I really don't know if I'll ever post here consistently or not, but we'll give it a try.  Many things to talk about.  But today, I just feel like focusing on the stupidity of things that happened...today. 

Got a call in Drug Info from a pharmacist (or maybe a doc, I actually never got that information) at an unnamed hospital (well, sorta unnamed I guess...it was a Veterans Affairs hospital) who was asking if they could borrow some Acetadote from us.  For those who don't know, Acetadote (also known as acetylcysteine) is used in the treatment of Tylenol overdose, and comes in an injectable form.   There's also an inhalation product called Mucomyst, which is used to break up thick secretions, but it can be used orally for treating Tylenol overdose.  Apparently, the patient wasn't tolerating the oral form.  I don't know exactly what the called meant by "not tolerating", but my guess would be that he/she didn't want to take it because it tastes like ass.  Acetylcysteine contains sulfur, which means it smells (and presumably tastes, I don't know) like rotting eggs.  So I can understand not wanting to take it.  But look, if my choice was between drinking some rank-ass crap and dying of acute liver failure, I think I'd suck it up and choke it down.  I also have a lot of trouble feeling bad for this person because I would suspect that most Tylenol overdoses in this country occur in Vicodin abusers.  I don't think the FDA has done an especially good job warning the public of the danger of taking large doses of acetaminophen, but you have to take >4 grams a day (8x500 mg tabs or like 12x325 mg tabs) before you start to get into overdose territory, and for most of us that's pretty tough to do.  But since Vicodin has anywhere between 500 and 750 mg acetaminophen per dose, and since druggies pop those things like candy, it's pretty easy to do. 
Now, I'm jumping to a lot of conclusions...it's entirely possible that the person was taking Vicodin for some acute or chronic pain issue (which isn't out of the question since this WAS a VA hospital), or that Vicodin had nothing to do with it at all.  But still, unless you physically can't take the oral form, which is cheaper and easier to give, just suck it up.
So anyway, I connected this person with the people who had the ability to loan (or not) the drug to them.  Minutes later they called back with a few questions that led me to believe they were not that smart.
1) They asked if Mucomyst could be given IV-The answer is no.  It says on the freaking bottles "Not for Injection".
2) They asked me how to dose the IV acetylcysteine-Dude, you're a pharmacist (or a doctor).  Look it up!  That's what I'm gonna do.  Turned out they were staring at the Micromedex (drug info software) page so I'm not sure what exactly they thought I was gonna tell them.
Finally...what the hell is a large, government run hospital doing not keeping an important antidote in stock?  Ugh.  Fantastic.

Later, when I was covering in our Neuropsychiatric hospital, I got this fun order: Advair 250/50, 1 puff twice daily as needed for shortness of breath.  Now, as impressed as I was that the doctor actually wrote for the Advair strength (usually they just write Advair, even though it comes in three strengths), this order was completely retarded.  Advair is a combination of fluticasone (an inhaled steroid) and salmeterol (an inhaled beta-agonist) used for treating chronic asthma.  Basically it helps prevent asthma attacks from occurring.  It is not used to treat acute asthma attacks or shortness of breath.  If you don't take it regularly, it basically does nothing.  Thus, the order is retarded...not only does it not make sense to give it for shortness of breath (because it won't do shit...that's what albuterol is for), it's just a waste of money because it isn't effective when only given periodically.  Sometimes I wonder if these doctors really took pharmacology/therapeutics classes...I mean, this is basic basic stuff.

Actually, this brings me to a huge pet peeve about our house staff.  Since I work at a teaching hospital, we have tons and tons of medical residents.  They're learning and so they make mistakes and we have to call them and correct that mistakes.  That in itself isn't a problem.  The problem, though, is that after a while, they start to get savvy about it.  They realize that they can pretty much write whatever they want, because they know we're going to catch it before entering the order and fix it.  This leads to, in some cases, extremely sloppy order writing.  One time I got an order that read: nicotine patch.  That was it.  No dose.  No schedule.  Nothing.  Clearly, the doc had no clue how to write the order.  But instead of calling the pharmacy (or looking it up online) to figure out how to dose it, they wasted their time and mine by scribbling some random stupidity onto the order sheet.  When they called the pharmacy after I paged them, they were like "Oh, yeah, I didn't think that I ordered that right."  Really?  Wow, glad you were able to figure that out.  And sadly, things like this aren't exactly isolated incidents.

Ok, enough anger for today, I think.  I'm sure more stupidity will rear its ugly head tomorrow...

Pharmacy and Nursing.  Two groups, working together to help get hospitalized patients the medications they so need.  Probably at some base level we love and respect one another.  Unfortunately, one small hitch gets in the way: in order for nurses to give patients their medications, the pharmacy has to get the medication to the nurses.  This, of course, isn't the smoothest process.  Many fights have ensued.  The Great Pharmacy Uprising of 1951* left both sides licking their wounds and searching for answers.  But still, little to no progress has been made.  Let's face it, like Hatfield's and McCoy's, here are two groups that may just not be able to coexist peacefully.  Or as they say, this town might not be big enough for the both of us. 

But of course, we have to coexist because both groups provide such important services to patients.  And without pharmacy and nursing, doctors would be totally lost.  And we wouldn't want that.  So here I offer 10 suggestions, 10 things nurses can do to help smooth out this relationship.  Follow these simple rules, and your pharmacist will love you.  Or at least not think you're a complete moron. 

Number 1: It's a numbers game-The exact ratios are going to be different at all places, but it's important to remember that there are more nurses than pharmacists.  You are not more important than the other nurses.  Your patient is not more important than the other patients.  Do NOT call me and ask me when the order you just faxed will be ready.  I don't know, and I'm not going to waste my time looking through all my faxes to find out where you are in line.  I promise that I'll enter it once I get to it.  Unless you call me too much, then I may just ignore it out of spite.

Number 2: Don't waste words-Probably the most common call we get is nurses asking if their medication is ready to be picked up.  I don't especially mind this.  But invariably, once I've told them that it is ready to be picked up, I get one of two responses.  1) Can I come get it?  and 2) OK, I'll come get it.  Please, don't say either one of those things.  The answer to number 1 is, obviously, YES.  I just fucking said that.  And as far as number 2 goes, I don't really care if you do get it or not, so you don't need to notify me.  That's 5 second of my life I will never get back.

Number 3: Don't argue-This isn't all inclusive.  But if I say "It's in the pyxis" or "Pharmacy doesn't dispense that", don't tell me that I'm wrong.  If I tell you we don't have an order for a certain medication for a patient, and ask politely that you refax it, don't tell me that you faxed it already.  That doesn't solve the problem.  And for the love of god, don't ever use the "but (so and so) did this for me the last time" argument.  I'm not (so and so), and if they chose to do it that way, that's fine, but I'm not going to.  Deal with it. 

Number 4: Pick up the god-damn phone-I dunno about anybody else, but all our nurses are assigned cell phones so that they can be contacted at all times.  So, when it rings, pick it up!  If you're on break, give your phone to someone who will pick it up.  I pick up the phone when you call the pharmacy, so it's only fair. 

Number 5: Learn to triage-Understand the difference between a real STAT order and a STAT order that was just written stupidly by the doctor.  For instance, bisacodyl is not something you need STAT.  If your patient is crashing and you need some life-saving drug right away, I will make it for you right away.  If your patient is constipated, they can wait a few minutes.  Calling me over and over again won't get it done any faster.  On a similar note, if you call me a million times to ask if your drug is ready yet, you had better come pick it up the SECOND I say yes.  Don't wait for the delivery.  If you needed it enough to justify your bugging the hell out of me, you need it enough to walk your ass the 100 yards to the pharmacy. 

Number 6: Learn your drug names-I realize that there are a ton of drugs, and that they all have two names.  I realize that's a lot of information to remember.  So here's my suggestions-if a doctor order a drug that you don't know, look it up real quick.  At our hospital, everything on the MAR (medication administration record) is put in as the generic name.  The doctors sometimes order things as brand name.  Point being, I should NEVER get a call saying "I can't find my Lipitor for Jane Doe." only to find out that's because you didn't look for the drug in the pyxis under the name atorvastatin.  On a similar note, don't come asking me if you can pick up a patients atenol or lisopril.  Learn how to pronounce the drugs names, especially the common ones.  If not, you end up sounding like a layperson with no formal education about drugs.  And that makes me nervous.

Number 7: Follow the administration times-This is most relevant for IV drugs.  Especially antibiotics.  We schedule hang times!  It's on the MAR!  If a drug is scheduled for q 12 hours at 5 AM and 5 PM, don't give the drug at noon and midnight.  Some drugs have expiration times, and if it expires, we have to make an extra dose!  Waste of our time.  For oral medications not in the pyxis, we exchange the patient's drug drawers at the same time every day.  Make sure you give that dose schedule for 2 PM at 2 PM!  If you wait until 4 PM, the cassette will be gone, we'll take your unused dose back, and you'll have to request another dose from the pharmacy.  Again, waste of our time.  Finally, don't send me a missing medication request for a drug that's not due for 4 or 5 hours.  It's not missing at 10 AM if you aren't suppose to give it until 2 PM.

Number 8: Look before you leap-In the name of all things holy, make sure you actually LOOKED for the drug before you tell me it's missing.  For EVERY drug, look in the pyxis, the cassette, the refrigerator, and the new drug bin.  If you don't find it in any of those places, give me and call and we'll figure something out.  And if you do give me a call, don't say "Oh, Oh, I can't find it, you didn't sent it, wah wah wah", only to realize, in the middle of the call, that you just found it.  Now I KNOW you didn't look before you called!  I mean, I knew it already, but still.  Lie to me or something.  Along the same lines, if you have a question about giving a drug, call and ask before you just wing it.  Don't call and say "I just ran drug X through this line that I was also infusing drug Y.  Is that OK?".  Well, what does it matter?  You already fucking did it.  If it's not OK, you'll know pretty soon.

Number 9: Give us time-To make everything run smoother, do everything in your power to make sure that we have at least an hour to prepare any medications you need.  This especially goes for continuous drips that have variable rates.  Don't call me and say "The bag is dry, I need another".  Call me when the bag is LOW so that the bag never gets dry!  Brilliant!

Number 10: Don't play the blame game-If there is a problem, don't try to place blame on me or my techs or my delivery people or whatever.  Let's try to solve the problem so that the patient gets the best care, because that's what's really important.  Once we've solved the problem, we can figure out who caused the problem, and take the appropriate actions.  And if you make a mistake, don't try to blame it on me.  I'm sorry that the labels aren't big enough, or that they're all the same color, or these vials look alike.  You have a license to give dangerous substances to a patient, so read the damn label or vial before you give it.  That would be great.

Overall, please, don't be lazy.  That's the major key.  If you're diligent about your job, and I'm diligent about my job, everything should run smooth, there shouldn't be medication errors, and we can all live in peace and harmony.

By all means, I would love to get suggestions from some nurses as to what we pharmacists can do to make your lives easier. 

*obviously I just made this up.

PS-This wasn't nearly as angry as I had hoped it would be.  But gratuitous cussing just seemed, well...gratuitous.  I guess I shoulda done this on a day I worked.

Can I say retarded?  Do I have to use intelligence challenged?  Whatever, I don't really care about political correctness.  I'm sure you're asking yourself, though, why is the FDA retarded?  Well, there are a lot of reasons, but let's just talk about one.  A little thing the FDA likes to call the Black Box Warning.

According to the code of federal regulations (and I'm very loosely quoting it) a black box warning is the strongest warning the FDA can require a drug company put in their product package insert.  Black box warnings generally warn of adverse events or situations where the use of a drug can lead to serious injury or death.  However, black box warnings do not always contraindicate the use of a drug in certain patient populations.  And example of a black box warning would be the warning for ALL antidepressants that warns of the risk of suicidality in children and adolescents.

So in essence, the black box warning is a good idea.  But the problem is, nobody understands what the fuck the significance is.  And I'm dead serious about this.  I was reading the transcript from the FDA advisory committee meeting on telithromycin (Ketek), and nobody on the advisory committee even understood what should be added to the black box.  Seriously, people were abstaining from voting because they didn't understand the ramifications of adding a black box warning to this product.  These are the leading experts in their field!  People on the god-damn FDA advisory committee!

Why am I ranting about this?  Two reasons.  First is drug safety.  The FDA only approves drugs that it deems are effective AND safe.  If a drug has a black box warning, there are obvious safety concerns.  The second is the ramifications of the black box warning.  Since the FDA doesn't really give any scope to their significance, regulatory agencies can interpret this as they will, and this can totally screw over patients, practitioners and institutions.  For instance, the drug droperidol, a commonly used agent for treating post-operative nausea and vomiting, carries a black box warning.  In 30+ years of experience, the incidence of side effects when the drug is used at appropriate doses is insanely low.  Like less then 1%.  Now, if you're in that 1% and you get an arrhythmia, that sucks.  Ffor the 99%+ that don't get an arrhythmia, this is one of the most effective drugs for the conditions it's used for.  But because there's a black box warning regulatory agencies, who have nothing better to do than try to impose impossible regulations on hospitals and other agencies, have decided to take a stand.  A number of hospitals in California have been cited for the half-hazard use of droperidol (aka not following the recommendation that all patients should have a 12-lead EKG and cardiac monitoring for at least 2-3 hours after the drug is given).  This has led to this drug being removed from the formulary at my institution.  Not because it isn't a good drug, not because it isn't safe, but because if we use it, we have to use it in a certain way or risk losing our funding.  Now, if there were a significant link between this drug and causing QT interval elongation (a potentially serious problem) and causing torsades des pointes (an often fatal arrhythmia), I could understand this measure.  But if that were the case, the drug would get PULLED OFF THE MARKET.  I guess my point is, if the FDA feels a drug is unsafe for routine use, it should not be on the market.  Instead they give us these vague warnings that may or may not mean anything, and it causes lots of trouble because nobody really knows what to make of them.

This is getting long and ranty, and I haven't even discussed all I really want to discuss, but here's the bottom line.  Life is not black and white, but in the case of the FDA and drug safety, it needs to be, because we are dealing with real people and real lives.  If you're going to have these black box warnings, make them mean something.  The list of drugs that have a black box warning is staggeringly huge, to the point that nobody really takes them seriously.  So come on FDA, get your shit together, please, so we aren't all in the dark.  Because at the end of the day, patient safety is the most important thing.


I know you're all anxiously awaiting the 10 things nurses do that piss me off, but I've not worked on the floor for a while so I can't really remember everything that I need to complain about.  By Friday, it should all come back to me.