I Hope This Patient is Okay…

ChronicHeartFailure

 

So, I have an interesting story from today. It’s one that worries me, but also makes me shake my head.

I had a woman call me, asking if I could give her a few pills to tide her over until Monday when she can call the doctor for more refills. I ask her name and find that she hasn’t been to our pharmacy for over a year. I ask what she’s looking for and she tells me it’s a heart medication that is for 40mg. I notice there is a very old script for furosemide, so I ask if that’s what she’s looking for, she says no and that it starts with a “car” sound. I ask her if it’s carvedilol, and she says yes. The most recent script is for a low strength. I ask if she’s gotten it filled since the previous time she was here. She tells me her cardiologist has been directly dispensing it from his office. (I wasn’t aware they did this for things other than controls or samples of brand name medications, but I didn’t question it.)

She states she really needs it because she’s out of town and very far away from home. I tell her that there’s not much I can do, since the dose she’s asking for is not on record with us. I also tell her that since she hasn’t been to our pharmacy in so long, I don’t fell comfortable providing the medication. She suddenly tells me she has retained 15 pounds worth of fluid in the past few days and her skin is yellowing. I tell her that’s quite serious and that she should be seen right away. She starts asking what she should do, since she’s worried about her condition. I tell her that the best option is to head to the ER. I told her that even if we did have a current prescription on file, I’d still suggest going to the ER because she could be going into congestive heart failure. She tells me she doesn’t want to because “the ER sucks big time”. I tell her that even though ERs are usually a pain, this situation requires action be taken soon. She continues to tell me I should just give her the medication. I again tell her no. She asks what will happen if she doesn’t go to the ER. I tell her that she could possibly go into heart failure, which has very poor outcomes when left untreated.

“Oh well. I guess that will have to do. I don’t have time to go to the ER.” –Click–

I did try to call her back right after she hung up, thinking maybe I could calm her down and get her to see my reasoning. Her number on file was invalid. I don’t know what else I could have done. I will gladly give people a few pills for a maintenance medication if they run out on the weekend or the prescriber hasn’t replied to our refill request by Friday evening. Seeing as how this woman had not been to our pharmacy in so long and how the dose she claims to take didn’t match up with the one she used to take, I didn’t feel comfortable giving her any. In all honesty, she probably needs some IV diuretics and a few diagnostic tests. The way she described herself is not something that should be left alone. I am worried that she will start experiencing organ failure, especially considering the jaundiced skin.

It’s people like her that make me both sad and confused. If she’s seeing a cardiologist, then she obviously has heart problems. I am sure he explained to her the difference between emergent and non-emergent problems. Most do. For her to refuse to go to the ER like that is very stubborn. It’s sad because she doesn’t seem to understand the gravity of her situation, but it’s also frustrating. People need to be more involved in their own health care. If you see your skin suddenly turn yellow, that means your liver is probably not doing so well. It’s not something you wait around to see if it gets better. If you gain more than 10 pounds in a day or two, that is water weight. It takes a lot longer to gain weight due to fat accumulation. Lots of water weight usually indicates your heart isn’t working right. It is also not something to be taken lightly. Both require at least a call in to the doctor. He will probably either have you come in to the office that day or go to the hospital. Regardless, a physician should be involved as soon as the symptoms start.

-Sigh- I hope that woman is okay. =(

 

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Puffy Eyes

 

So, I had an interesting phone call today. A woman who isn’t a patient of ours called to ask about her eyes. She told me they were red, puffy, and almost swollen shut. I asked if both side were equally swollen, and she told me they were. She also told me the few medications she was on, but stated that she had been on them for a while. At this point, I had come to the conclusion that is was either really bad seasonal allergies or that she had consume or used something that she was allergic to without knowing it.

I asked if she had eaten anything out of the ordinary or new recently and if she had switched soaps or detergents in her house. She answered no. I started telling her that she should take some diphenhydramine and call her doctor first thing in the morning. She interrupted me, asking if there were any interactions with that and her other medications. I told her no, and she replied back to me:  “Well, that’s good. I just wanted to make sure, since these medications are all sort of new to me.” Whoa. Back up. Rewind. Didn’t she just tell me she had been on them for a while? I asked her when she began taking the medications. She told me she started them a week ago. *facepalm*

So now, the tables have turned. Now, I’m leaning more towards a drug allergy being the cause of this. But, the question is, which one is causing the problem? She started each of them on the same day. I told her this and let her know the only way to know for sure which drug would be the cause is to discontinue all of them and restart each individually. Again, I told her to take the diphenhydramine and call the doctor first thing in the morning. I also told her if she experienced any throat tightening or trouble breathing to go to the emergency department of the nearest hospital. She agreed to do so if needed, thanked me, and hung up.

The take home point of this story is to always ask questions. Lots of questions. Ask the same thing in different ways. Use open-ended questions (when did you start these medications vs. have you been taking these medications for a while). It’s important for us to ask these questions and get to the root cause of why the patient is speaking with us. It’s how we screen them and determine what action needs to be taken next, whether it be self-treatment, a call to the doctor, or even a hospital visit. Never be afraid to ask the same thing again if you need to. When patients seek out your help and advice, they usually don’t mind the questions. Most times, they appreciate how much effort we put in to helping them. This is one of our duties to our patients. It falls under the “Do No Harm” portion of the Hippocratic and/or Pharmacist’s Oaths. And, it can make all the difference in a person’s life.

 

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Routes of Administration

 

Today, I ran into an issue that should be shared with all patients. I saw one of my favorite wife/husband patient combinations during my shift. I met them not long after starting at my current pharmacy, and I was able to help them save some money on prescriptions. They have sought me out for advice ever since.

Today, they came into the pharmacy to return a steroid cream. I asked them why, and the wife responded that the list of side effects on the medication guide scared her. She said she had decided not to use it. I asked her if she has discussed not using it with her physician, and she told me she had not. So, I started to go through the medication guide with her sentence by sentence to see what was the most troubling for her.

After some explanation, I realized the side effect she was most worried about was the immunosuppressant effect steroids can have. I explained to her that this adverse reaction was not one that should concern her too much. I told her that this effect happens after months of therapy and is more likely to occur with oral steroids. She calmed down immensely afterwards. She ended up taking the medication back home with her. I encouraged her to call or come back if she had more questions.

I have come across this situation a few times before. A patient has a non-oral therapy. They decide to read the warnings and other patient information, and they come across side effects that are mainly related to the oral form of the drug. It scares them, and they stop taking it. Once they realize there is no reason to worry about side effects A and B, though, they calm down and become more adherent.

One thing patients need to realize is that the medication guides that print out with the prescription labels at the pharmacy are required to include everything under the sun for that drug. It will include the side effects for the oral form, as well as other routes of administration (topical, rectal, vaginal, etc). So if you are picking up a prescription for a non-oral medication and are concerned or unsure, ask the pharmacist which side effects are the ones most likely to happen while you’re on it. Try not to scare yourself out of using the medication before you ever use it. As a general rule with many medications, you will probably never experience most of the side effects listed on the medication guide, especially if the prescription is for something non-oral. They are there to tell you all the possibilities for every person who might ever use the medication, not to forecast what will definitely happen when you use it.

 

Image courtesy of http://i1107.photobucket.com/albums/h393/Douglas_Ross/rxPills.png

Change

 

So, I feel all better! Hooray! I worked yesterday, but it was a repeat of Saturday, so I didn’t even bother posting. Today was like a whole new world, though, and food has never tasted better. =) So, back to the normal entries!

I feel the picture up above is a great description of many types of drug regimens. You start at one point, and you may continue along that line for the entire time you’re on it. But, at any given time, the prescriber may decide the dosage should be changed or something should be added/subtracted. This can leave patients confused about what to take and when. This, in turn, leads to all kinds of issues.

Lately, I’ve been coming across a lot of the same general problem. People come into the pharmacy and want to fill Drug X. We attempt to fill it, and it is WAY too early, so the insurance rejects it. Now, I’m not talking 4 or 5 days early. I mean 14-20 days too early. I tell the patient this, and the most common reply, as of late, has been, “Well, the doctor told me to double it, so I’ve been taking two pills instead of one.” This situation has also applied to diabetes testing supplies a lot lately too. I try to explain that without a new prescription with the new directions, there is nothing I can do to get the insurance to cover it, but people tend to either get upset or confused. So, allow me to lay out the scenario here in short story format, and then I’ll explain where things went awry.

*****
The character below is purely fictional. Any resemblances or similarities are purely coincidental.
*****

Bertha Jones comes to the pharmacy with a prescription for Accu-Touch Lite blood glucose meter and supplies (notice my play on common brand names there ^_~). Her endocrinologist wrote on her prescriptions that she uses her supplies to check her blood sugar twice a day, since she is a newly diagnosed diabetic. Bertha’s insurance covers everything for a 30 day supply, and she gets the meter for free. Bertha is a happy patient and goes home to start using everything that night.

About a week after her first refill, she goes for a follow-up visit with her endocrinologist. Her blood tests and other such things haven’t improved. In fact, they’ve worsened a little bit. The physician wants her to start testing her blood sugar more often. He tells her to test herself 4 times a day until her next appointment. She sighs, but understands the importance and starts following the physician’s orders. Ten days later, she’s down to only two test strips. “Oh no!” she thinks to herself, and she rushes off to the pharmacy. She tells them what she needs refilled and says she wants to wait. She just takes a seat, only to be called back to the drop off window. The person there tells her the insurance won’t pay for the supplies for another week.

“But, I’m almost out!” she tells them. “I only have two strips left!”

The person at the window tells her she just filled them a little over two weeks ago, and that she should have more than enough at home. She insists that she doesn’t because her endocrinologist told her to start using them 4 times a day, instead of 2. She is told that she needs a new prescription stating this or the insurance won’t cover it. “But, why?” she wonders. “My doctor told me I could. Isn’t that enough for the insurance?” She tries to explain herself more to the person, but they keep telling her she needs a new script. She gets frustrated and leaves. “I’ll just have to wait a week, I guess.” She uses her last two test strips and decides to return to the pharmacy once the insurance will pay for it. She never calls her physician, and the pharmacy never receives a new prescription. This pattern repeats itself until she is out of refills and is forced to get a new script.

*****

So, where did things go wrong? Ms. Jones was on track with her first refill. What happened? Well, her physician made a significant change to her testing regimen. He doubled the frequency. The good news is that she understood it and followed his directions. The bad news is that no one else involved in Bertha’s health care knows this. The one and only way both pharmacies and insurance companies know when something has changed is by having a prescription alerting them of the change. Otherwise, both assume all is the same. So, when Bertha ran out of the test strips, she couldn’t get a refill. Why? Because only her and the physician know something has changed. To the pharmacy and the insurance company, it appears that Ms. Jones is only using her supplies twice a day, even though that’s not the case. So, Bertha cannot get her refills based on the original script.

So, then is it Bertha’s fault that the pharmacy was unaware? No, not really. The physician should be well aware that any changes in therapy have to be documented and sent over to the pharmacy. But, some physicians forget or their office staff doesn’t get around to it or things get lost in translation or a bunch of other things arise that may have prevented this. Whatever the reason, though, there are many times that physicians increase the frequencies of therapies and don’t notify the pharmacy. This leads to much frustration on the patient’s part, unfortunately.

So, how can this situation be avoided? It’s simple. Anytime something changes with your prescriptions, whether it be for diabetes supplies, like in the above example, or for other maintenance medications, TELL YOUR PHARMACY. Actually, the best thing to do is to ask the physician before you leave the office for a prescription for the changed prescription. But, even if you don’t, by telling your pharmacy, they can call the physician’s office if it doesn’t show up. Now, in the ideal world of retail pharmacy, this would be done on the day you have your appointment, and the pharmacist will call you to let you know when it has arrived. In the real world of retail pharmacy, this doesn’t happen and never will due to high volume. It’s not that we don’t want to; it’s that we don’t have the time to do this for everyone every single day. So, as a huge favor to your pharmacy staff, try to remember to give us a call the day after your appointment to ask about the new prescription. By then, the physician will have had ample time to send it over, and the pharmacist will be sure to call on it if it’s not there. A really good pharmacist will remember your name and call you back when the prescription has been filled. (*coughcough* ^_^) All self-praising aside, I do try to do this if I personally speak with the patient, since it’s how I would want my own family treated. I don’t typically answer those calls that much (my techs do), and a phone call takes all of a minute.

So, yeah, that’s my blurb for today. Long-winded, I know, but I think I made my point clear. I think. Let me know if it seems choppy or confusing. =) Toodles!

 

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A Breath of Fresh Air

 

Today, I have a lovely story to share. It warmed my heart and made my day. ^_^

Around lunch time, I received a call from a physician’s office inquiring about an elderly woman’s most recent fill date for a rescue inhaler. Looking at her profile, I noticed it was filled less than a week ago. The nurse I was speaking with told me the woman stated that her inhalers are always defective when she gets them filled. I remember a month or so ago the patient had contacted the manufacturer about it, and they sent a replacement to our pharmacy to give to her. I told the nurse to have the woman come to the pharmacy, and I would be able to determine if the defect was real or if this was simply a case of the patient not knowing the correct administration technique. The nurse thanked me and hung up.

A few hours later, the patient stopped by. Now, I love my elderly patients, especially the little, old ladies. They are full of stories and generally appreciate the pharmacy staff’s help. I tend to go out of my way to help them, since they seem to put the most blind faith in us. The woman handed me her inhaler. I pushed the canister down, but nothing came out. I told the woman I would be right back. I went over to our sink and gently cleaned out the mouthpiece with a paper towel and warm water. Putting it back together, I found that a good clean was all it needed. I returned it to the lady, who used a puff right then and there as a test. I gave her a few tips on inhaler technique and the proper way to clean it. She looked at me with a very serious face, waved her index finger, and said, “Come here for a minute.” Thinking she was going to ask me something else about the inhaler, I was happily surprised by the big hug I received from her with a whispered, “Thank you,” in my ear. She said I relieved her fear of not being able to breathe. She told me I would be her go-to person for help from now on. It’s amazing how one small action can mean the world to some people.

^_^

It is days like these that make everything worth it. I am proud to be a pharmacist, and I love my job.

 

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