Recently in Nurses and Hospitals Category

I'm tired of candy coating and being all "politically correct" about this issue, so I'm just going to come right out and be an asshole. You've been warned:

If you cannot speak clear English, do NOT call in prescriptions. Yes, I'm calling you all out: STOP FUCKING CALLING IN PRESCRIPTIONS IF YOU HAVE A THICK ACCENT. PUT DOWN THE FUCKING PHONE, AND EITHER FAX OR GET SOMEONE WHO SPEAKS CLEAR ENGLISH TO CALL IT IN.

Do you know how fucking frustrating it is to have to have a 'nurse' repeat him/herself about 20 times because it all sounds the fucking same?

Now I'm not saying that you aren't smart, or capable, or a bad person. I'm making a statement of fact that when lives are on the line, pharmacists need someone who can speak clear English when calling in medications. I'm tired of this happy-go-lucky huggy embrace everyone society that we have now that just looks the other way when some un-educated foreign drone calls in 20 Rx's that all sounds like vowels on my answering machine. I'm sorry, but stop it. Get someone who can speak English to make that call. Me calling you back to "confirm" is not only a waste of both of our times, but 100% unnecessary if it was done correctly and clearly in the first place.

You think I'm being an insensitive racist asshole. You're right, I care about my patients, and my state license/livelihood/my patients life is riding on your piss-poor language skills coupled with a 'degree' from a 3 month community college program. I'm sorry if I hurt your feelings, welcome to the world of medicine. I'm sorry if you cant help your accent; doesn't mean you need to change jobs, just don't call in Rx's. They don't let retards fly fighter jets and you don't see them getting butthurt by this.

So pony up and accept it. Drugs sound the same. Obviously you don't know this because you are still calling in Hydr-vowel-vowel-bok-bok-bok and require an interrogation session for me to determine if you mean HydrALAzine vs HydrOXYzine, TopROL vs TopaMAX, BID vs TID, etc etc etc.

This doesn't stop at nurses, oh no. Pharmacists and Doctors are just as bad. If I request you to fax over that copy, and you are "too busy" and want to give a verbal, I'm just going to come right out and say that I want it faxed because I can't understand what the fuck you are saying. I pressed "1" for English bitch!

So yeah, I'm an asshole. However I'm an asshole not because I hate you, or your race, or where you came from. I'm an asshole because you don't seem to get the very clear and very important concept that you lack a very vital language skill that puts not only my patients life on the line but my license and store as well. Medicine requires clarity or people get hurt, you should of learned that in school. Sorry for fucking caring for the whole at the expense of insulting a few.

Oh, you know when I said I was sorry up there? I lied. I'm not sorry. I shouldn't be sorry for standing up for patient safety when nobody else seems to have the balls to confront this issue (and make people upset? Oh no!).

There are some things that go on in a pharmacy that are set in stone like the sun rising in the morning. Pharmacy school should publish this list for their students. Seriously, its all true. Lets examine a few:

I know I'm going to get some hatemail with this one, but this topic really bugs the hell out of me.

I get this call today from the hospital (as if the gods themselves read my blog and graced me with discharge orders) from a self identified "Nurse" from the "floor" who could barely speak english. I asked her "Oh? You're a nurse? Where did you go to nursing school?" She gave me some junior college somewhere I had never heard of. I then asked her "Are you an RN?" She said "No, i'm just a nursing assistant".

Why are Nursing Assistants and Medical Assistants and other NON REGISTERED NURSES calling themselves NURSES? Why?! Do pharm techs call themselves pharmacists? I dont see why they cant by their standards, they go to school, and do 3/4th of the work a pharmacist does.. Why doesnt a PA or an NP call themselves a doctor? They do basically the same job dont they? Do security guards call themselves policemen? NO!@#!

I'll tell you why, because ITS FUCKING WRONG. Thats right, MA's and NA calling themselves nurses is WRONG. Why haven't the tried and true RN's of the world put the backhand of justice down on the ignorant fools who are calling themselves something that they aren't. Here you have the title "Nurse" splattered around any half-witted moron who completes a 4 month course at some shitty junior college only to throw "Nurse" around and ruin it for the people who went to an actual college, actually have a BS in Nursing, and actually KNOW something about medicine. It's shitty I tell you. If I were an RN I'd be mad as hell and backhanding mofo's left and right!

Now once in a while I'll get someone who identified themselves as an "MA", but with the accent it sounds like "PA" so I get confused for a second before I realize whats going on. But the majority of the grunt hospital "Nurses" really arent nurses at all, but go around using that title. Its a conspiracy, and I'm the first to report it.

Now I also get down on pharmacist who go around waving their PharmD penises in the air and demand people off the street call them "Doctor". I can see using the "Doctor" title while you're working on the floors in the hospital (sorta), but with the common folk? Gimme a break. Put your tiny penis away and just face the fact that you're just a pharmacist like me, the drugnazi, and all other retail folk. Hell, I have a PharmD, didnt realize that did you? Its because I DONT FUCKING FLAUNT IT. Doctor only in title, not in spirit is what I always say.

I still havent gotten an email from DrugNazi about PharmBoozeFest'07

Whats more fun than a kick in the balls? More exciting than seeing plastic bags full of random pill bottles plunk on your counter? More uplifting than seeing that 65 year old who cant tie her own shoes walk in the front door with yet another barrage of same questions she asked yesterday? More hilarious than watching an Alzheimer's patient go greeting card shopping?

DISCHARGE ORDERS!

Thats right! Pages upon pages of fun!

Let me explain why they frustrate the hell out of us:
If they are phoned in, they are usually called in by a nurse (i use that term VERY VERY loosely) who cannot speak english. They usually involve 20 some-odd drugs, and the nurse cant figure out how to fax them over, and demands to just verbally give them. After 20 mins of 'eye tink dats hydoxyzyzine (?!?!?)' sort of mayhem, they want you to READ back to them all of the medications they called in, upon which they somehow get really confused and make you start over not once, not twice, but three times. Did I mention that she cannot read the doctors handwriting, so shes GUESSING at most of these? Yanno, people really throw the term 'Nurse' around like it means something now days.. You a MA? You're a NURSE! You're a Nursing Assistant? NURSE FOR YOU! You clean the floors? NURSE! If I were a 'real' RN-type nurse, and associated with these types of 'nurses', i'd be pissed. Of course I'm in the camp that gets pissed when PharmD's call themselves "Doctor". Anyhoo, I digress, back on track.

When you are fortunate enough to get a REAL nurse who calls you and spends all of 30 seconds getting your fax number and saying "i'll send it over" (thank you, we love you). One of the following will (not maybe, will) happen:

Its very rare that I rag on an entire healthcare system. I don't expect anything to be perfect (except myself of course.. :) ) and my standards for nurses is at an all time low, so you impress me if you can manage to pronounce 'Atenolol' correctly.

Today however, I completely lost my faith in a particular health care system. Now I wont tell you which group this doctor came from (it rhymes with Kaiser), but heres how it all went down.

I get this phone call from a nurse at a local hospital here in town. She is calling in discharge medications for a patient who recently had hip surgery. She calls in 100 vicodin (of course), and Lovenox given once a day for a month. Now I can see all of the retail pharmacists assholes puckering at the cost of a month of Lovenox, and I can see all of you "I'm Mr Clinical Hospital Pharmacist, look at my fancy pants and PharmD title! Call me doctor!" chumps roll your eyes. Oh no, it gets better.

I politely tell the nurse that there must be a mistake. First off, Lovenox is given twice a day (its half-life is 12 hours). Second, no doctor who graduated medical school would give it for an entire month. Lovenox really isnt designed nor intended for that! The nurse politely told me that this was a Kaiser doctor, and thats what was ordered. I asked the nurse to page the doctor, it was time for some schooling!

For all you students and non-pharmacists out there, heres what the problem is.

When you get any hip surgery, they usually put you on some sort of anticoagulant (such as Coumadin) to prevent a clot from getting stuck in your noggin or your lungs. The problem is that Coumadin takes about 5 days (60 hours or something like that) after you start taking it to start working. Coumadin inhibits your body from producing clotting factors (its a Vitamin K analog that Taliban's the clotting factories), and some of those clotting factors hang around for a few days before your body coat hangers their life and recycles their little innards. So you need to wait until the existing clotting factors are cycled out so your body cant produce more (because of the Coumadin). With me? Good! You now know more than this doctor does.

Now in the hospital, nurses give the patients Heparin to prevent clotting. Heparin does magical things with your existing clotting factors to make them stop clotting. They don't inhibit the production of the clotting factors. The problem with heparin is that it causes this nasty condition called Heparin Induced Thrombocytopenia (HIT) that basically makes you stop producing platelets. Bad news. So they only give heparin in the hospital so they can watch you die vs having you die at home. You may be asking "Why cant they give Coumadin before surgery?". Ah, if you bleed out on the operating table because you're loaded up with Coumadin, that tends to make your family less than happy.

So in steps Lovenox. Its a Low Molecular Weight Heparin which doesn't cause HIT, thereby it can be given at home. Person gets a shiny new Rx for Coumadin and Lovenox, starts taking the Coumadin while giving themselves shots of Lovenox twice a day for 5 to 10 days, then when they have used up the box of Lovenox their Coumadin has already started working and you're good to go. Its called "Bridge Therapy" because Lovenox acts as a 'bridge' between Heparin in the hospital and Coumadin tablets at home.

Now you can impress your friends and family with useless pharmacy knowledge. If I got any of the above wrong, blow me, its 2:30am on a Friday night/Sat Morning, and I'm sitting here in front of my computer sober rather than asleep or drunk.

So the doctor calls back. He asks what the problem was. I explain my problem with his orders and he still doesn't get it. His excuse for the month of Lovenox: "The patient wasnt going to be seen at Kaiser, so she'll have to use this". Yeah, riiiiight. As if any insurance company is going to say "Sure! I'll pay $3000 for a month of Lovenox vs $30 for a month of Coumadin!" So I explain to him that maybe we should just do a 10 day run, and she can go and see her primary care for Coumadin therapy. Nope, wanted a month of Lovenox at once/day. So now I bring out the big guns. I ask him why he is giving it once daily, when the half-life is 12 hours? Stammering and silence on the phone. Then a "This is how we do it at Kaiser". Bull-Fucking-Shit. I guess if thats the case, they are spending all of their cash on Lovenox and not on hiring decent doctors. After much 'this is how its going to be' and basic pharmacology lesson of Coumadin and Lovenox, I manage to get him to do what I say and authorize a 10 day run at twice daily. Patients life has been saved thanks to yours truly. I slammed down the phone, and waved my pharmacology penis all around for everyone to see.

This is basic shit. This isn't a super complex protocol. Its not like we are putting her on a MAO-I *shudder* or even titrating up her Coumadin! Maybe I put too much faith in doctors in knowing their medications. Oh, and to any of the pharmacists at Kaiser who might be reading this, just don't get me in trouble. :)

Now feel free to correct me if i'm wrong, but is every county hospital the most mismanaged, poorly ran, sinkhole of my tax-paying dollars on the planet?

Why dont I just throw 1/3 of my paycheck into the air and let the retarded rejects of the medical profession (if you want to associate them with that) pick up the free money?

Now i'm just going to be talking about the county hospital in my county. This may or may not apply to yours. Where should I start bitching:

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.

We all get those uppity patients once in a while who think they know it all. Give a patient an inch of information thats somewhat techincal and the'll run a mile with it. Show one www.webmd.com and they think they know as much as a pharmacist. Suggest something and you'll get 15 printed out pages from message boards from 'medical professionals' (we all know doctors just sit around on message boards all day) saying how wrong you are. Sometimes I hate the internet, and wish all the patients were dumb, compliant, and happy.

One class of patient though really really bug me. Ex-Nurses. Thats right, nurses. Especially older nurses that have long since been retired. We all know that once you become an RN, it doesnt matter how long you've been out of practice, you must know 1000x more than my dumb-PharmD ass about the latest treatments. You'll argue me to death about therapies and shit that you cant even prounounce let alone know whats its MOA is. I want to tell these people:

"Bitch please! When you were a nurse you only had morphine, aspirin and digoxin! You're so dumb that you still thing MAO-I's are first line for depression! "
(i can hear all the pharmacists laughing at the MAO-I joke, if you're not a pharmacist you wont get it.)

But what gets me, is that now i'm seeing not RN's getting uppity, but like Nursing Assistants and Medical Assistants. Just because you call in prescriptions doesnt mean that you know more about the medication as I do, or can belittle me with the "Yeah, i know, im an Medical Assistant" bit.

But ya know what, these people are quick to belittle you, but are the first ones to call up with a stupid question that they should know because "They are/were a nurse".

Actual conversation between a pharmacist and a nurse.

-Phone Rings
RPh - "Hello, this is the pharmacy."
RN - "Yes, hello. I am calling to inquire about Mr. Xs medication."
RPh - "OK, what's going on?"
RN - "Well, the problem is this: He's supposed to get 20 mg of this medication, but you guys sent me a 40 mg tablet."
Rph - "OK, so what's the problem?"
RN - "Well now, that's not the correct dosage."
Rph - heavy sigh.... "Here's what you do... Take the tablet, break it in half across the score in the middle and give half the tablet to the patient."

RN - long pause.... "Which half?"

This is the type of crap that scares the hell outta me.