescriptions waiting, I temper my obsession with being 100% accurate with the necessity to get them out quickly.

On the final step, I check about 3 tablets directly, and then make sure all the rest have the same relative shape and color. Then I close the vial and shake the bottle to see if it's about the right quantity (30 vs 90-day supplies). Easy peasy.

But in the dead of night, I've spent up to 2 minutes doing that last check which should only take 5 seconds max. Open, check, close, shake. Open, check, close, shake. Repeat until I get frustrated.

It's like turning a light switch on and off. It is safe to assume that when you flick the switch, it will work (even though it may potentially not work); you don't have to check 10 million times. I tell myself the same thing with the verification, and it's gotten better. It seems to be really bad when I'm tired, which will happen when you voluntarily work 23 12-hr shifts in a row.

All logic fades, and I'm left with my basest instinct to be right.
--

*not to be confused with a date-rapist, this is the old-school term for pharmacist

Whoa whoa whoa...

Take it easy…

First off, I hate censoring people. I hate censoring myself, but there’s stuff you don’t want people to read about you (stuff like how I think Leprechauns are real and that if I find one, I would trick it to show me where its pot of gold is so I’d never have to work). Whoever seen the leprechaun say yea!

I am a non-confrontational kind of person, and when I see or hear gunfire, I instinctively run the other way. That’s what real people from the ghetto do. So if there’s a squabble, I like to get as far away as possible, get some popcorn, pull up a chair at a safe distance and enjoy. But as this fight has broken out in my own house (aka blog), I have to respond. On a sidenote, don’t let people get plastered in your own house (thank you to all the people who have cleaned up after me! I owe you one!).

The one lesson I’ve learned as a retail pharmacist is that getting angry with people does absolutely nothing to help with a situation. You only irritate them more and you expend a lot of energy by having to quell your emotions after the confrontation. Don’t do it. Step back, breathe, and relax. There’s absolutely nothing anyone can do to you that will hurt you if you don’t let it affect you. Take their weapons away from them, and they will have nothing with which to fight. Some lady called me ‘withholding’ because I wouldn’t let her touch the tablets, another guy said I didn’t do my ‘due diligence’ because I neglected to process his discount card, a third called me ‘racist’ because I didn’t ring up her OTC med immediately because I was busy with hospice prescriptions. Whatever. Go on and brush your shoulders off.

A battle not fought is a victory won.

So to directly address the situation: did eggs’ comments affect me? Sure, but I have built my foundation upon my own self belief, that what I do and write is my true self (excluding stuff that would be TMI). And though that true self may be narcissistic, prejudicial, superficial, and arrogant, it is also humorous, light-hearted, deep-hearted, middle-hearted, and educational. Though I do not know if I am ‘good’ (or if human beings can be ‘good’ or if there is such a thing as ‘good’), I try to be ‘good’. Therefore, when anyone makes ‘attacks’ on my character, whether real or imagined, I have confidence in my attempted goodness. Thus, nothing anyone can say or do will have power over me (up to a limit, of course).

Upon this rock of my self-worth, I have built the temple of my mind.

So I shrugged off the ego-deflating comments. I cannot control others’ thoughts; I can only control my response to them. And when the comment feud broke out, I found it insanely comical because it was a (relatively) unnecessary fight.

But since peoples’ feelings have been hurt, and I foresee some escalation, I’m going to end it. I don’t trust that people have my prodigious fortitude (don’t you dare make a comment about my weight!) to deflect criticism. Because after all, we all know that I’m pretty much a big deal. :)

So keep enjoying my blog. Keep commenting on what you like or what can be improved. Posts are also forwarded as boxes on my FB page, so you can just hit the ‘LIKE’ button there. After all, I live off of comments because I am a narcissist, but do keep them positive or playfully insulting. Anything else will be removed. Call me an idiot but do it with a smile and temper it with something like how my tie has the most perfect dimple and drops exactly to mid-belt buckle or how you’d have to sue me for retinal damage because my Gucci is so sparkly.

Life is too short to live it angrily. If anything I say comes off as vaguely insulting, understand that I do it with a smile, and that I aim to offend everyone equally and myself especially. After all, the story of blonde 9.7 was not my proudest moment, but I shared it with you all (and you must admit that it was a pretty funny story at my expense).

People should die with stupid grins on their faces. That’s how I want to go, facilitated with loads of friends (and morphine). It’s a celebration! Enjoy yourself.
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On second thought, this isn’t Cuba or China. There is free speech after all, and you can do whatever you like (insofar as it is what I like). But as Catch-22 says, I have the right to do anything you can't stop me from doing. I am a delightful tyrant, but still a tyrant in the tradition of Nero (except without all that in-bred perversion), and this blog is my despotic realm.

So keep it above the belt or you’ll find your comment trashed. And don’t recruit people in your fights. Agreed?

Sanofi Aventis’s RockBand Title

Dear Guitar Hero/Rockband recovering addicts,

The other day while dispensing a prescription for an insulin analogue (an insulin that has been modified to alter its pharmacology), I had a quick musing about the brand name on the box. This particular insulin-analogue has been around for a few years now; I’ve dispensed it as an intern when I was in school. But I think the development of this particular delivery device is a (relatively) new thing.

Just a quick background: Insulin in the olden days would just come in vials and would need to be drawn up in a syringe separately. Most insulin still comes this way, and most customers will have a prescription for both the insulin and the syringes (I like to tap the sign that reads 'NO SYRINGE SALES WITHOUT PRESCRIPTION'). But a few drug companies had the smart idea of making pre-filled syringes and packaging those in boxes. Voila. The insulin pen (so-called because it looks like a pen) was born.

Diabetics would just need to attach a needle to the device and inject themselves. And since the pen could control the amount of insulin injected, there wouldn’t be need to draw up each individual dose. I’m not insulin-dependent, but I’d bet it would suck to have to draw up each dose of insulin and stick yourself several times a day, so at least these pen devices make it mildly less inconvenient. And I think you could tote around a pen without having to refrigerate it. I wish I had an pharmacist-intern to look up the answer, because that's what they're for (besides fetching coffee).

And the boxes the pre-filled pens come in are fairly large, so I like being able to stick the label on it without having to fold it around the box. If you’ve labeled a Novolin insulin box, you know how irritating it can be to have a flap of prescription label hanging around the edge of a box (or is it just my being anal?).

Getting back to the product, I’ve dispensed this particular pen device quite a few times, but for some reason I was thinking about old-school rock and the now ubiquitous RockBand/GuitarHero/Clone games.

I waxed silently in my head, ‘Lantus Solostar. That sounds a lot like a title for one of those video games!’

Then I said it aloud, causing the (pharmacy) tech to give me a funny look that implied, ‘WTF are you talking about?’ Sometimes you should keep your random thoughts to yourself. But then again, silences can be awkward.

Blue Eyes

Most nights when I’m working, I want to holler and scream the staff at the two emergency care centers across the street for sending me so many new customers. There’s another repeat offender 10 miles up in Plano which also sometimes incurs my wrath. But a couple of times a year, I’m blessed by the presence of beautiful blondes with devastatingly deep azure eyes, liltingly pained dulcet voices (because they’re sick), and the patience of a third grade school teacher when Barr runs a mass recall on generic Adderall.

One such heavenly creature came by recently, but unfortunately, it was during a time of abysmal turmoil: three insurance problems all at once, and all of those customers were there waiting. No tech, no problem; I am g, after all (excuse the arrogance, when you work this job, you have to have some confidence so that people don’t walk all over you). A couple of 1-877 numbers later, I got everything resolved, got those scripts out pretty damn quick, and even added some patient counseling in there (may cause drowsiness, take with food, this is my cell number in case you need to reach me for any reason, wink* etc).

When the night slowed down a few hours later, I felt haunted by those cobalt gems that rested underneath the shock of honey wheat bangs. I don’t really obsess over girls anymore (those restraining orders became troublesome**), though this girl did warrant some stalker-ish action. But thankfully the trance, caused by the iridescence of the windows of her soul, tapered off over the remaining hours of my shift.

Though I confess to be equal opportunity when chasing after the fairer sex, I have such a weakness for blue eyes, the true blue eyes that shine without need of refraction from pieces of plastic. That pretty much all but precludes women of negroid or mongoloid descent. The pretty Chinese girl that came by earlier with the blinging watch (my Gucci’s relative?) did absolutely nothing for me; I might have been more turned on by the watch. But the girl with skin the color of pale amber makes my spine tingle just thinking about her.
--

There’s a line in a song by Tupac that reads

Lately, I’ve been really wanting babies
So I could see a side of me that wasn’t always shady

Around the start of the third year of pharmacy school, I started to dislike myself. It was the time when my classmates were thinking about what they would do after pharmacy school (residency, retail, hospital, or other), while I was stuck contemplating the MCAT that I was about to take to apply for 4 more years of floggings, plus 3 years of being an attending physician’s man-servant (aka internal medicine residency).

I think that was the time when I started growing the fat tire around my waist and started drinking more. And over those final two years, I wished that I was someone else or that it would all be over, including my life at the depth of my despair.

I had told my ex during one of my vulnerable moments that I hated myself. Thinking back on the reasons she cited for breaking up with me, I think it was my own self-worth issue that was the problem. I don’t blame her: Most people think I was well-adjusted when in reality I was a couple steps away from six feet under. (Note to the guys: saying that you don't like yourself is generally considered a bad move. No one had told me.)

During orientation for new pharmacy students the year prior, I had said something which I had forgotten in the madness: ‘Some of you will fail; it happens to the best of us. But no matter what, you’ll always have your life and your health; school is secondary to those things.’ For myself, I would add God in there as well. But in the course of my misguided quest to redeem my family, I had lost all those things, like Okonkwo in Achebe’s Things Fall Apart. And I began to loathe the man in the mirror.

So it was this time that I began to look for things which were dissimilar to myself, since I hated myself. It was about the time I started digging vanilla and whitemeat, and the blue eyes that I would never have, in an attempt to see the 'side of me that wasn’t always shady' in my future kids, who hopefully wouldn’t look similar to me. Otherwise, I might grow to hate them as well for being so much like myself.

But alas, blue eyes are recessive, and unless I have some French blood in me from when France raped Vietnam in the mid-20 century (instead of cab-fare, they gave us French bread and pate), my kids are condemned to having earthy-colored eyes. But I’m starting to like dark colored eyes again.

And I like myself too, even with the 30 extra pounds and diseased liver***.

[I have intentionally not used the phrase ‘brown eyes’. If you don’t know, don’t ask; it’s a disgusting metaphor.]
--

*joking, of course
**again, joking
***joking…hopefully?

The Time-Has-No-Meaning Watch

The weekends are slow, like the calm before the zombies start gnawing on your leg a la Shawn of the Dead. It's as barren as the Dallas streets when the Cowboys are playing; more people were outside after Fat Man (an atomic bomb, not an actual Fat Man) dropped on Nagasaki. If tumbleweeds still existed in this part of Texas, I'd be ducking and diving to avoid them. Slow. S...L...O...W...

But I like my work like I enjoy some of my music: chopped and screwed, i.e. repetitive and slow. So weekend nights are oh so nice when my eyes are paid to remain open.

During weeknights, the job is hellish up until about 11PM, so I glance at my digital Casio ($20 at Walmart 4 years ago) every 5 minutes to see how much time I have left until I see some respite. I have contemplated trying to get a prescription that reads 'Xanax 2 mg #6 (six), i at 8PM on M,T,W every other wk PRN idiocy.'

Thursdays and Fridays treat me well, and Saturday and Sunday nights are paved with lollipops and generic Zoloft (which is coincidentally the preferred SSRI on my prescription coverage).

It was on a Saturday night when the Cowboys were playing the Eagles that I pimped my Movado, the one I nickname the Time-Has-No-Meaning watch. But the pharmacy greeted me with 4 waiters (people who want to wait on their prescriptions) and a couple of insurance problems. It was as if the world had sensed my assumption and arrogance and went out of it's way to punish me.

But at 9PM, even the world (or at least the 50 mile radius around Dallas-Ft Worth) took a break to watch the 'Boys skeet shoot some endangered birds from the air. And the only reason I knew the time is because 9PM is one of the few things I can look at the Movado and be certain of the time.

Elegant simplicity, for when time has no meaning except as a status symbol of how much money you make.

Is it 9:10, 10:10, or 11:10?

From the Mouth of Babes

Dear the not-so-young,

I have a tendency to use double entendres. But 'babes' is used in the traditional sense, as in 'babies.'

It's refreshing to see things from kids' points of view sometimes, when they're not throwing temper tantrums. It almost makes me want to have a kid of my own, but those things costs like $300,000 apiece and they don't carry the name Lamborghini or Ferrari. I'll pass for now.

One such blonde cutie (he's going to be a poster-boy for Abercrombie if they haven't gone under yet) was in there with his mom. He had done something stupid and had broken his left arm. It has held adorably in a little sling, and he still smiled bashfully as I asked, 'What's your name little man?'

'[name deleted due to the fact that I can't remember it, and I couldn't say it if I did remember it due to HIPAA laws]'

Anyway, I check to see if we have the medicine, and the boy asks his mom, 'There's so much stuff back there. How do they know where my medicine is?'

His mom suggests that maybe we keep it by usage, like the pain section or antibiotic section. Oh, if we were that smart. It's liquids, inhalers, reconstitutables, creams/lotions/ointments, and vaginal/rectal, and alphabetized by the name that shows on the label.

I told him it's the elixir section. Elixir sounds a lot cooler than solution. Elixirs are the stuff that the characters from Final Fantasy drink.

I wonder what kind of organizational system that boy would have figured out if I had not told him what we used. Sometimes I think we would have invented a lot more if we had not learned what actually works and just used our intuition.

Intellectual innocence, meaning not corrupted by learning what actually exists, is something I think is highly undervalued.

Lesson from the Druggie

Dear new pharmacists and pharmacists-to-be,

‘Druggist’ is old-school for ‘pharmacist.’ ‘Druggie’ is simply a controlled substance fiend, usually of the hydrocodone or codeine persuasion. Something I learned as an intern is to be wary when someone calls up and asks you for a particular brand of narcotic. If you’re hurting, it really shouldn’t matter that there’s a ‘WATSON 349’ or ‘M357’ (for Mallinckrodt) imprint on your hydrocodone.

Most of those ‘what do you have in stock’ questions get the canned response, ‘I am not sure what we carry, but it should all be the same.’ Then I try to get off the line as soon as possible. Don’t ever say you have something in stock when you’re not comfortable with filling it. It could be fake, and it takes time and energy to diffuse a bad situation.

A first for me was a call from a guy asking if we had the Actavis brand promethazine with codeine. If you’re not familiar with promethazine with codeine, it is the syrup the rappers commonly refer to as ‘purple stuff’ or ‘lean.’ They mix it with Sprite and sometimes crush some other illicit substances (Ecstasy, Xanax, Vicodin, etc) into it. Then all the music they listen to suddenly becomes chopped and screwed, even if it isn’t.

I glanced over to the shelf and saw another brand of the product. ‘We have another brand. Sorry.’ He hangs up. Typical.

When the workflow eased up a bit, I took a look at the product we had on the shelf. Guess what I saw. Not the characteristic purple of that ‘drank’ but a light pink hue of watered down Kool-Aid.

[a tasteless joke about grape being purple and watermelon being red has been excluded due to political correctness]

His loss. Regardless, I wasn’t about to fill that prescription anyway without calling the doctor.

Luxury Line of Generics

Friends, possibly Romans, and countrymen,

Very recently, Valtrex turned generic. The days of paying $250 for your 'cold sore' medicine are over! Hail the days of paying only $200 for it. Expensive drugs rarely drop precipitously during the first 6 months of going generic. It usually takes a second generic manufacturer to start making the stuff for people to start seeing a real price drop, and even then it's still in the hundreds. All are cash prices, btw.

One person was more than happy to support the decrease in U.S. healthcare costs ('generics are great'), while another chose to 'stick with what I'm already taking.' That's understandable: it recently went generic, and maybe they might find some stuff wrong with it. Who knows? I don't blame her much.

What was outrageous was someone asking for the 'real stuff' on an antibiotic which has been generic for hundreds of years (okay, maybe 20-30 years; it's not as old as penicillin, but it might as well be.) I didn't even know the brand name of the thing.

In my relatively brief stint as a real druggist*, I've noticed one particular generic manufacturer with the iconic 'GG' label on a vast majority of their meds. I didn't know that Gucci made generics! I wonder if 'GG' had made that particular antibiotic, would that person have taken it. Another question which shall forever remain unanswered; it will remain up in the pantheon of the chicken or the egg debate.

'I don't have the brand, sir, but I do have the luxury line of generics. Some would say it may be even better than the original. There's even a rock song about it**.'

Want to take a guess at who's rocking the Gucci label? Answer below.

-g
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*old school for 'pharmacist'
**Girl Named Sandoz