Found this thanks to Ars. (Yeah that’s three “i”s in a row.)

Medical resident contracts first reported case of Acute Wiiitis.

From Ars:

The case report reads very tongue-in-cheek, containing a description of the Wii controller that can only be described as clinical, and noting that, unlike in real tennis, the resident’s level of fitness did not preclude his ability to overdo it: “Unlike in the real sport, physical strength and endurance are not limiting factors.”

Apparently, Acute Wiiitis is actually a variant of a disease that was first described in 1990, Nintendinitis, but the presentation is distinct enough to warrant a specific term. Those curious about these sorts of ailments may also want to check out the description of Nintendo elbow and Ulcerative Nintendinitis.

Genius!

Selling syringes is a sore spot for many pharmacy personnel, both technicians and pharmacists alike. I’ve heard technicians say that they wish that they (the drug abusers) would “just die.” I used to have moral qualms about it, too. Why sell something to drug addicts which only facilitates their habit? Why make it easier to abuse illegal substances?

I had an epiphany one day. It occurred to me that selling needles was the lesser of two evils.

Option 1: Withhold clean needles.
Outcome: Person still injects drug of choice, potentially using an unclean needle.

Option 2: Sell clean needles.
Outcome: Person still shoots up, but may avoid infecting or becoming infected with a blood-borne pathogen.

Option 2 is the better option, if for no other reason than it’s more economical. By possibly reducing the spread of infectious disease, we’re possibly saving taxpayer money. Drug abusers are typically uninsured, and wind up in the ER where tax money will pay for the cost of their care. It should go without saying that withholding clean needles isn’t going to stop an addict from getting their fix. Of course drug abuse leads to other medical complications, so there’s no guarantee that they won’t end up there anyway…

Naturally, I play the “Gee I wonder if they’re using it for insulin… or maybe their cat?” game all the time, even though I know it’s unlikely. When they haven’t showered in about a week, look as though they’ve been living in a box under a bridge somewhere, and complain that you’re not snappy enough about selling them their $2.10 bag of syringes, it’s probably a good sign that you’re not using said needles for healthy reasons.

But it’s a comfortable delusion nonetheless.

[tags]Medicine, pharmacy, needles, syringes, drug abuse[/tags]

I don’t often participate in blogosphere or Internet drama, but I do want to briefly add my comments to the general blogosphere reaction to the outcome of Flea’s trial. If for no other reason than Flea was one of my favorite blogs, and its disappearance is a loss for medbloggers and the Internet community at large. I won’t pontificate long. My thoughts boil down to this:

It saddens me when a case is settled not on the facts of the case, but rather on issues that are only tangentially related to the matter at hand, at best. That said, perhaps Flea was confident in his anonymity, but probably shouldn’t have been. Being nearby, I considered going to the courthouse in Boston and asking a court clerk where and when “the malpractice case of the pediatrician” was being heard, simply because most of my days are free, and I would have liked to observe the trial. I wouldn’t have revealed Flea’s identity.

Unfortunately, hindsight is 20-20, and things that are obvious after the fact are often not so obvious while they are occurring. We’ve all done things that were dumb in hindsight — myself especially — so I will refrain from being an armchair jackassexpert and saying that Flea should have known better.

But ultimately we have a legal outcome wasn’t about the truth. The truth — whatever it happens to be — is apparently irrelevant. Unimportant, even. I think that alone is poor commentary on our legal system.

[tags]Medical malpractice, malpractice[/tags]

There’s a bizarre misconception that pharmacies have a Batphone that connects us with The Doctor at the push of a button. Anytime, anywhere.

The Batphone phenomenon generally rears its ugly head on the weekends or after hours when someone inevitably needs a refill on their Allegra, or their kid’s fluoride prescription has run out of fills, or their Patanol copayment is higher than they’d like it to be. Eleventh Law stuff.

I’ve had people literally scream obscenities at me because I won’t give out the doctor’s special phone number. You know, the magic one that all you doctors have to every other doctor on the planet so you can have your secret conversations with one another and that pharmacies can use periodically when there’s a medical emergency. Like that Patanol copayment. That super special phone that’s never busy, and doesn’t get answered by the front desk.

Why oh why are you holding out on us, doctors?? WHY???

We’ve got this one doctor’s office that refuses to accept prescription fax refill requests. This means we have to actually pick up the phone and call — but most of the time the phone is busy, so it takes 3 or 4 tries to actually get through. This is annoying, but not the end of the world — we fill a moderate number of prescriptions for him, but most of them seem to be antibiotics and such, with no refills.

What is disconcerting is that when we do get through to the office, a receptionist answers the phone, looks up the file while you wait, reads the prescription in question back to you, and then invariably authorizes it with two more refills. Every single time. I have no idea who this person is or what their qualifications are, but it makes me uncomfortable. Yeah, I have the refill “authorization” within 90 seconds which is nice and convenient… But who’s doing the authorizing? Is she qualified to make the decision? Is the doctor being notified? Are the charts being updated? Who is doing the monitoring? When was Mr Smith last seen in the office?

Am I going to get a phonecall later asking me how the patient is taking the medication?

Call me old-fashioned, but I prefer the black box method of requesting a refill, where a request goes out electronically, via fax, or by leaving a voicemail, and then comes back some time later either authorized or denied. This delay lets me think that the prescriber is actually, you know, looking at the patient’s chart to see what’s going on before making a decision.

I like my comfortable delusion. Even if it is a fantasy and the med in question is “just” glyburide.

I suspect a great many doctors shoot from the hip when it comes to refills. What makes me think this?

Well there’s this weird little loophole in our automated refill request line where someone can request a refill and trigger an auto-fax to the doctor if the script has expired or run out of refills. It’s all automatic — no pharmacy personnel even see the refill request before it gets sent. Our computer systems aren’t typically smart enough to check and see if there’s a replacement prescription in patient’s profile already.*

What’s amusing is that often this second prescription differs from the first. Not significantly, but where the first might have 5 refills, the second has 3. Or 11. Or maybe zero. Often we’ll get two scripts with the old refill number on it sent back on the same day, each with a different number of refills, usually in the same handwriting. This makes me wonder… how are you guys charting this stuff?

Is this why we get phonecalls asking what strength of a drug a patient is taking? And how are they taking it? And please give them six months worth of refills?

Not to beat the EMR drum — because I don’t think they’re perfect either — but I have never seen this happen with an EMR.

It makes me scratch my head. Shouldn’t the order of operations be something like:

1. Request comes in and is put aside for later perusal.
2. Patient’s file is checked
3. A determination of the appropriateness of a refill is determined.
4. The number of refills is written on the request AND the patients chart — along with any changes.
5. Chart is closed, request form is faxed back to the pharmacy and then thrown away or placed in the patient’s files once you get the confirmation that the fax has gone through successfully.** If not, re-fax periodically until it does go through, or if it’s a constant problem, just CALL it in. That’s what we do when we can’t get a fax through.

Just askin’.

* This seems a good time for a digression. This little loophole, I suspect, is where the aggravation on a prescriber’s part that a prescription refill request has already been responded to, comes from. “I already took care of this, dammit! Why am I seeing it again?” Well now you know that patients can trigger second (and third, and fourth) requests all on their own, with no human intervention. This seems to be popular with elderly people who will often try to call in the same refill four days in a row before they actually come down to the pharmacy “just to make sure it’s there” — and our system isn’t smart enough to catch it and weed it out. It sucks. I hope this loophole is closed, too, because some pharmacy personnel aren’t smart enough to throw those second and third redundant prescriptions away when they come off the fax machine. They’re not real, people. Just toss ’em.

** Another digression: when irate patients come in demanding to know why the pharmacy doesn’t have a prescription because Goddammit-I-spoke-to-Jane-at-DrBob’s-office-this-morning-and-she-said-it-was-faxed-last-Thursday- what-the-fuck-is-wrong-with-you-people and we call the office, and get a sheepish “Oh, it was faxed but it says the line was busy. Sorry. We’ll do it now.” — it really tends to piss us off.

Update: Thanks to Kevin, MD, The Consumerist, and The Wall Street Journal Health blog, this entry is getting a lot of traffic. If you enjoy it, please take the time to Digg it. :)

The first round was popular, so I thought I would share another round of Bad Prescriptions. Answers will be posted tomorrow (Thursday) night around midnight.

Remember there’s more to a prescription than the drug. You need to get:

• Drug name
• strength
• directions
• quantity
• number of refills

The last prescription is totally legible. I have included it so you can cringe along with me. It was for a 6 year old child. And the folks in the Ivory Tower think MinuteClinics are bad…

Exhibit A:

Exhibit B:

Exhibit C:

(Standard disclaimer about electronic prescribing not being the perfect answer applies.)

[tags]Medicine, pharmacy, prescriptions, bad handwriting, doctor’s handwriting[/tags]

Generally little things cost small amounts of money. Unless it’s a diamond. Or some medications. And this was brought to my attention most recently by a comment left on an old Plavix post. My premise is that the public thinks about the cost of medical intervention the wrong way. (Duh!)

It’s not uncommon to hear people complain about the cost of Ambien (with apologies to Dr Dino :) ). Until recently, Ambien was one of the most expensive, yet most common medications. And also widely complained about. Patients don’t like the fact that it’s costing them $45/month to take some tablets to help them sleep.

But this anger is the result of a flawed perception. Instead of valuing the tablets as something that you hold in your hand and swallow, you should be valuing the quality of life that they afford you. Is it worth $1-1.50 per night to sleep well? If you asked a person with insomnia if they would pay $1.50 to enjoy a full night’s sleep just before they’re about to go to bed, most would pay without complaint.

It would be foolish NOT to.

It amuses me that people pay the high cost of Viagra without any problems. And that they’ll throw down $10-15,000 on plastic surgery, or $75/month for Propecia, but they complain about a medication that is keeping them alive. Honestly, if having high cholesterol was a cosmetic issue, and relative attractiveness correlated with your LDL levels, there would be NO complaining about the cost of a given statin.

This whole week, I’ve seen probably double the number of Ambien CR scripts as usual. Cutting into the usual volume of new Ambien prescriptions. This makes sense, of course. What with generic Ambien now available, we must educate those docs on the benefits of a controlled release zolpidem formulation!

What a crock of shit.

Also of note is that generic zolpidem is less than half the price of it’s name-brand counterpart — startling, given that new generic drugs typically run around 80% of the price of its brand competition for that first six months. I’m sure insurance companies are lovin’ it.

I’m exhausted, so this probably won’t read with as much impact as how the events actually unfolded…

Today has got to be one of the most fucked up days on the pharm on record. Possibly even weirder than the OxyContin bust day.

The two main highlights were the evil woman and the transgendered dude trying to pass a phony Duragesic script. Then there was the woman who was illiterate.

Evil Woman (EW) entered the pharmacy and made herself known to me first by shouting at me from halfway down the aisle. These aisles are about 150 feet long, so she was a good 75 feet away. And she was shouting. That was our first interaction. That got me mentally labeling her as Garden Variety Harmless Eccentric. (GVHE*)

After consulting with some techs about where to find the item of interest (wasn’t in my normal store), I sent the lead tech out to help her. She does so, and within 15 seconds, EW’s got her off to do some shopping for her while she gets a couple of other things. OK, that’s a little weird, but no big deal, we were in the middle of a 5 minute breather.

This woman drops a basketful of shit on the counter, and announces very loudly that she would like to return an item. No receipt, of course. I page the manager since I couldn’t be arsed to know the policies regarding returns without receipts. The manager handles the transaction personally, and she’s heckling him the entire time. Just a stream of low-impact derogatory comments, and insinuations that he’s ripping her off because she spent “much more money than that on this item” and “I spend a lot of money here and in this pharmacy so what the hell is wrong with you!” I’m starting to get a little irritated, since I don’t like people who treat others poorly. EW has now elevated herself from GVHE to RPWEI — Rude Person With Entitlement Issues.

EW starts in asking me if I can ring out her script. I tell her that no, I can’t, not until the return is complete. Anyway, the manager is soon done, and wisely, he’s kept his mouth shut the whole time. (Really there’s no better way to deal with this sort of thing, since as soon as you engage it in any way, you’re officially fuckedtrapped.)

He scoots, and she starts heckling me now about how goddammit we’re not supposed to fill any prescriptions unless she asks for them. (She had two waiting, and she was only expecting one.) Whatever. This woman is irritating but she hasn’t quite perfected the art of being rude, since I’m largely ignoring her and she’s letting me get away with it. Unrefined evil. Quasi-evil. The Diet Coke of evil, if you will.

She wanders off — finally — and someone thinks to look at her profile. Liar. She’s been coming to the pharmacy for a grand total of two weeks. Even better, in big bold letters in the comments section: “Wanted by police!!!”

Fantastic. I was just happy she was gone.

Not five minutes later, this other person walks in. I noticed her right away. She was tall with dark hair. Really tall. Didn’t think much of it until I walked over to wait on her.

Wait a second, this isn’t a woman. It’s a man, baby! A man with full D cups, makeup, mascara, and possibly a wig. And tall. I’m about 6’1, and I’m standing on a 4″ ledge, yet he’s nearly looking me in the eye. He hands me a script for Duragesic (“no substitution”), and I tell him that we probably don’t have it. He giggles and starts making out with this black dude who’s shorter than he. I go check The Book, my mind still boggling at what is transpiring in front of me.

We don’t have it, so I send them on their merry way, still trying to wrap my brain around it. (I didn’t finally settle the Male/Female debate until I handed the script back to him and saw the size and musculature of his hands.) Something stuck in my craw about the prescription, but I was so caught up in the Transgender Experience that I didn’t think about it until later. It was a fake prescription. Not a terribly good fake, but I didn’t notice because I was distracted. Clever little misdirection they’ve got going on there.

We get a PharmAlert about an hour later flagging all scripts by this particular nurse practitioner, and this was a script that she had supposedly written.

The last person of note was a new one for me. I’ve seen fake prescriptions, transgendered people — though never the two combined — other RPWEIs, and myriad other oddities. This last one made me stop dead in my tracks.

I had dealt with this woman earlier in the day, and she had tried my patience then. I was on my way out for the night, and was already five minutes late. (Five minutes is a long time when you’ve spent hours numbering in the double digits in the same little 10×20 space.) She was trying my patience yet again. Just so bloody needy. Asking trivial questions. I thought maybe she had forgotten her reading glasses at home or something. Finally she looks at me when she’s all done and says “Thank you so much for your help and not getting upset with me. I can’t read or write.”

…

Talk about feeling like an asshole. Whether she was just being nice or not, I don’t know. Nor does it matter — I still felt like a complete jerk.

I’ve never come across someone (that I know of) that can’t read or write. Not in this country, anyway. I’m going to be more careful how I deal with needy people from now on, I think.

* I tend to like GVHEs. They’re the most interesting people we deal with on a day-to-day basis.

[tags]Medicine, pharmacy, gender dysphoria, WTF[/tags]