Bring down the house.

New rotation, new enemies.

Now, I'm not saying I have enemies, per se, but let me just say:

Dear red-headed med student,
WE ARE NOT RETARDS.

I'm on rotation at RHUH, if you recall, in the SICU.  There are always a TON of people rounding with the SICU team.  Aside from the critical care attending, we have some interns, R2s and R3s from other specialties (right now, we have an anesthesiology R2, surgery R3 (I think), two ED R2s, and two interns - one from ENT, and one from anesthesiology), and an NP or two.  Then, we have myself, my classmate, and my preceptor.  And, as usual, since RHUH is a teaching institution, we have some fourth year med students from Really Huge University.

Now, I know med students don't know what we learn, and vise versa.  But what I do know (and I'm sure at some point I've ranted about this before) is that we spend 4 years of our lives learning about drugs - labeled uses, unlabeled uses, mechanism of action, side effects, kinetics, interactions, the list goes on.  When it comes to really important things, like life-threatening adverse reactions, we're pretty well-versed in those.

Our attending yesterday, who BTW, is a former pharmacist who decided to become a doctor and is super hilar and smart, ordered IV Haldol for a patient who was a little delirious.  As he walked back into the room to finish his exam of the patient, he turned to the NP who was writing orders during rounds and said, "Let's order some Haldol for this patient, but I want an EKG to check her QT interval first."  Red-headed med student turns to me and says, "You know why he wants to see an EKG, right?"

Nooooooooooo, Mr. God-Complex Med Student.  I'm just a dumb, retarded pharmacy student who went to school to learn about medications for 4 years of my life and I completely missed the fact that he said he wanted to check the QT interval.

For my non-pharmacy readers, or for pharmacy personnel/students who haven't heard of this yet, first generation antipsychotics, like Haldol, and basically cause an increase in the time between the Q and T waves on an EKG, which can essentially send a patient into a life-threatening arrhythmia.  That's why it's so important for the doc to check an EKG - he wouldn't have given the patient any Haldol if her QT interval was large to begin with.

So, Red-Headed Med Student, I'd appreciate the next time you think you know more than me, keep it to yourself, or else I might have to remind you that, when it comes to drugs, your 1 semester of pharmacology doesn't quite add up to my 4 years of training, just like I wouldn't presume to tell you why they are doing some type of diagnostic test on a patient.  We should both probably stick to what we know.  K, thx.

Anywho, our attending is pretty hilar, as I said.  At one point during rounds yesterday, he goes, "I'm a little hypo-Pringlemic.  It can be resolved with a can of Pringles.  Anyone got Pringles?"

Only three weeks to go before I get to go home foreverrrr!!  Weeeee!

Do what we gotta do.

Day 3 of my inpatient rotation at Really Huge University Hospital - DONE.  Today consisted of working on a journal club assignment and almost falling asleep in our freezing cold dungeon-like office, then almost passing out from hunger while on rounds in the SICU where I couldn't hear a damn thing, then listening to a painfully long lecture on the history, evolution, and definition of death.  I suppose it's only 5 and a half more weeks.  But I still can't believe that it's almost time for me to go home.  The summer went wayyyyy too fast.

The highlight of my day was at lunch.  I was sitting with my classmate, minding my own business, when suddenly, in my peripheral vision, something looked, well, different.  After a double take and a (subtle) closer look, I noticed what I can only describe as odd - a balding, 60s-ish man, wearing a burgundy cap sleeve ballet leotard with womens' low rise jeans and a cowboy belt (one of those belts with a ginormous buckle).  I mean, whatever, but it was awkward to see in a crowded cafeteria at RHUH.

Tonight, I am spending the night at my friend's apartment.  We're having an America's Next Top Model sleepover.  Don't judge - us hardcore pharmacy chicks have guilty pleasures, too.  It was makeover day!  Of course, some girls were crying and bitching about their makeovers, and one of the whiners got sent home.  Come on, now, ladies.  It's cycle 15...you should know by now the judges HATE whiny little divas.

I hate whiny little bitches...but I love myself!

 
LOL.  Anyway, until next time.

Tell me, tell me...

...yes, I realize it's been 3409582038947 years since I've updated.  Life on rotations got a bit crazy, plus we recently welcomed a niece into the family!  She's a doll...I love her to pieces.

Anyway, I should probably update you on what I've failed to tell you all in the past, oh, three months.

I finished up APPE 1, but wasn't overly happy with how things ended.  My preceptor, who I saw maybe 2 weeks total out of 6 weeks,  didn't evaluate me fairly.  I mean, I got a decent grade, but not the grade I felt I worked for.  In his evaluation of me, he said we (my classmate and I) "procrastinated" because we waited until the last minute to finish going over our assignments with him.  WTF?  Let me explain something to you.  My preceptor was on vacation for the entire first week of my rotation.  Then, they decided since our new store was so slow, we would split time between a busier store and our actual site.  So the days he floated to the busier store, we were TOO BUSY to actually go over anything, and the other days we were at the slower store, he wasn't always there...he said he wanted to keep up his clinical skills (which is understandable), so he floated to other stores a lot.  All of that left us with the last day to go over anything.  I'm not saying I don't wait, but how can he say we procrastinate when we never see him?  Ugh.

My second rotation was at Rural Community Hospital (RCH, as I will call it).  It was pretty good.  My preceptor was the head of five, yes five departments - Pharmacy, Cardiopulm, the sleep center, Respiratory Therapy, and Cardiac Rehab.  Needless to say, I went to A LOTTTTT of borrrrring meetings.  I spent lots of time playing on my iTouch (yay for free wireless internet).  I had an awesome classmate with me.  At least it helped the time pass quickly.  I did medication reconciliation for new admissions and renal dosing.  I really think it helped me develop confidence in my clinical judgment.

RCH also has a long-term care facility.  One of the highlights was when I was on one of these particular floors with my classmate, we'll call him Jake.  We were going to do a review on a patient who had a history of falls.  Out of nowhere, this little old lady (let's call her Olive) comes up to him and starts to poke him in the side.  Under her breath, she says, "tickle tickle tickle," and proceeds to yodel at Jake.  Jake looks from me to Olive, plays along with her tickling for a few seconds, and backs away slowly.

Anywho, I just finished my amb care rotation at an inner city medical practice.  They have approximately 18,000 patients, and about 80% of the patients are Medicaid patients.  Lots of them are refugees or immigrants from other countries. 

So, we had to go to a diabetes ed class for patients who have been diagnosed with DM 2.  We were talking about losing weight.  Guy raises his hand and says, "My girlfriend lost 22 pounds...I mean, I like it but I don't.  She started sagging...she looks old."  WTF??

Right now, I'm on my inpatient rotation...today was my second day.  I'm at Really Huge University Hospital, and they tell me it's 1/4 mile from end to end.  My preceptor rounds in the SICU...lots of complicated patients.  Nothing crazy has happened yet...I promise I'll update more regularly.

I'm moving home in 6 weeks to start my electives!  I'm really excited, but I can't believe I'm moving back home, pretty much for good.  It's sort of bittersweet; I'm excited to get back to my fiance and my family, but I've made some pretty amazing friends here (you all know who you are) that I'll miss like crazy.  I kind of don't even want to think about it.  Favorite memories include school Christmas parties (LOL) and Mexican food (mooooh kaaaay??).


I'm going to be a pharmacist in less than a year!  And married!  HOLY SHIT.  Summer 2011 = stress to the max. 

Here's to taking it one step at a time.

I'll be good for you...

...if you're nice to us, that is.

On this lovely Saturday, as I sit in Franchise Cafe finishing up the shitload of assignments I've let pile up for this rotation, I viewed a customer become upset with a cashier because their stupid sandwich wasn't made correctly.  That made me sit back and think about the real similarities between food service and pharmacy, which I'm sure we're all aware of.  I think I've made some mentions to this effect before, but I couldn't help but think of my favorite mantra:

This is not Burger King - you cannot have it your way.

So yeah, at Franchise Cafe you can technically have it your way, but to all you patients out there...be careful about you you piss off...you could end up with a Spit Special, as my fiance likes to call it.  In a pharmacy, you really can't have it your way 99% of the time.  You're out of your #120 Vicodin after 7 days?  Nope, sorry, no early refill...you can't have it your way, and I'm not falling for the 'but my pills fell in my toilet' excuse.  You're completely out of your Xanax and it's a Friday night, can you have some to get you through the weekend?  Hell no, you can't have it your way.

Here is a prime example of a pharmacy-type Spit Special:  You're dropping of a prescription with a write date of three months ago and you get pissed because we tell you that you have to wait 20 minutes and you need it right this second.  'It's just some pills in a bottle, 20 minutes is ridiculous!'  No, sir, you can't have it your way, and I will make sure it takes at least 20 minutes to fill it.  Oops!  Typed the sig wrong, need to redo it.  Your insurance is expired, do you have another card?  Give me about 5 minutes to rebill that, sir.  By the time you're out of there, it's at least 30 minutes by design.  I may be cynical, but if you'd dropped off that prescription and had us hold it until you needed it, it would have been done as soon as you called us to fill it.

Recently, I was reading the Pharmacy Chick's blog, and she makes a very valid point:  "How long will this take?" and "when should I come back for this?" will elicit two totally different responses.  The person accepting the prescription or refill will respond more favorably to the latter.  Asking how long it will take to fill the prescription makes patients come off as impatient and ungrateful.  Most of the time, patients asking this question seem perturbed an in a hurry, like our time is not as valuable as theirs is.  And when we tell them it will be about 20 minutes, they usually roll their eyes or sigh.  Sorry, you should have called ahead for your 8 refills or dropped off your new prescription with the intention of waiting a little bit.  For those who bring in a buttload of refills and give me shit for having to wait a little longer than normal due to the amount, I put stickers that say "For refills, call 24 hours ahead!" on every single bag receipt.  My hope is that the patient will get the subtle hint, but usually they don't.  If I wait on them at the cash register and they complain about the wait time, I very politely say, "Well, next time you need your refills, you can always call the night before!  And if you don't want to use our automated system, dial the phone number and press zero...that way, you'll be connected directly with someone at the pharmacy!"

Part of Pharmacy Chick's message in her last post is that "you get in what you put out."  I totally agree with her.  If you form a great relationship with your pharmacy staff, they will be totally receptive to you.  Trust me - we can tell when you're genuinely in a pinch versus just being a d-bag.  And it's important to form a great relationship with everyone that works behind the counter, not just the pharmacist.  The technicians make the pharmacy world go round.  Without them, if pharmacists were solely relied on to input, fill, call insurance companies, and deal with customers in addition to what their real duties are (ie visual verification, taking verbal prescriptions, catching drug interactions/duplicate therapies, anomalies between what a patient was just prescribed versus what they'd had before [this is in no way an exhaustive list]), every pharmacy would be in chaos.

Be nice to your pharmacy staff...or else you might end up with the pharmacy's version of a Spit Special.

PS:  Worked with Floater Pharmy this week!  To my dismay, I've left my Little Notebook o' Quotes at home.  I will be posting some gems when I get the chance!

so tell me what do do now, 'cause...

...I am a weirdo magnet.

For realz, yo.  It's been what, a week since I've blogged?  That's because nothing really interesting happened last week.  But this week, oh, this week has been very different.

I'm at a busier store this week, so I get lots of patients.  And lots of patients means lots of counseling.  And lots of counseling means you're bound to get the weirdos from time to time.  How do I even begin??

Let's start with the 70-ish-year-old old guy with yellow teeth, most likely from smoking, a shirt that used to be white with holes in it, and jean-short cutoffs.  He was picking up a prescription for Vicodin (obviously), so I counseled him on it.  At the end of our conversation, I said, "Do you have any other questions for me?"  His response:  "Can I have your number?"

Now before you all say, "Oh, he was just joking," you didn't see his face.  He was completely serious.  Then when I said, "I don't think so," he shrugged and said, "Well, I hope you have fun tonight.  I know I will," then he winked and left.  Creeper.

Today, however, took the cake.  This middle-aged guy, probably in his 40s, came to our drop-off window.  He presented me with a prescription and told me that his address was incorrect because he "used to be in prison" and was "probably going back next week because [he] got a DWI" and that I'd probably read about him in the newspaper.  If this wasn't enough, he also informed me that he was poisoned with antifreeze, was hospitalized in the ICU for 4 days, and that his serum creatinine is currently about 2.8 mg/dL and wanted to know if the kidneys regenerate.  He kept smiling at me and as I counseled him, our conversation went something like this:

Ex-con guy:  Oh, hi.  I see you're wearing a ring.
Me:  Yes, yes I am.
Ex-con guy:  Well, rings can come off.  **wink**
Me:  Uhm, mine doesn't.

I mean come on...what is it with people?  He creeped me out from the get-go because he was too friendly.  The pharmacist on duty who is about 8 months prego (bless her heart...and she's working up until her due date) said if she would have known, she would have taken the counsel because she's got such a big baby belly.  But how would she have known?  And...some guys like that kind of stuff.  Eek..whatever.

On Monday, I also had a googly-eyed lady freaking out because the doctor didn't call her prescription in correctly.  She screamed at me that she needed to use our phone so she could call her "godddamned doctor" and "get my pills because I'm out of my damn pills."  So after she yells at me and simultaneously spits on me while doing so, I lend her the phone next to the drop off window.  She gets ahold of the office and screams into the phone at the secretary, who puts her on hold so she can look into the problem.  The lady turns around and yells to her equally attractive husband, "THE GODDAMNED BITCH PUT ME ON HOLD!"  Mind you, there are lots of other people milling around as well as small children (oh, those poor kids).

The NP from the practice finally gets on the phone and tells the patient that she will talk to someone right then to straighten out the mishap.  The beauty shoves the phone in my face, so I took the prescription and talked with the NP, who apologized for her patient.  Why should she apologize?  Googly-eyed Lady owes everyone an apology!  She told the NP at her appointment that she takes Effexor XR 75 mg, which comes as a capsule.  The NP called in a script for that, but the catch is that it's not generic.  There are, however, venlafaxine XR 75 mg TABLETS, which is what the lady wanted because they're cheaper than the capsule.  I understand the lady was frustrated, but I will NEVER, EVER understand why patients think yelling and screaming will make things happen faster.  It will most likely cause me to move even slower just to piss you off.  UGH...people.

I was really, really frustrated in general today, though.  I worked with a pharmacist whom I've never met, and she made me stay at the drop off window for my entire 10 hours because I'd "learn sooooo much standing there."  That might be good and all IF I WAS A TECH TRAINING ON THE COMPUTER.  I'm not saying I shouldn't learn to do all I can so I can help while I'm there, but how is taking prescriptions preparing me to be a pharmacist?  I should be counseling, making MD calls, taking prescriptions, and making OTC recommendations.  I don't mind helping out at drop off for a little bit, but 10 hours?!  Honestly...no one else stood there their whole shift.  I'm just free labor so they can do whatever they want, I guess.  Whatever...here's to hoping tomorrow is better.  At least I'm off Friday.

I'm going home this weekend...yay for four-day weekends!  I work four-10 hour days so I get Fridays off, plus Monday is a holiday and I don't have to go in...YAY!  Working Saturday at home...will update if I have stories!!

I'm going crazy

Today was first official day of APPE 1.  Woopee.  It's my first of two retail rotations, which is my bread and butter.  This particular pharmacy I'm at right now has only been open since late March, so they don't have too much business.  When I talked to my preceptor on the phone, he told me that they're kind of slow, but that it would give me an opportunity to counsel a lot (which is something I am looking forward to since I don't get to do much of that at home).  BUT...when he said "kind of slow," he wasn't telling me the whole truth.  When he said "kind of slow," he meant "so slow you could watch paint dry and it would be more exciting."  In my 8 hours there, I did a grand total of 3 transfers, took 6 drop-offs, and answered the phone twice.  And they got not one phone call from a doctor's office, either directly or left on the voicemail.  Luckily, I have a good classmate on rotation with me to pass the time with. 

Oh, and my actual preceptor wasn't even there...he's on vacay for the next week.  We were fortunate enough to work with this eccentric 60s-ish floater from Taiwan.  I've decided that he's a conspiracy theorist.  He thinks everything is evil and out to get people - ie the higher management in the company he works for, drug companies, the government.  Don't get me wrong, I really liked him...he was just strange, lol.  And I may not have gotten any interesting patient stories, but Floater Pharmy had plenty of one-liners:

(overhearing employees cheering somewhere in the store**) "Drug Store loves me, Drug Store hates me...no, Drug Store is just using you."
**apparently there was some type of manager's meeting this morning...I have no clue what they were so happy about.

Tech:  "It's hot in here."
RPh:  "Because I'm hot."

(referring to inserting rectal suppositories)  "You just spank it and it automatically shoots in - it's a nursing skill."

This last one needs a little explanation:  Floater Pharmy had a big blue jug of water that was crystal clear early in the morning.  Throughout the morning, the water began to turn a greenish hue, and I noticed that there were 3 teabags floating in the top.  An employee stocking the OTC section noticed as well and asked what was floating in the top of his jug.  His response:

"Goldfish."

And 10 minutes later, when the tech noticed the teabags and asked about them, she was awarded with an totally different answer:

"Dead rats.  Mmm...rats."

I work with this guy tomorrow, too...should be interesting!!!

I just wanna tell you how I feel.

Today I spent most of the day doing our narc audit with another intern.  So fun!  NOT.  We found at least 5 discrepancies...and that's 5 too many.  We were lucky enough (again, please infer sarcasm) to have to figure out why there were discrepancies.

But, never fear!  I wasn't that busy with narcs that I couldn't wait on a customer or two to get this gem: 

I ring out this patient who gets a script for Vicodin ES and something else (I can't remember what it was...an antibiotic maybe?).  I ask him if he has any questions for the pharmacist, and he responds laughingly, "Well, can I drink alcohol with these?  Haha..."  I smiled, thinking he was joking, and replied that it is never advisable to drink alcohol with any medication, especially Vicodin ES.  The following is the subsequent conversation we had:

Patient:  But seriously, can I drink while I take these?
Me:  It's really not recommended, sir, especially with the Vicodin.
Patient:  Well, can you ask the pharmacist how long I should wait between drinking and taking one of these then?
Me:  Uhm, okay. (I consult the pharmacist, who rolls her eyes and shakes her head as I relay the conversation.  She tells me what to tell him, and I return to the customer.)  Sir, she says she can't even recommend  that.  You really shouldn't drink while taking that medication.
Patient:  Oh, I was just wondering...I have horseshoes on Thursday nights.

Really, I mean really?!  I should have said, "Would you rather be pain-free or almost dead?"  And come to think of it, he probably shouldn't even be playing horseshoes while taking Vicodin, anyway.  You're not supposed to "operate heavy machinery", ie cars, steam rollers, farm equipment.  How are you supposed to chuck a heavy horseshoe toward a pin sticking out of the ground?  Too bad he didn't get metronidazole...we probably would have still had the same conversation, then I would have told him to make sure he drinks a fifth of vodka and call me in the morning to tell me how he feels.

Oh, how I love my patients.