CNM/PA/NP, Home Health Nurses, and Stupidty

I love getting hate mail from people who try to defend what I bitch about. Here is a good one:
Most CNMs have Master’s Degrees…hardly career college.
My response to that:
Then learn your shit so I dont have to correct your errors. If you have a “masters” degree, then obvously you should have some brain cells in your noggin so I dont have to waste my time correcting your fatal fuckups. I get my shit in order before I speak with a doctor about a medication, so you should have your shit together before you speak with me about medication.
Lets rehash the whole CNM/PA/NP issue shall we? For those of you who arent in the medical profession, heres a quick breakdown:
CNM: Certified Nurse Midwife – Basically someone there when you have a baby. Why they gave these people the ability to write prescriptions is beyond me. Their scope of practice is about a half dozen drugs.
NP: Nurse Practioner – At one time could prescribe everything a doctor could except C-2 narcotics (Morphine, Ritalin, etc). Thats changed.
PA: Physicans Assistant – A NP but could write triplicate Rx’s for Morphine, etc.
Now PA/NP’s are interchangeable.
Back to the rant:
How many pharmacists in the crowd have saved a CNM/PA/NP/Whoever-they-are-allowing-to-write-Rx’s-now-days/etc asses from something severe. Say like confusing hydroxyzine with hydralazine, or my favorite lamictal with lomotil.
I had a NP sit there and argue with me that hydralazine was for itching. This was a white chick too, so there wasnt any accent (dont get me started) or language issues. She was dead set that hydralazine was for itching. Well, I guess if you take enough of it you wont have an itch anymore.
Now this isnt a bash on all NP/PA’s, because i’ve met some of them that really know more than the Dr they work under. This is just a bash to all the stupid ones with the ego of a doctor, but without the schooling or balls to back it up.
Lets move on now to Home Health Nurses. I had a nice call day before yesterday from a Home Health Nurse that went something like this:
Her: “We have a problem here”
Me: *sigh*
Her: “I am supposed to give this person 10mg of methadone twice daily, but you dispensed the 5mg tablets”
Me: “What does it say on the label”
Her: “Take 2 tablets (10mg) twice daily”
Me: “So whats the problem”
Her: “These are 5mg tablets!”
Me: “Yeah, you give 2. 5 + 5 = 10”
Her: “Oh”
Me: !@#!$!@#!@#!$!
I swear, thats how the conversation went. When I hung up, I walked into the back room, sat down, and sobbed for the medical profession.
Another fun story involves a tube of Regranex. Now most pharmacists out there are rolling their eyes at this point, because Regranex comes in a 15gm tube (small), and costs about 500 bucks a pop. Its used for chronic wound healing, and has a mathmatical formula to specfiy how much to squeeze out based upon the wound dimensions. Its like width x length x 0.6 = inches to squeeze out.
So I managed to jump through the hoops to get this covered for this poor lady. Spent a few hours on the phone, and the insurance company decided to auth a few months of treatment to see if it’ll work. I call up the patient, and talk to the home health nurse:
Me: “You know how to apply this right?”
Her: “Yes”
Me: “Its width x length x 0.6 = inches to apply – change with saline dressing after 12 hours”
Her: “Ive done this before”
Her: “Okay, just making sure”
Drug goes out, and I get a call a day-and-a-half later. Its the home health nurse:
Her: “I need another tube of Regranex”
Me: “uh, why? This should last you for 2 weeks”
Her: “I used it all up”
Me: “But the wound is . You would need like 0.75″ of cream”
Her: “I used it all up”
Me: “You realize thats 500 bucks a tube right?”
Her: “Will another tube be sent out today?”
Now at this point I get the patient on the phone (who is very kind and sweet). She tells me the dumb twat was just latering it on like neosporin and used up the whole tube. I come unglued. I speak with her manager, and proceed to give her both barrels. It took me an act of God to get this shit covered, and a fucking dumb ignorant twat just blew what small chance I had. What burns me up even more is that I asked the dumb hoe if she knew how to apply it, and she blew me off.
Ive been scarred by home health nurses ever since. The real pushy and demanding ones are the worst. When they start off the conversation with “You need to do…” my brain shuts off, and I just lay into them. I’m not their bitch and i’m not going to do their job for them.

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19 Comments

  1. Not a CNM says:

    First of, my mail was not hate mail. I love this blog and read it religiously. There have been very few entries where I haven’t laughed.
    Most CNMs have their MSN or MS. That’s not career college, that’s graduate level education. Studies prove that patients are more satisfied with a CNM attended birth, and a 1998 study shows that neonates delivered by a CNM have a 33% lower mortality rate. Now, of course, this statstic is slightly skewed since the most complicated births are out of the CNM scope of practice, but it’s still clear in studies that CNMs are very safe and an excellent choice for OB/GYN healthcare.
    Also, studies show that patients cared for by NPs have the same clinical outcome, but higher patient satisfaction rates, when compared to MD/DOs. Also, a recent study shows that patients who have their HIV/AIDS managed by an NP/PA have the same clinical outcome. Unlike PAs *all* new grad NPs have graduate level education. PAs don’t even need a college degree — there’s still certificate programs out there. So, if anything, you should be worried about them.

  2. rxcat says:

    Just a comment on PAs….you should come here. In this state they can only write for 72 hours or 14 days worth of CIIs and CIIIs (and no refills allowed on CIIIs) depending on what the doctor they work under allows them to. And on the state board of medical examiners website we can check to see what their prescribing rights are. It makes it a little easier to keep them in check. But I totally get the frustration. I don’t know how many times I’ve had to call and tell a PA that the strength of medication they wrote for doesn’t exist. If they would just think a little bit before they write the Rx it would save them and me alot of time.

  3. Jesse says:

    Ya know, its against federal law to fill a script for 10mg Methadone with BID 5mg. Or at least that’s what I’ve been told.
    In other news, I enjoy the blog.

  4. Karen says:

    Ok, so I am filling a new Rx for a NP that we don’t have in our system. I call for DEA of physician that she “works under” since she doesn’t have her own. The message I get is just f-ing priceless. “THIS IS SO and SO and I DO NOT WORK UNDER ANYONE. I COLLARBORATE (emphasize this word) WITH DR. SO AND SO. DEA # BLAH BLAH.” Someone needs a reality check.

    • Rick says:

      Sorry- but that is a per peeve of mine- same with being called Dr. so and so’s Nurse Practioner- My name and credentials are all that is needed. Also, unless the prescription is a narcotic a DEA # is not needed

  5. CeeKay says:

    I’m getting tired of covering everyone’s ass. We are the last bastion before the patient but not getting paid for it. We cover drs, stupid nurses, stupid parents, insurance company formularies, all insurance company contact with the patient (when they need a pa or can’t have their medicine because pbm isn’t making enough money), patients asses, etc. Louisiana rph’s showed the whole country what we are made of. Someone needs to start listening.

    • Rick says:

      NOT GETTING PAID FOR IT! That is exactly what you are getting paid for- that ia why they call you a PHARMACIST and not a drug dispenser- The pharmacists I know make a hell of a lot more than me!!

  6. michelle says:

    I tried to choose the best “place” to share my personal experience with the local doc in the box.
    First let me give a little credit to the doctor. We have jobs because they write prescriptions. Some of them may not have brains but they can write an RX
    Second- I would like to thank all the patients out there in our “all about me society” because when you say I hope you get to feeling better what I would like to say, “A couple of days in bed is really what I need but you come first AND there is no one to fill in.”
    Except for annual physicals, UTI’s, and an occasional break down because I have a 15 year old who (like the doctor’s office) knows everything. It takes an act of congress to get me to go to the doctor. In three years I have missed one day of work to illness, not that I have not been sick other times, but I needed to stay near the porclein throne.
    I leave work early one day this weak to head to the doc in the box because I have had this awful cough and drowning in my own snot sickness for a week now. Getting into the PCP is difficult when one cannot call in sick because there is no one to cover. Funny how that works.
    I arrive, sign in, fill out the paper work, and proceed to sound as if I coughed a lung up as other sick people just stare. As if they are not there because of illness. Maybe it is just a social call for them…after all we have nothing better to do.
    I finally get called to the back and the lady takes a brief history of the meds I have been taken for a week.
    To make the story short. I was prescribed a
    Z-Pak because apparantely I was running a temp that even I was not aware of and Sinutuss DM. Now explain this one to me. What is in Sinutuss DM? I do not mean literally…AFter all I work in the pharmacy and am familiar with the drug. The three ingredients in sinutuss are available OTC as 3 single products or in combination. What do you think the odds are I have medicated my self with the three products and other products just to cover the bases? The odds are high that I can multiply and get the same dosing.
    I am sure many of us are in the same boat…we need to fill RX’s to cover expenses. If you are not familiar with the product than you just got your miracle drug. The RX that will fix you. After all we only go to the doctor for him to write a RX because any RX will make a person feel better. It is almost like a patient who brings in the RX for you to fill. “How fast can you get this ready.” Do you every want to say, “You mean any drug will do you just want it fast, right?”
    Back to the story. The PA (who is fresh out of school and only has a temporary license) said to me, “I do not want to supress the cough because you need to get it all up.” I just look at her and think you cannot be a complete dumb ass are you not familiar with all the products I have been taking this week. I just take the RX and walk away…I know I should have been more forcful but one cannot argue with ignorance. I call the next day and get some idiot who cannot speak english and you know is only working the front desk answering the phone and taking messages. Stupid me, this person graduated from medical school OVERNIGHT. I tell her the story blah, blah, blah. Well, this person tells me you have to give the Sinutuss DM a few days to work. HELLO, what have I been doing for a week. THE MAGIC RX is, after all, nothing I can get OTC. She puts me on hold and does not return. I go back to my busy work day and start fuming. I almost feel like I was being treated like a drug seeker. I call back later and ask to be transferred to the PA voice mail. Apparently the doc in the box does not have voice mail for the PA. I get transferred to the nurses station and explain the situation again, including reminding the “nurse” that the Sinutuss DM ingredients are availble OTC and I had already been taking that for a week. She takes a message and I leave my contact information which is the same as the pharmacy number and I do not hear from them again.
    Why did this PA feel the SINUTUSS DM was the magic pill for me? Was it because I was not feeling well and did not look fresh and appealing by the time I got to the office. Was it because had slightly urinated on myself because I was coughing so hard I may have smelled like urine? Or was it that she was too stupid to realize the ingredients in the drug WAS the same thing I had taken all week. What did she get extra from the drug rep for prescribing my magic pill?
    My prayer-“Dear god, please do not let the PA insult my intelligience as I call her again and tell her what I really need. Because if she calls in Benzonatate it may send me over the edge.”
    FYI-some insurance will not cover prescription medications when the ingredients of the medication is available OTC. But, I am sure we have all run across that problem before.

    • Rick says:

      Do what I do- go to the doctor dressed in a lab coat, tell him what your symptoms are, tell him what you want to remedy those symptoms and tell him you will call him next week. Anyone who orders a Z-Pak doesn’t have time to deal with your problems- he will assume you are someone in the medical field and be thankful for the recommendation. The best thing for you in your case is plenty of fluids, a couple spots of Vicks in the nares, and a shot of whiskey three times a day.

  7. WarNerd1 says:

    Higher/graduate education for paraprofessional occupations (which didn’t need those qualifications until recently) is a time-tested political maneuver. It is really a status boosting tool that doubles as a pretext for scope-expansion in the future. Therefore, even they did give out PhDs for crapper-cleaning, it doesn’t make crapper cleaners more productive or anything more than crapper-cleaners, contrary to what board members for those “professions” would vehemently insist. Instead, what will always dictate the status and position of a profession in society lies with the entry standards, demands and quality of the graduates.
    The NP is just a politically-savvy class of nurses serving as a cut-rate GP. Many of them, I daresay, would not even be able to compete for a place in Pharmacy School much less, Medical School. Sad but true. If you didn’t know that, now you do.

    • Rick says:

      That may be true WarNerd- but I make 40, 000 dollars more a year with my degree than when I was doing the same shit without one. And in case your blog was supposed to be condescending- I know plenty of PharmD’s that have the scope of a guppy- Try dealing with mail order pharmacies.

  8. Bryan says:

    I am a PA student that will be graduating next fall. Although we do not receive the amount of pharmacology that PharmD’s receive, we do complete an entire year of didactic pharmacology as well as a year of internship. Most PAs do not start writing Rx completely on their own for some time (usually an additional year). I can say that in my short time in rotations, I have seen medication errors on behalf of Physicians, PA’s, nurses, as well as PHARMACISTS. Everyone is capable of making a mistake, so labeling all mid-level providers as being ignorant is just absurd.
    Every profession has a small percentage of retards that the rest of us unfortunately have to deal with from time to time. Honestly, if all providers knew as much as you hoped they would… many of you Pharmacists would not have a job. Personally, I extensively look up all medications before presenting to my attending physician my treatment plan. When I graduate and enter into practice, I will continue to ensure that all medications I write for are the proper medication, dose, route, as well as the right choice for the patient. If ever in doubt, I will consult with my colleagues for assistance… or even contact a local pharmacist if I still have a question or concern about a specific medication.
    I know that I am limited on every aspect of the medications that I will one day prescribe; therefore I must rely on other professionals to assist me in selecting the correct medication for my patients when I am in doubt. Perhaps there are those in my profession that feel as if they know everything� and make careless mistakes out of arrogance. I do however feel very confident in saying that it is a small number of individuals that are idiots and create a negative stigma that we all sometimes get lumped into. I just want to set the record straight for the remaining 95% of us that use good clinical judgment and know when to ask questions when we are in doubt. For there is always someone smarter than you on a given topic� and there is nothing wrong with seeking their advice when it comes to the treatment of patients.

  9. Piss & Vinegar says:

    I’m an intern and had my first experience with this yesterday. NP calls in and leaves a message for dilaudid and flexeril. So I proceed to call her back and let her know we need the hard copy for the dilaudid. She didn’t give the patient a hard copy before they left the office and we had to deal with the aftermath. Fortunately, she was able to get a hold of the patient before they showed up at the pharmacy demanding their drugs.

    • Rick says:

      That was probably because she was seeing 30 patients in a 4 hour time span, ordering 20 diagnostic tests, answering 10 phone calls from patients who just wanted to chat and then typing 30 treatment visits in the computer. All that, opposed to, standing by a phone counting pills and putting them in a bottle.

  10. StudentMD says:

    Awesome. Doctor of Nursing is an oxymoron… where do they come up with these titles. Just because your the highest educated in your group doesn’t mean your educated. Chief Fry-Cook.
    Medicine slowly circles the drain…

    • Rick says:

      Says the StudentMD- talk about oxymorons. Doctor of Nursing means you hold the highest degree in the field of Nursing, not that you are highly educated; just as being a Doctor of Medicine (M.D.)does not mean you possess any knowledge or skill only the highest degree in Medicine. FYI, it was Academia that bestowed these titles- not Medicine.

  11. soame.wordpress.com says:

    “Not a CNM” is lying out of her ass unless her studies come straight from the cows at the AANC. Well pharmacists.. just wait until you start seeing more DNPs (Doctors of Nurse Practitioner) or some other such hilarious bullshit of that nature. Then your gunna people with the education of NPs but with the egos of physicians who truly believe they are on-par with physicians as far as knowledge and experience goes.
    Those studies are garbage. She said it herself. NPs handle the easy cases in OB/GYN. They’d never let a fucking NP around anything other than a standard vaginal delivery and even then they’d have a fucking OB/Gyn with a real education nearby incase they fuck it up. Same goes for CNAs who are now bitching about being able to practice independent from an Anesthesiologist. They handle basic ass shit, and the real doc has to be there anytime they give an epi. The nursing profession is gaining way too much power. Expect more patients to die in the future because of idiot politicians who let them do shit they aren’t nearly qualified to do.

    • Rick says:

      Hey brainiac: DNP means Doctor of Nurse Practice, not Practioner. Let’s hope you are not a practioner in the medical field. If so possibly you could spend time learning to speak and write. “Then your gunna people with the education of NPs” Let’s face it, you’re just another backwoods moron with a big mouth and nothing intelligent to say.

    • Tawni says:

      actually what she said was that complicated births were outside of the scope of a CNM NOT an NP… they are different.. a CNM is required to have a masters along with a certain practical experience application.. an NP has a PHD. a DNP has a doctorate level education in their field as well but the degree is not based in traditional research and theory as much as evidence based practice..as far as distinguishing their scope in practice- i can’t really predict how this will pan out- I am not familiar enough with the differences in experience and training levels- I do know that the DNP has a significant clinical experience portion to it requiring nearly 400 clinical hours with a capstone experience in lieu of a dissertation- in regards to your statements about CNAs– it is not a new thing by far for CNAs to practice independently.. they are trained to do so and the only real consideration that intervenes with this is state law.. CNAs are independent licensed personnel in the Army and are the leading providers for anesthesia in veterans and public health administrations- many developing countries are dependent on them because they far outnumber medical anesthesiologists in these areas- furthermore in 2001 centers for medicare and medicaid allowed states to override the physician supervision requirement.. I think your experiences are probably limited to the legalities of your state and you should have a more open mind about the experience base in other areas of CNAs- the education program for these individuals is designed to teach them how to practice independently without a physician.. just my 2 cents..

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