Dosing Amoxicillin is not Rocket Science

All retail pharmacists see this on a daily basis.
A 1 year old get an Rx for some Amoxicillin 250/5. Standard issue. However the sig is “3.4mL tid x10d”.
Now what mother with half a fucking brain is going to know how to measure out 3.4mL? Its Amoxicillin for gods sake, not digoxin or something with a super narrow therapeutic index. 99% of the time these are from a NP or PA.
Let me spell it out for you. Round up or down in 1/2 teaspoon measurements. Why? Its because its what our dosing spoons/droppers have HUGE markings for, and there is a less chance of some dumbass mother giving her crotchfruit 4 teaspoonfuls instead of 4mL.
I know exactly how they get these weird doses. Rather than KNOW the drug or use common sense, they have a little book that says that the ‘dosing for amoxicillin is 22mg/kg/day (or some bullshit like that)’. With calculator in hand (and huge erection in pants) they determine that the proper dose is 3.4534mL of the 250mg/5 solution. They write this magical number down, and send their patients away with a medical hard-on the size of Florida.
I take one look at this, and round up to 1 teaspoonful. Seriously, its Amoxicillin. Its like the douches who write an actual sig for pedialyte. As if you are going to force the baby to drink pedialyte or shove a tube up its ass and dump it in that way.
You think that when we reconstitute the Amoxicillin I count the number of drops in the graduated cylinder? Hell no, I just eyeball it, dump it in, shake, and send it to the mother who’s child is either screaming his/her head off or running around tearing shit off of my shelves (Amoxicillin reconstituted with choral hydrate would be interesting). So your magical 5 digit significant figure dose just got horked out the window by a $4 graduated cylinder.
Reminds me of the time I had my intern calculate a Flagyl compound. She was so proud when she told me that she needed to crush 5.4 tablets of the 500mg Flagyl and mix it with x amount of OraPlus/Choclate Syrup (Flagyl has an ass after-taste. Gotta mask it with Hershey Syrup). I look her square in the eyes, and say “I’ll let you make it if you tell me how the fuck you are going to get 0.4 of a tablet”. InternEgo, meet AngryFist. “Round up to the nearest tablet, and recalculate how much solution to add based upon that “. And who says that I don’t teach anyone anything.
Much like during your crusades in retail, you need to choose your battles. You are exact on the things that count, and you roll your eyes and swear at the NP/PA/CNM/Janitor when they write a stupid sig for a drug that it really doesn’t matter with.

White Coat Ceremony – Part Duex

Well well well…
Turns out my rant about the White Coat Creremony got mixed reviews according to my mole at the University of the Pacific (from where I heard, is where it all started).
Lets take a look at the breakdown:

  • To the professors/staff who hate me for ragging on your precious white coat ceremony:
    Seriously, why get angry at me? Because I have the balls to publically call out how stupid your ceremony is? How everyone across the nation agrees with me as to the utter waste of money this mutual-masturbation session is? Seriously, have you taken a step back and realized why I think this is stupid?
    1. Its a waste of money
    2. You go to school because you want to learn. You shouldn’t have to attend a ceremony to make you feel “special” for what you are paying an assload of cash to go there for.
    3. Its stupid, seriously. Its like a birthday party for a 2 year old, they aren’t going to remember anything and its just there to make YOU feel special.
    4. You made it so the alumni couldn’t even attend! They are the ones who are footing the bill!
    5. Some of your stupid students were actually excited about the whole thing!
    6. Pride and respect for your future profession should come from your acts and from within, not some stupid ceremony that the school puts on. If you need a $30k handjob ceremony to make you feel good about being a pharmacist, then please, go kill yourself. We don’t need you going postal on everyone in 10 years when you realize that its not all candy-canes and fruit-loops like UOP pretends it is.
    Now, I’m going to give you all a little hint as to how to make the white coat ceremony seem not as retarded. I know that almost all schools (at least mine did) had a rotation program setup where you finish classes, then go off on rotations for x months working in bum-fuck Egypt for minimum wage. When you get back, you graduate, take the boards, etc. Have the stupid white coat ceremony AFTER you are done with classes but BEFORE you go off on rotations. You know, symbolizing you are finished with classes and are off to work “in the real world” (sorta). Mini-graduation to so speak. Thats a whole lot less corky than having the ceremony before the first round of midterms (which im sure some of them failed. Go cry into your white coat you failure!)

  • To all of the UOP students who hate me, and think that I should not be a pharmacist:
    1. You have no idea what you are dealing with.
    2. Go have fun at your little association meetings pretending you are a “leader in pharmacy”. Remember me when you are begging for copies with your broken bok-bok engrish at the end of your 12 hour shift for Walgreens.
    3. Go actually work in a pharmacy before you shoot your mouth off about me.
    4. You are in for a rude awakening once you leave the comforting colon of UOP and get shat out into the ‘real world’ without anyone to wipe your ass or tell you how special you are.
    5. Mommy and Daddy can’t pay your way to making people not yell at you for their soma. The sooner you learn this the better. Dealing with the public (especially the sick public) sucks ass but it has to be done.

  • To all of the UOP students who think I am awesome:
    1. Join my facebook group.
    2. Obviously you have either worked with the public or have worked in a pharmacy.
    3. Spread the word of angry around campus. I need more moles (druglord@theangrypharmacist.com).
    4. Go kick the asses of those uppity bitches who dont like me. Obviously they are going to get screamed at eventually, mine as well have it be by their classmates.

  • To all the UOP students who failed out of pharmacy school after the first semester:
    1. Be sure to hang up that nice white coat. We don’t want the symbol of your failure to get dirty.
    2. Have fun wearing that coat around the house pretending to be something that you are not.
    3. Haw Haw. Now you see why I think the whole ceremony is stupid?

  • The Elderly need to go…

    Everyone has the stereotypical elderly patient.
    Comes in with a smile on her face, and a few flies buzzing around inside her empty head. She comes in, plunks down 10 bottles from 7 different pharmacies, then hands you a fistful of Rx’s and wants them all filled. About 3/4 of what doctor writes for isn’t covered, and she sits there an argues with you about why you need to call the doctor to get them changed.
    Medicare part D has to be the cruelest joke that anyone could ever play on the elderly. Lets take a concept that takes working in the industry to fully understand, throw it at the segment of the population who cant tie their shoes without assistance, and see what happens. Add-on salesmen offering lapdances, free geritol, and 24 hours of Jag reruns and you have yourself a real problem.
    People say “Well thats where the pharmacist comes in!”. Bullshit. We are not insurance agents, salesmen, or explainers. We do not get a fat check from AARP for helping these idiots out understanding the coverage gap or deductibles.
    Theres really only a few problems when dealing with the old folk. When I say old-folk I mean in their late 70’s to 80’s. When you bring up that patient profile, see a fat age of 85, a piece of you dies as you pick up the phone to take the call.

  • Simple concepts become complex concepts. Deductibles are easy to understand. You pay $x out of your own pocket until your insurance kicks in. Simple. You have a better chance explaining quantum physics to Mrs Jones.
  • They dont listen. They are so damn stubborn they will sit there and ask the same question over and over and over. When you answer it, they ask it again! However they will listen to some douche on TV to call Liberty Health for free test machine but not their pharmacist. When you tell them that they dont need their Avandia filled because they picked it up 3 days ago, they will sit there and argue with you until they get it. When they finally stop stroking out and find it sitting right in front of them they wont even apologize for being so retarded.
  • Gullible as all hell (except when you talk). Salesman comes up to their door promising them a piece of gold the size of a thanksgiving turd if they switch to Wellcare. Guess who’s life got a bit harder when they come in for Rx refills? Of course it takes 30 questions, 3 hours of your time, and them bitching at you that their Rx’s arent covered for them to admit that they talked with a salesman (even though you told them not to).
  • Cheap as hell. They dont want to pay those $3.10 copays because they are on a “fixed income”. Yeah, if there wasn’t Medicare part D and you had nothing, you’d still be on a “fixed income”. Stop bitching and pay your fucking copays or i’ll glue your wheelchair to the ground.
  • Talking to them is like talking to a cow. Ever see the blank look a cow gives you? Ever see the blank look someone in their 80’s gives you?
  • Needy as all hell. They call you on a monday when you are swamped to tell you that they have not pooped in one day. They want you to call the doctor RIGHT NOW to get something so their bowels will move. Completely beside the fact they have not eaten anything since yesterday, poop somehow magically gets formed from nothing in their world. When you try to explain this to them, they obviously “dont get it” and just want some magical pill that will make their bowels explode. Thats when the Mag Citrate comes in. At least they’ll be shitting so hard they wont have a chance to get to the phone to call you.
  • They think they know more than anyone. Being around for 80+ years gives you a sense of empowerment and knowledge. Knowledge that somehow replaces going to grad school for 4 years and getting a degree.
  • They always lose/misplace/eat/destroy their medication. Of course it cant be like Lisinopril or something that costs pennies, but Avandia. They lose it like its going out of style. I swear that when half of my patients die I’m going to buy their house so I can recover the 1.3 million dollars of lost medications that are scattered about. Plus they refuse to acknowledge that they lost their medication! They just call in a refill 20 days early and expect you to fill it. Oh, did I mention that they dont wish to pay for said lost medication replacement?
    I hope that if I make it to 80+ years old (highly unlikely) that I can be a burden on everyone like our current aging population is. I figure that its just proper paybacks. Lord knows that I’ll never see a dime of the fistfuls of cash I’m throwing away on the current Medicare system.
    PS: I just got an email that some of the professors at UOP are angry at me for trashing their White Coat Ceremony. Guess who’s getting another entry!!!

  • Everyones a Fucking Genius

    So I got some hatemail in response to this entry

    They may be corporate assholes, but at least they hold nobel intent.

    Nobel intent would be charging a fair price for /all/ generics. Not $4 for amoxicillin yet $40 for a month supply of lisinopril or HCTZ.

    People are dying; antibiotics save lives. No company *has* to give this type of break to anyone since the parasitical lobbyists from healthcare industry have penetrated both aisles of Congress. Yet they do.

    Actually inappropriate use of antibiotics kill people (MRSA? VRE? VRSA?). Maintenance drugs that cost pennies will save more lives than all of the antibiotics combined. Why aren’t they giving all those away for free?
    You’re right, no company /has/ to give this type of break however it looks really, really good for business if they do. Plus guess what, if you transfer all of your drugs there for 2 or so drugs at $4, you get to pay 10x what an independent charges for the remaining 5 of your Rx’s. Bait-and-switch. Bend over and grab your ankles. They are making up for the loss somewhere.

    Get over it.
    And when a universal coverage system hits, get over it too. You may have to put your new Porsche up for sale and switch to a Honda (get a hybrid and you can save the environment and maybe someone’s health, all that the same time).

    Nah, myself and all the other pharmacists will be out of business at that point. We’ll determine that the cost of our schooling outweighs our income and we’ll just all do something else that makes money. Then as the pharmacies start to dwindle, the ones remaining can charge whatever the fuck they want or just refuse to serve you. Then what? You’ll just bitch that pharmacists are a bunch of greedy bastards because they don’t wish to work for free to fill your trade name Coreg for $1.50 profit.
    Oh, I dont drive a porsche. I think fancy cars is just pissing money away. I prefer to spend all my money paying taxes so welfare folk don’t have to work and for this website so you’ll have something to bitch about at work.

    If you wanted to make money, you should have went to work on Wall St not a place where reimbursements have been dwindling for years. Did you think that was going to change?

    You think money is on wall street? I should of opened a PBM and started raping the system a long time ago, however anally raping the sick and poor isn’t really my cup of tea. Maybe to you wall street types its okay.

    You’re a self-loathing narcissist; get over yourself.

    You’re just a retarded douche who has totally made an ass of himself in front of a few hundred pharmacists.

    N.B. I have been reading other comments on here and it’s somewhat nauseating. I think, instead of rx’ing myself Zofran 8mg tid I’ll go with Phenergan 25mg q4-6h off the $4 menu. Where’s your pharmacy.

    Zofran is pennies now. Its generic, so yes, I will be Rx’ing myself some Zofran because it costs about the same a Phenegran and doesn’t have all the sedation side effects. My pharmacy however does not have a $4 menu because we charge a fair price for /all/ medications, not cheap out over a few to draw people in to rape them on the other ones. Fair prices and good service, like all pharmacies should be.
    Plus what does my post have to do about anything that you are ranting about? Did you even read my post? Let me recap because I know I used some big words.
    My rant was about these pharmacies giving away free/$4 generics away setting a precedent to the insurance companies to cut our reimbursements due to the fact that if we can get by selling things for $4, then obviously their reimbursements are way too high. They are fucking it up for the rest of us who cannot afford to sell medications for $4. Its a marketing scam and its going to draw the opinion of all the major PBM’s to make that AWP-30%+1.50 sound like a wet dream.
    Wait to see how many pharmacies are left when the PBM’s make all the reimbursements $4/rx, and next time read my damn post before flaunting your ignorance.

    Arguing that water is indeed not wet

    Before I get into my usual rant about the stupidity of the common-folk, if you wish to get email notifications about new entries here (rather than refreshing my website 1000 times a day), just enter your email in the area on the right hand side of your screen marked “Subscribe to this blog”.  No, I’m not going to sell/use/molest your email address.  If you are paranoid about that, then get the sand castle out of your vagina and waste lots of time refreshing my site for content that others will get emails about.

    Now, onto the stupidity.

    Have you ever noticed that some people just like to argue?  Not the usual ‘I think I have a valid point, so I shall argue with you’, but ‘I am so retarded and cannot understand the big words that you speak out of your mouth’.  What’s sad is that no matter how clear you make it, they just dont get it.  Usually this involves refills in one way or another.

    • Person comes in and wants a refill for an Rx for some TAC cream that was filled over a year ago.  The Rx had 5 refills on it, but was over a year old so the Rx is expired.  Even though I am really clear (how much clearer can you get than “the Rx is over a year old, it has expired, the refills are no longer good”) the idiot just sits there and argues that he has 5 refills on the Rx and he wants it filled.  Eventually I get frustrated and make some really vague analogy to drinking expired milk (which he probably does) and eventually the neurons fire and he ‘gets it’.  My soul died a bit to realize that this idiot is reproducing.
    • No refills on C-2 narcotics always seems to completely throw everyone for a loop.  Every month the same idiot wants you to fax the doctors for a refill for Methadone and every month you tell the idiot that a C-2 narcotic cannot have any refills and you need a new Rx.  Once in a while you’ll get a new doctor on the phone (or mostly a seasoned PA/NP) arguing with you that since the little Rx blank has a refill bar that C-2’s can now be refilled.  They are completely oblivious that their Rx pads are for /all/ controlled substances, not just C-2 narcotics.  Most of the time just telling these people once will solve the problem (misunderstanding/confusing/didnt know that percocet was a C-2/etc)  however its the repeat offenders that worry me.  These people have prescriptive authority too, that makes my heart sad.  If you tell a dog to stop eating his own shit enough he eventually will learn.  Jury is still out however on these idiots.
    • I’m not going to get into the whole 30 day supply of medication.  The calendar is a vague and confusing thing, and depending on how you split it, saying that something needs to last 30 days could vary between a week to a few months.  I guess when you need a “Must Last 30 Days” warning on your Rx, your definition of a “day” can shift depending on how much of Prince Valiums cock you have sucked.
    • Copays.  You have been paying a $25 copay for the last 5 years, and every time you must argue with me and have me look up how much you have been paying in the past.  Surprisingly I come back with….. $25!  Thank you for wasting my time.  Double thank you for sitting there and arguing with me about it.
    • Trade name medication and DAW-1.  Patients still feel doctors are the magical do-as-I-say deities that everyone should listen to.  They feel that if the doctor writes DAW-1 on their Coreg Rx that the insurance company is forced to cover it.  No matter how many screen printouts of the insurance company saying “I DONT CARE ABOUT YOUR DAW-1” they still will sit there and argue with you about it.  They don’t wish to pay $100 for their medication, but feel the insurance company should because of a small checked box.
    • Everyone has heard the “Doctor told me to take this twice a day” as they come in with a new written Rx for the same drug at once a day.  They will sit there and argue that they were told twice a day despite you having a new Rx there showing it at once a day.  Once I even used the line “Since you aren’t going to listen to me or the doctor, you just take it however the hell you want, but doctor has here once a day and thats whats going on the bottle.”  Guess who got his ass chewed by the doctor for not taking it correctly, it wasn’t me!

    When did they start putting lead in the water?

    Pharmacists are NOT DOCTORS!

    Reading the DrugNazi’s site, I came upon this gem of a rant regarding a comment from ‘Dr. Anonymous, PharmD’ (More like Dr Dipshit, PharmD).
    I couldn’t agree more with what the DrugNazi has to say. Given that I personally have a PharmD, I would never ever call myself a doctor (and are the first to say that I am not a doctor). Why? Because I’m not a fucking doctor. I’m a pharmacist. I don’t wish to be called a doctor because I am not a doctor! I get down on NA and MA’s for calling themselves Nurses, now I’m getting down on my own for calling themselves something they are not.
    Most lawyers have a JD, but do they call themselves Doctors? No. Where do all of these fucking uppity pharmacists get off by calling themselves ‘Doctor So-And-So’ because they have a stupid PharmD after their name? Are they so socially retarded that they feel like they have something to prove to somebody? Do they not realize that most every pharmacist out there that has graduated within the last 10 to 15 years has a PharmD? You are not special compared to the BS crowd. Do the PharmD crowd have special powers or licenses? Hell no! We are all in the same boat, so quit flaunting your perfectly measured out PharmD penis (vs the BS folk who just work and just know they have a big penis) and just get to fucking work!
    Let me spell this out if you are a PharmD and do not understand.
    WE.. ARE.. NOT.. DOCTORS!! QUIT CALLING YOURSELF A DOCTOR!!!
    Any pharmacist who calls himself a “doctor” needs to stop going to those mutual-masturbation circle-jerk pharmacy association meetings and actually work in the ‘real world’ for a change. If I call for a copy, and you call yourself a doctor, I’m going to call you a fucking retard who should of settled for medical school vs going to pharmacy school.

    MRSA is going to end the world…

    Another typical example of the media getting a hold of a medical concept and completely instilling fear and chaos into the unwashed masses.
    mrsa.jpg
    Everyone is playing chicken little throwing MRSA around and implying that its somehow a death sentence if you get it. This magical strain of staph is resistant to everything short of a blowtorch and will not only kill you, but kill your children and make your minority cousins horribly disfigured.
    Lets be realistic here. MRSA is nowhere nearly as bad as people are making it. For those at home living in a box, MRSA stands for Methicillin-resistant Staphylococcus aureus. Yes, it sounds extremely scary. People think that MRSA is resistant to everything, and there is no hope of treatment.
    They are wrong. They are in fact extremely wrong.
    First off, I have never ever seen a MRSA case that has been resistant to everything under the sun. Yes, MRSA is resistant to all of the penicillins/cephalosporins, but we aren’t living in the dark ages here, we have a shitpot more antibiotics than those two classes. Of the dozens and dozens of Culture and Sensitivty reports that I have gotten trying to get Zyvox covered, I have found that in 99% of the cases the “evil” MRSA infection is perfectly suspectible to the Fluroquinolones (Levaquin/Cipro/etc), Tetracycline, Clindamycin, Rifampin, SMZ/TMP, etc. If you want to go IV route, Vancomycin.
    Seriously, its not that big of a deal. The problem is that people want to throw Zyvox at everything instead of doing a proper C&S report to determine what else they can use other than the biggest bacteria bazooka that is on the market (at $60/tablet no less). Give them Zyvox, send them home and forget about them. Right, you try to explain that to the insurance company when they are staring at the C&S report that I faxed them showing that clindamycin has exactly the same efficacy as Zyvox in this case. Retarded I tell you, utterly retarded. The PA’s that I have gotten for Zyvox involved a ton of confirmed type-1 allergic reactions to what was effective. If you have drug allergies then you start stripping of available agents and things get a bit complicated.
    So I blame the media here (as always) for clipping out only choice words that will cause the most fear and panic (read: ratings) and have patients come in to me in a tizzy thinking their life is over because they have a stupid minor MRSA infection.